This qualitative study, forming a segment of a broader teledentistry research initiative, received approval from the University of Minnesota Institutional Review Board (STUDY00014736). The study was conducted across several sites in Minnesota, United States, and Khon Kaen, Thailand, including clinical facilities at the University of Minnesota, Khon Kaen University, and research venues at the Minnesota State Fair. In this paper, the term “patient” encompasses both dental patients recruited from clinics and fairgoers recruited at the State Fair research facilities, as both groups underwent the same teledentistry procedure. The quantitative and qualitative research methods used in the overarching project were recently reported [12,20]. In the quantitative segment, 11 trained and calibrated dental professionals used a Samsung smartphone equipped with an image acquisition app Teledental (CSIRO) to take dental photos (frontal, upper occlusal, and lower occlusal views) from consented dental patients and fairgoers and uploaded the images to a secure cloud storage for remote reviewers to assess [12]. Figure 1 illustrates the flow of the photographic acquisition and assessment in this mHealth model.

This study was approved by the University of Minnesota Institutional Review Board (STUDY00014736). Written informed consent was obtained from all participants prior to data collection. All study personnel complied with institutional review board–approved protocols governing data access, confidentiality, and privacy. Participating dental professionals based in the United States received compensation (dental therapist: $40 USD; dental student: $15 USD); Thailand-based dental professionals did not, due to university restrictions on out‑of‑country payments.

For the qualitative segment, we used a study design guided by the technology acceptance model (TAM) [27] and interpretivism [28] to examine the experiences of dental professionals and remote reviewers in using mHealth technology [20]. This work represents a portion of the qualitative segment and specifically explores patient discomfort from the perspective of dental professionals. Except for 1 dental professional (MS) who is an author of this paper, all 10 of the 11 dental professionals who captured dental images in the larger study were invited via email to participate in this qualitative study. All 10 professionals consented and attended a 60-minute interview conducted via Zoom (Zoom Communications). A combination of one-on-one and group interviews were conducted, with group size ranging from 1 to 6 interviewees, determined by their availability. Due to time zone differences, interviewees from the United States and Thailand were placed in separate groups. A total of 2 US-based researchers conducted the interviews in English, and all interviewees were proficient in English for the discussions. The study adhered to the Consolidated Criteria for Reporting Qualitative Research guidelines throughout its execution and reporting [29].

Each one-on-one or group interview was conducted by 2 interviewers: MS, a female honors college graduate with a bachelor of arts degree, and ECS, a female dental hygiene faculty member with a master of science degree. BH, a male senior dental academic and principal investigator with doctor of philosophy and doctor of dental surgery degrees, observed all sessions. Before the first interview, the interviewers received training to adopt a neutral interviewing approach, ensuring interviewees’ perspectives were captured without bias. While most interviewees had no prior relationship with the interviewers, 3 were previously acquainted with an interviewer as dental professionals in a prior study led by the observer. The interviewers and observer introduced themselves first, and the objectives and details of this study were explained through the informed consent form and at the start of each interview.

The interviews were attended exclusively by the interviewees and researchers. During the Zoom sessions, the interviewers took field notes to record nonverbal cues and additional observations. All interviews were audio-recorded and securely stored on a cloud-based server. Following each interview session, interviewees were emailed the complete study instrument and given 2 weeks to provide additional feedback. Data saturation, defined as the point at which no new information emerged across 3 consecutive sessions [30], was a criterion applied to the broader qualitative project involving a larger participant pool [20]. Nevertheless, to ensure a comprehensive and diverse range of perspectives, all 10 dental professionals were interviewed across 4 sessions, irrespective of whether data saturation had been reached. No interviews were repeated for the same dental professionals.

The interview instrument consisted of guided questions designed to explore the dental professionals’ perspectives. These questions were adapted from published resources [31,32] and rephrased to align with the context of this qualitative study and the specific mHealth technology used. A multidisciplinary panel of researchers, with expertise in qualitative study design, medical informatics, and dentistry, reviewed and finalized the interview questions to ensure their relevance and comprehensiveness. All dental professionals were asked 2 questions by the same interviewer. The first question was as follows: “How comfortable or uncomfortable did you feel about using the technology for dental trauma cases?” This question focused on the dental professionals’ own comfort levels when using the smartphone and mHealth app. The second question was as follows: “How might you have observed either potential distress or comfort from patients of the study?” The question was intended to capture the dental professionals’ perspectives on their patients’ comfort level. These 2 questions were part of a broader qualitative study [20] conducted, observed, and analyzed by the same research team. Although the larger study explored additional dimensions of mHealth use, only these 2 questions are reported here because they specifically addressed the anxious or emotional reactions experienced by dental professionals or patients during teledentistry procedures.

The qualitative data from the interviews were analyzed using a consensus coding process to summarize responses and synthesize the results, with a deductive approach [33-36]. Prior to conducting the interviews, the coding team met via Zoom to calibrate their approach, ensuring consistency in interpretation across transcripts. Audio-recorded interviews were transcribed and independently reviewed by the coding team. Throