1 Perspectives of Front-Line Clinicians and Remote Reviewers on Smartphone-Based Photography for Assessing Traumatic Dental Injuries: A Qualitative Study Emily C. Schultz1,2, Boyen Huang1*, Margaret Shenouda1, Mohamed Estai3, Sarbin Ranjitkar4, Jeffrey P. Louie5, Patimaporn Pungchanchaikul6 1 University of Minnesota School of Dentistry, Minneapolis, Minnesota, USA 2 College of Allied Health and Nursing, Minnesota State University, Mankato, Minnesota, USA 3 School of Human Sciences, The University of Western Australia, Perth, Australia 4 Adelaide Dental School, University of Adelaide, Adelaide, Australia 5 Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota, USA 6 Faculty of Dentistry, Khon Kaen University, Khon Kaen, Thailand *Corresponding Author: Dr. Boyen Huang Postal: 515 Delaware Street SE, Minneapolis, MN 55455, USA Email: huan2321@umn.edu ORCIDs: E.C.S.: 0009-0001-4775-8869 B.H.: 0000-0002-1246-7447 M.S.: 0009-0001-5113-4231 M.E.: 0000-0001-7109-0267 S.R.: 0000-0003-1957-0719 J.P.L.: 0000-0002-8945-8880 P.P.: 0009-0009-8963-6366 mailto:huan2321@umn.edu 2 Abstract Background: Mobile health (mHealth) is increasingly utilized in teledentistry for telediagnosis and other services, yet the perceptions of front-line and end-line users regarding these technologies in dentistry remained unexplored. Objective: This study examined the acceptability, feasibility, and usability of an mHealth model for telediagnosis from the perspectives of front-line and end-line users. Methods: A qualitative design using focus group interviews was employed. Participants (N=15) included front-line clinicians who captured dental photos via a smartphone app and remote reviewers who assessed the photos through an mHealth platform. Transcriptions of the audio- recorded interviews were analyzed thematically using consensus coding. Results: Thematic analysis identified nine key themes: feasibility and perceived ease of use, perceived usefulness, compatibility, self-image and social influences, self-efficacy, voluntariness and behavior intention, anxiety, facilitating conditions, and attitudes toward a behavior. Participants considered smartphone-based photography acceptable, feasible, and usable for remote dental assessment. Facilitators and barriers to implementing the mHealth model were highlighted, and recommendations for improvements were proposed. Conclusion: Cyclical education and professional development are essential to boosting user self-efficacy and technology usability. Addressing resistance from patients and clinicians through targeted education, effective communication, and operational enhancements can facilitate adoption. Suggested improvements include incorporating camera grids, integrating with patient management systems, and streamlining login processes. This study highlights the significant potential of mHealth in the initial assessment of emergency cases and patient screening, particularly benefiting underserved populations and fostering interprofessional collaboration in emergency departments. Future research should explore broader clinical applications, including other oral health conditions. Keywords mHealth, teledentistry, telediagnosis, traumatic dental injuries, feasibility, acceptability, usability, user perception 3 Introduction Traumatic dental injuries (TDI) are prevalent [1] and demand urgent attention when accompanied by pain and/or bleeding [2]. Most TDI cases presenting in emergency departments need consultation and evaluation from dental professionals [2]. However, the limited on-call availability of dental professionals in emergency settings often leads to unnecessary patient transfers and increased healthcare costs [3], an issue that worsened as dental emergency services declined during the COVID-19 pandemic [4]. To address these challenges, technologies for virtual dental examinations have been developed and implemented [5]. Mobile health (mHealth) facilitates the incorporation of mobile phones and wireless technological devices into healthcare practices, supporting the promotion and maintenance of health, enhancing preventive care, improving clinical decision-making and operational efficiency, and enabling remote communication and interaction. This approach has gained widespread adoption among healthcare professionals and caregivers [6]. Key benefits of mHealth include increased accessibility to healthcare services, the provision of anonymous consultation, and decreased reliance on travel and physical contact. These advantages were particularly valuable during the COVID-19 pandemic, when social distancing measures were necessary [7]. The concept of mHealth as a modality of teledentistry, or more specifically, m-oral health [8], includes teleconsultation for treatment planning and review [9], telediagnosis with virtual examination [9-14], telemonitoring using patient-generated health data [15-18], telesupport with interactive multimedia [19], and teleintervention to improve therapy adherence and complication management [20]. Prior mHealth studies have demonstrated adequate diagnostic performance for the remote assessment of traumatic dental injuries (TDI) [10], dental caries [11], and oral cancer [12] using smartphone-acquired photographs. In a survey conducted in Saudi Arabia, more than 60% of dentists have utilized mHealth technologies to capture and/or transmit clinical photographs, and the majority of them were confident in the diagnostic accuracy using this approach [21]. Our recent work described a workflow for telediagnosis of TDI, where trained clinicians and students used a smartphone camera and app to capture dental photographs, uploading them to secure cloud storage. Remote dentists and dental therapists then reviewed the images, recorded dental findings, and provided clinical recommendations through the same pathway in reverse. While the quantitative performance metrics of this mHealth practice were promising, areas for improvements - such as image quality and professional development on dental photography and remote assessment - were also indicated [10]. Within the Technology Acceptance Model (TAM), perceived ease of use and perceived usefulness are the determinants for an individual’s intention to use a new technology [22]. Based on different roles and concerns, Wallis et al. categorized mHealth users as patients, 4 front-line users (point of care clinicians), and end-line users (academic experts) [23]. Building on a similar classification, the users of our telediagnosis model comprised human subjects (patients and non-patient individuals who provided consent for dental photography), front-line users (front-line clinicians responsible for capturing dental photos), and end-line users (remote reviewers assessing the dental photos) [10]. When searching literature with keywords of feasibility, acceptability, usability, or user perception, we found that only a few studies have reported front-line and end-line users’ perspectives on specific mHealth models, practices, or technologies for dental care or oral health promotion [13, 15-18, 20]. Among these, only one study focused on telediagnosis [13], but their diagnostic method was not photography-related. Of further note, an earlier mHealth study reported the perspectives of parents and caregivers on a photographic telediagnosis model for detection of dental caries [14], but they did not investigate the perspectives of front-line and end-line users. Thus, the perspectives of front-line and end-line users on mHealth practices and technologies of photographic telediagnosis remained unclear. With the purposes to understand how healthcare professionals adopt new technologies and to fill the knowledge gap in mHealth, this study aimed to explore the perspectives of front-line clinicians and remote reviewers on their recent use of the mHealth model, using a qualitative research approach. The mHealth model investigated in this study was smartphone-based photography for telediagnosis of TDI, which was an extension of our recent work [10]. The users’ perspectives included feasibility, usability, and acceptability of the telediagnosis approach, as defined by Ginsburg et al [24]. Methods Study Design and Setting This qualitative study was part of a larger project, and was reviewed and approved by the University of Minnesota Institutional Review Board (Study ID: STUDY00014736). The study setting consisted of multiple sites located in Minnesota (USA) and Kohn Kaen (Thailand), including the University of Minnesota clinical site, Khon Kaen University clinical sites, and Minnesota State Fair research facilities. The quantitative component of the larger project has been reported recently [10]. Following that, a qualitative study design grounded in the TAM [22] and interpretivism [25] was used to evaluate the perspectives of front-line clinicians (dental photographers) and remote reviewers on their use of the mHealth technology to assess TDI. Qualitative study data were collected in November and December 2023, and analyzed in January to August 2024. The conduction and presentation of this study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines [26]. Participants 5 This study built upon our quantitative work of TDI remote assessments using an image acquisition app “Teledental” (CSIRO, Canberra, Australia) and a web-based data management platform “Remote-I” (CSIRO, Canberra, Australia) (Figure 1). From August 2022 to July 2023, the photographs of teeth were captured by 11 trained front-line clinicians using the Teledental app, and then remotely reviewed by 5 licensed dental professionals using the Remote-I system [10]. Excluding a front-line clinician who was involved with data collection and analysis of this qualitative research, 10 front-line clinicians and 5 remote reviewers were approached by email and invited to participate. All 15 users of the mHealth model consented to participate in this qualitative study, and were notified of the requirement to attend a 60-minute focus group interview through the Zoom app (Zoom Communications, San Jose, CA, USA). Each focus group was composed of 1 to 6 participants according to their schedule availability. The participants based in the USA and in Thailand were separated in different focus groups due to different time zones. The interviews were conducted in English by two USA-based researchers together. All participants were capable of communicating in English during the Zoom interviews. 6 Figure 1. The mHealth app and platform used in this study: (a-d) the user interface of the ‘Teledental’ app, (e) front-line clinicians attending one-on-one calibration after completing a ‘Teledental’ app training session, (f) the user interface of the ‘Remote-I’ platform showing a patient record created at the calibration. The clinicians consented to have their images and data presented in the publication. Data Collection and Instrument Two moderators, E.C.S. (a female dental hygiene faculty member with a Master of Science degree) and M.S. (a female Honors college student with a Bachelor of Arts degree) conducted each focus group interview, while B.H. (a male senior dentistry faculty member and the principal investigator with a Doctor of Philosophy and Doctor of Dental Surgery degrees) observed all sessions. Prior to the first interview, the moderators underwent training to adopt a neutral interviewing stance, ensuring that participants’ perspectives were accurately captured. Since participants were recruited from front-line and end-line users of a previous study led by the observer, the moderators had a limited prior acquaintance with three participants. To maintain transparency, the moderators and observer introduced themselves and outlined the research objectives and content on the informed consent form and at the beginning of each interview. Only the participants and researchers were present during the interviews. Field notes were taken by the moderators during the sessions, and all interviews were audio-recorded and securely stored on a cloud server. After each focus group, participants were emailed the full study instrument and given two weeks to provide additional comments. Although data saturation was defined as the point at which no new information emerged across three consecutive focus groups [27], we chose to interview all 15 participants to ensure a comprehensive range of insights, regardless of whether data saturation had been achieved. Repeat interviews were not conducted. The study instrument used for the interviews consisted of guided interview questions, exploring the perspectives of the front-line clinicians and remote reviewers. The interview questions were adapted from published resources [22, 28-32], and were rephrased to reflect the context of this qualitative study and the mHealth technologies used. Subsequently, a multi-member researcher panel with diverse expertise including qualitative study design, medical informatics, clinical dentistry, dental public health, and special needs dentistry reviewed and finalized the questions. The interview questions included in this study are presented in Table 1. The purpose of using this guided interview instrument for the interview was to gain a well-rounded perspective from the participants on their experience with the mHealth model and maintain consistency among all focus group interviews. Table 1. Guided interview questions adapted from the Technology Acceptance Model (TAM) 7 Interview Questions References Tell us about the feasibility of using the mHealth app/platform. What factors played a role? [22, 28] How do you feel this mHealth app/platform can contribute to work with dental trauma cases? (In terms of efficiency, usefulness, etc.) [22, 28] How does this mHealth app/platform fit with the way dental trauma cases are examined and diagnosed? [28, 29] How do you feel the use of the mHealth app/platform may change the way you and other people in your profession, specialty or field are viewed? [28, 29] Did your previous experiences influence your use of the mHealth app/platform? Anything positive? Anything negative? [28, 30] How willing are you to use the mHealth app/platform to examine and diagnose dental trauma cases in the future? [28, 29] How likely are you to utilize an mHealth app/platform like the one we used in the future for dental trauma cases? [28, 31] How comfortable or uncomfortable did you feel about using the technology for dental trauma cases? Front-line clinicians: smartphone and Teledental app Remote reviewers: Remote-i charting platform Only to front-line clinicians: How might you have observed either potential distress or comfort from the patients or fairgoers enrolled in this study? [28, 30] What attitudes do you believe your superiors have around your use of the mHealth app/platform to examine and diagnose dental trauma cases? [28, 31] What resources, knowledge or assistance do you feel should be available when using the mHealth app/platform to examine and diagnose dental trauma cases? [28, 32] What do you feel went well with the mHealth app/platform? What improvements do you feel could be made with the mHealth app/platform? [28, 31] Data Analysis A consensus coding process was used to summarize and synthesize the qualitative data from the interview questions and determine the results [33, 34]. Guided by the TAM [22] and the study objectives of assessing the feasibility, usability, and acceptability of the mHealth model, the two moderators applied a deductive approach throughout the analysis [33, 34]. The audio- recorded interviews were transcribed and reviewed independently by the moderators. After all 8 interview sessions had taken place, a Zoom meeting among the research team was held to analyze and discuss the qualitative data, use the transcripts to identify common themes, and extract appropriate evidence, such as descriptive terms and quotes, from the participants’ responses. The transcripts and findings were not returned to participants for review. Results A total of 7 interview sessions were conducted. Among the 15 study participants, 10 were front-line clinicians who took the dental photographs, and 5 were remote reviewers who interpreted the dental photographs from a distance. The 10 front-line clinicians included 5 general dentists, 1 pediatric dental specialist, 1 dental therapist, and 3 dental students. The five remote reviewers consisted of 1 pediatric dental specialist, 2 general dentists, and 2 dental therapists. The 6 dentists who acted as front-line clinicians and took dental photographs were all based in Khon Kaen (Thailand), while the other 4 front-line clinicians and the 5 remote reviewers were based in Minnesota (USA). Table 2 lists the focus groups, roles, professions, genders, and countries of the participants included in this qualitative study. Table 2. Focus groups, roles, professions, genders, and countries of the participants Focus Group Role Profession Gender Country 1 Remote Reviewer Dental Therapist Male USA Remote Reviewer General Dentist Male USA 2 Remote Reviewer Dental Therapist Female USA 3 Front-Line Clinician Dental Student Male USA 4 Front-Line Clinician Dental Therapist Female USA Front-Line Clinician Dental Student Male USA 5 Remote Reviewer General Dentist Male USA Remote Reviewer Dental Specialist Male USA 6 Front-Line Clinician Dental Student Female USA 7 Front-Line Clinician General Dentist Female Thailand Front-Line Clinician General Dentist Female Thailand Front-Line Clinician General Dentist Female Thailand Front-Line Clinician General Dentist Male Thailand Front-Line Clinician General Dentist Male Thailand Front-Line Clinician Dental Specialist Male Thailand Data saturation was achieved within the 7 interviews as no new codes or themes emerged after the first 4 interviews. Thematic analysis of front-line clinicians’ and remote reviewers’ structured interviews revealed nine main themes: Feasibility and perceived ease of use, 9 perceived usefulness, compatibility, self-image and social influences, self-efficacy, voluntariness and behavior intention, anxiety, facilitating conditions, and attitudes toward a behavior (Figure 2). Figure 2. Visual representation of the main themes and subthemes from the thematic analysis of the data. Feasibility and Perceived Ease of Use 10 As a whole, the front-line clinicians based in Thailand and the USA found the mHealth app feasible and straightforward to use, stating the app itself was self-explanatory, simple and easy to use. The front-line clinicians at the Minnesota State Fair (USA) used the technology more often and more consistently, while the front-line clinicians at clinical sites in Minnesota (USA) and Kohn Kaen (Thailand) used the technology more sporadically. With this being said, front- line clinicians who used it more consistently found it easier to use than those who used it sporadically as they were more familiar with the technology. Almost all front-line clinicians felt a more streamlined login process is necessary to improve mHealth app use. They criticized the need to login each use with a username and password, as it could be time consuming. Front-line clinicians in the USA suggested some options for streamlining the login process including: facial recognition for login, the ability to stay logged in and/or the ability to save username and password on login page. Both front-line clinicians in Thailand and the USA mentioned lighting and picture scale as potential barriers. Both parties suggested some type of template or guide to help with image flow, image angles, image scale and believe this would make images more consistent. A front-line clinician also mentioned at times he would have trouble focusing the image, “For some reason, when I was taking photos, I felt like I couldn’t focus on what I wanted to focus on. Sometimes, I would take multiple pictures of the same thing and try to get a really good picture, but I couldn’t get a clear image of things.” Remote reviewers had similar feelings to the front-line clinicians as far as feasibility of the mHealth data management platform. Generally speaking, remote reviewers mentioned the platform itself was feasible, simple to use, user-friendly and straightforward. Regarding the mHealth platform, a dentist remote reviewer stated, “I think it’s something that would be kind of intuitive to a new user.” A dental specialist and a general dentist mentioned if a charting error was made there was not a simple way to correct the mistake. They found the easiest way to correct it was to exit out of the platform and start over. They mentioned the importance of fixing this, because they believe teledentistry should be fairly efficient due to the volume one may be reviewing. A dental therapist remote reviewer, stated the most difficult thing was that the platform could be slow at times. Despite the hardships, overall remote reviewers found the learning curve to be manageable. Perceived usefulness As a whole, front-line clinicians perceived the mHealth app to be useful. Several front-line clinicians believed that the mHealth app was beneficial, particularly for increasing access to dental care and reducing the burden on emergency services. Front-line clinicians based in the USA commented, “People might not have access to dental services right away following trauma.” They also stated, “I believe this app is very useful and beneficial, especially like when kids gets trauma and they don’t have a dental home, it gives them quick access to care.” Front- line clinicians in Thailand also thought that the app would be a game changer for teledentistry. 11 Specifically they thought the mHealth app was great for those in remote areas where they do not have a dental specialist. Front-line clinicians in both countries did suggest they think the app would be more useful if it could include more information like patient age, radiographs and better image quality. They also felt some limitations with its current scope of only TDI and suggested widening it to a broader and more general dentistry scope. Remote reviewers deemed the mHealth data management platform useful for teledentistry, especially for initial assessments. They mentioned its potential for timely diagnosis and usefulness when there is not a dental provider in the near area. Similar to the front-line clinicians, remote reviewers also felt having more patient information, like pain, chief complaint, chart notes, etc. would be beneficial and useful. They also mentioned that suboptimal image quality of some dental photos may hinder minor trauma diagnosis and recommend that be addressed for future use. Compatibility Both front-line clinicians and remote reviewers felt that the mHealth app and platform were compatible with the way existing dental cases and TDI cases are treated. Meaning both parties felt the technology was not too out of the realm and could be useful for handling trauma cases. A front-line clinician and a remote reviewer eluded to the fact that “as a society we use technology every day, and some the younger generations rely on technology so we are already familiar with it.” They stated most people are using smartphones every day, so there likely would not be a learning curve for widespread TDI-based teledentistry. Future improvements for the mHealth app and platform, as recommended by the interviewees, included fine-tuning of the odontogram and patient chart displayed on the platform, and integration of the mHealth model with the practice management software available in the market. Self-Image and Social Influences The front-line clinicians expressed that using the mHealth app did not significantly alter their self-image or how they were perceived by others. They felt the app was generally viewed positively as a helpful tool in the dental care process. A front-line clinician in Thailand stated, “there have been no bad attitudes from superiors when using the application.” Although front-line clinicians generally had a positive perception on using an mHealth app, some concerns were raised about patients’ questioning the provider’s competence if they relied heavily on the app for diagnosis. One participant mentioned, “If the parent sees a provider using the application on their child they may question their intelligence as to why they are not confident in diagnosing on their own.” They also eluded that older generations may potentially have similar concerns. 12 Four out of five remote reviewers felt using a teledentistry platform like mHealth would have a positive impact on their professional images. They mentioned it would showcase their adaptability to utilizing new technologies. The other remote reviewer, a general dentist, thought that professionals in the field would not view him or his work any differently whether he used the technology or not. The only concern mentioned was initially there may be some push back, as health professionals have seen this when implementing other new technologies until the entire team is familiar and comfortable with it. Self-Efficacy Front-line clinicians felt confident using the mHealth app after the initial training, citing their familiarity with smartphone technology as a contributing factor. One front-line clinician stated, “Once we had the training, I was very comfortable with how to utilize the technology and then since I’ve used my phone a lot and taken a lot of images before, it was pretty streamline for me to be able to use.” Another made a similar comment, “I felt pretty comfortable. I felt familiar with using a lot of apps and utilizing that app wasn’t very challenging, and then taking the images were pretty easy.” All remote reviewers also felt confident in their ability to use the mHealth platform effectively after receiving the initial training. Remote reviewers attributed their confidence to the training session and prior experiences with other electronic charting and dental record systems. There were no barriers or negative experiences in regards to self-efficacy reported by remote reviewers. Voluntariness and Behavioral Intention Front-line clinicians indicated a willingness to use the app voluntarily, recognizing its potential benefits in improving access to care and streamlining the diagnostic process. One participant said, “I think it’s beneficial because, in terms of increasing access, people might not always have access to dental services right away following trauma.” They also suggested the app could be more widely adopted if it included additional features and addressed current limitations, such as the need for frequent logins and better image quality mentioned earlier. There was a strong willingness among remote reviewers to adopt the mHealth platform for future use, especially for screening and remote consultations. Most of them saw it as a great triage tool to get their patients to the right place in a timely manner. Remote reviewers saw it as a valuable tool for patient care and were open to integrating it into their daily practices, despite some initial hesitations. Per one reviewer, “I would definitely be willing to use it, I think it’s a very valuable asset.” Another reviewer stated, “I’d say I’m very likely to use it in the future.” 13 One remote reviewer, the dental specialist, was concerned with how the application would integrate into other dental practice software in an attempt to have more patient information available for the reviewer. Another remote reviewer, a general dentist, thought it would be beneficial to be able to communicate with the patient through the app, whether that be through voice, face time or text messaging. Anxiety The front-line clinicians overall seemed comfortable with using and capturing photos on the smartphones, as they use them regularly. Initial anxiety among front-line clinicians was noted due to the unfamiliarity of using the specific mobile app for dental assessments. Their anxiety lessened overtime as they became more familiar with the process. Those front-line clinicians witnessed a wide range of anxiety among patients and state fairgoers that were getting their dental photos taken. The most anxiety from patients was reported in a Minnesota community clinical setting. Front-line clinicians attributed this mostly to privacy issues, stating that some of the patients are potentially illegal immigrants, and became hesitant once they found out their picture would be acquired. However, anxiety decreased among some patients once they fully understood the study purpose and applications as well as the photos taken were limited to their mouths. Minnesota state fairgoers were less anxious, as they had agreed to come in the research facilities and learn more about the study, and willingly came in to learn about the study, versus being at the dentist for an oral health issue. The front-line clinicians in Thailand did not notice much anxiety from their patients. They credited this to previous use of intraoral cameras during dental examinations and the fact that participants had previously gone through and provided an informed consent. When it came to utilizing the mHealth platform, remote reviewers were overall comfortable and felt the dental charting they did was straight forward. They did report anxiety when it came to system charting glitches such as forgetting which teeth they had already marked as sound, and the accuracy of their diagnoses when the quality of some images was less than ideal. Facilitating Conditions Front-line clinicians appreciated the training sessions and written materials provided, which helped them navigate the app effectively. One front-line clinician in the USA stated, “I think the research team did a good job training us through this, the app, and showing us how to use it, and they even did a one-on-one calibration when we got the phones from them.” The same interviewee thought that a couple of practice sessions and being provided with model images would have helped them have a better understanding and emulate the photo expectations. The front-line clinicians based in Thailand thought a video tutorial would have helped them better understand what angles they should be taking photos from. They found the most difficult part was needing to login to the application and connect to the Wi-Fi every time they went to use the app. 14 When it came to resources, knowledge or assistance, remote reviewers emphasized the importance of adequate training and support to maximize the platform’s effectiveness. They felt the training they received from the research team was adequate, and liked the guidelines so everyone was working off the same standards. However, a reviewer suggested going through a couple of cases together would have been even more of a help. As stated earlier in this article, reviewers felt including more patient information, or integrating with patients practice dental software to have access to patient dental history would make the diagnosis process easier. Attitudes Toward a Behavior Overall, the front-line clinicians had a positive attitude towards using the mHealth app, as it was straightforward to use and they recognized its potential to enhance dental care delivery. They thought if this dental model was integrated more widely, it could make a significant difference, especially in areas with a shortage of dental health professionals. The mHealth model was seen as a step forward in leveraging technology to improve healthcare access and efficiency. Front-line clinicians thought the experience could be even more positive by suggesting things like streamlining the technology by automating the photo-taking process to save and switch to the next photo without manual intervention and user interface enhancements such as making the app more child friendly with colors or cartoons. Overall, the remote reviewers’ attitudes towards using the mHealth platform was positive. Reviewers acknowledged its potential to streamline workflows and improve patient outcomes. They appreciated the convenience and accessibility it offered. Specifically, the photographs were consistent views for each patient, they appreciated the ability to zoom in on the photos and the ability to chart multiple conditions on the tooth. Despite the positive attitudes towards the platform and use, remote reviewers recognized some areas of improvement and future development. One suggestion in an attempt to standardize the diagnosis was integrating the trauma guidelines in the platform form quick references. Another reviewer suggested making the reviewing platform into an app that could be easily assessed with a smartphone to improve convenience during emergency situations. Discussion When implementing teledentistry in clinical settings, its impacts on oral health outcomes [35], patient satisfaction [36], and cost-effectiveness [35] are commonly taken into account, and these effects have been regularly reported in literature [16, 17, 20, 35, 36]. Despite our belief in patient-centered care [37, 38], we point out the relevance of healthcare workers’ roles in adopting mHealth technologies in contemporary dental care. In this study, smartphone-based photography is regarded by front-line and end-line users as a feasible, acceptable, and usable 15 mHealth tool for remote assessment of TDI cases. The results suggested a relevant function of mHealth in the initial assessment of emergency cases (such as trauma) or patient screening (such as dental caries), and would particularly benefit underserved populations, and support interprofessional collaborative practice in emergency departments [2]. These concurred with a prior quantitative study evaluating primary caregivers’ experience in using the same mHealth app for dental screening and caries assessment in children [14]. While not investigating photography-related mHealth technologies or services, several other studies have also highlighted the relevance to include front-line and end-line users’ perspectives in the determination of feasibility, acceptability, and usability of mHealth technologies for dental care and oral health promotion [13, 15-18, 20]. Those studies reported additional benefits of using mHealth in dentistry from front-line and end-line users’ perspectives, such as the improvement of diagnostic accuracy [13], communication [17], patient-provider relationship [17], efficiency [18], and medication adherence [20]. Compellingly, some users of a non-photography-related mHealth app recommended to add a photo-capture-and-forward function into it [15], which happens to be a key characteristic of our mHealth model. This could also imply the viability of a smartphone-based photography in the mHealth modality of teledentistry. Based on the themes reported, the authors recognized the initial training and calibration as a facilitator for the use of this mHealth model. Both front-line clinicians and remote reviewers reported a gain of comfort and self-confidence in operating this practice after their completion of the training and calibration. Because training decreases the stress of uncertainty and self- efficacy uplifts performance [39], adequate pre-use training and professional development will be able to improve healthcare workers’ self-efficacy and enhance the usability of mHealth technologies, as also indicated in other papers [10, 15, 40]. A recent scoping review has found approximately 20 teledentistry educational programs provided to students and/or healthcare workers [41]. Reflecting on the summary of the scoping review, we believe incorporation of diverse training topics in the curriculum, such as virtual communication and assessment, technology utilization and troubleshooting, billing and reimbursement, and legal and ethical considerations, would enhance learners’ ability to develop and sustain teledentistry competencies. Alongside traditional lectures, incorporating simulated hands-on training and clinical practice offers effective methods for integrating teledentistry into the dental curriculum [42]. Of further note, the frequency of use also influences users’ perception of the feasibility, as described by some front-line clinicians who infrequently used the mHealth app to capture dental photos. Because familiarity with the technology can enhance its usability, periodic and continuous training sessions to refresh healthcare workers’ teledentistry knowledge and skills are required. This study also identified patients’ and other clinicians’ perceptions as potential barriers to the use of the mHealth model. Like a front-line clinician described, using a smartphone in front of the patient, as an aid to diagnosis, may be interpreted as a sign of incompetence by the patient or their caregivers. Although this concern has never been reported by other researchers, an earlier study pointed out that patients from older generations might consider nurses’ using a 16 smartphone at work as an inappropriate and disrespectful behavior [43]. However, younger patients and people familiar with mobile technology could view the use of a smartphone in clinical settings more positively [43]. To help patients understand the benefits of mHealth technology and improve their digital literacy, patient education in the dental clinic and health promotion to the community are recommended. On the other hand, pushback from other clinicians could also reduce dental professionals’ interest in using mHealth technologies. Surprisingly, a previous study reported that patients were more willing to adopt to telemedicine technology than medical professionals and healthcare managers, since the new technology would likely provide patients with greater autonomy in the selection of healthcare options [44]. To address the resistance from clinician groups, a strategy of inclusive development is recommended. Healthcare workers should be encouraged to provide informed contribution from the beginning of the development stage. Moreover, professional development opportunities, enhanced communication, and reduction of operational burdens could facilitate clinicians’ acceptance of the mHealth practice [44]. Several suggestions about the mHealth app and platform were put forward by the front-line clinicians and remote reviewers. As the latter group made telediagnosis exclusively based on viewing dental photos, adequate quality and consistency of the image would improve the diagnostic performance. To achieve this goal, in addition to continuous training and support to front-line and end-line users, incorporation of camera grids or standardized templates into the mHealth app could guide front-line clinicians to position the smartphone camera and capture photos from a consistent distance that enables a proper image size and quality. Moreover, remote reviewers suggested that the mHealth app and platform would be more useful for diagnosis with more comprehensive patient information such as radiographs and patient demographics. Since integration of an mHealth app with a patient management system and a cloud-based medical image storage service for data sharing purposes has been developed and implemented in a large hospital [45], future incorporation of the additional functions into the mHealth model for dental care is foreseeable. Of further note, almost all front-line clinicians wanted a more streamlined login process when using the mHealth app. At present they need to manually type their usernames and passcodes every time they log into the app. To minimize finger contact with the smartphone screen in clinical settings and ensure data security without compromise, a design to let clinicians use a Face ID or voice commands for logging into the mHealth app is indicated. To ensure the trustworthiness of this qualitative study, investigator triangulation and data source triangulation were used to test the validity [46]. The interview questions were created and reviewed by a multi-member researcher panel. Two moderators and an observer were jointly involved in data collection and analysis. These approaches broadened the focus of this research and reduced researcher biases. Additionally, the data were collected from the participants of different roles (front-line clinicians and remote reviewers), qualifications (dental specialists, general dentists, dental therapists, and dental students), genders (females and 17 males), and locations (Thailand and the USA). This participant pool contributed to diverse perspectives and validation of data. Using a focus group interview method is a limitation of this study. We included up to 6 participants in each focus group and some focus groups had a solo participant. The focus groups were created according to the participants’ available times other than self-selection. Nevertheless, outspoken participants might dominate an interview session, as pointed out in literature [47]. To minimize the inter-personal influence from any individuals, the moderators have been trained to be inclusive and inviting, and a follow-up email was sent to every participant to encourage additional opinions. A small sample size including 15 participants is another limitation of this research. The operation of this mHealth model required 11 front-line clinicians to take dental photos and 5 remote reviewers to diagnose TDI - all except one front- line clinician participated in this qualitative research. Limited generalizability due to small sample sizes of telemedicine and telehealth research is an issue identified by an integrated review [48]. However, this study achieved data saturation within 7 interviews, aligning with findings by Guest et al., who reported that as few as 6 interviews would be sufficient for thematic analysis and data interpretation [49]. Inclusion of front-line and end-line users of similar mHealth models to expand the sample size could be a strategy for future investigation. While the guided interview questions in this study effectively facilitated discussions across participant groups, future research could benefit from incorporating more role-specific elements into the interview topic guides. Moreover, employing mixed-methods research that combines qualitative and quantitative data could offer a more comprehensive understanding of mHealth implementation. Additionally, exploring patients' experiences with the mHealth model and conducting cost-effectiveness analyses would yield valuable insights into the practical and economic impacts of these technologies in dental care and emergency support. Our umbrella project was developed to investigate mHealth assessment and diagnosis of TDI due to the high prevalence and the need for immediate attention [1, 2]. This qualitative study confirmed the feasibility, usability and acceptability of the mHealth model for TDI. With viable evidence supporting the remote assessment of TDI [10], dental caries [11, 14] and oral cancer [12], future advancements could expand diagnostic capacities to include other oral conditions such as tooth wear [50], developmental dental defects [51], malocclusion [52], and temporomandibular disorders [53]. To ensure these technologies are well accepted, properly utilized, and continuously innovated, educational and professional development programs in mHealth and teledentistry are essential for future and current healthcare workers. Integrating photography-related mHealth into emergency department workflows necessitates structured training programs and clear protocols for photo capture and assessment. Developing specific competencies in teledentistry should be incorporated into professional development initiatives and dental education curricula. At the system level, healthcare organizations can leverage our insights on 18 infrastructure needs, resource planning, and policy development to facilitate successful implementation. Conclusion Within the study limitations, front-line and end-line users of this mHealth model considered the smartphone-based photography feasible, acceptable, and usable for remote dental assessment. Providing healthcare workers and students with cyclical education and professional development of diverse topics relevant to teledentistry and mHealth is critical to their self- efficacy and perceived usability of the technology. Resistance from more conventional patients and other clinicians is a potential barrier to implementation of an mHealth practice. Strategies such as patient education, health promotion, inclusive development, enhanced communication, reduction of operational burdens, and professional development can shift their resistance to a more positive attitude. The mHealth technology can be further improved from several aspects including addition of camera grids or standardized templates for photo-taking, integration with the patient management system and medical image storage service, and enablement of a more streamlined login process. Future clinical applications and research on other oral conditions are also indicated. Data availability The transcribed data are available upon appropriate request made to the corresponding author (B.H.). The audio recordings of the interviews are not openly accessible because the participants of this study did not give written consent for their recordings to be shared publicly. Declaration of conflicting interest The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding statement This study was supported with (1) a Department of Pediatrics Driven to Discover Grant by Minnesota Masonic Charities, (2) a Regional Development Program Grant by the International Association for Dental Research, (3) a Global Health Seed Grant by the University of Minnesota Center for Global Health and Social Responsibility, and (4) a Faculty Start-up Funding for B.H. by the University of Minnesota School of Dentistry. The funding sources had no role in the design of this study and did not have any role during its execution, analyses, interpretation of the data, and decision to submit results. 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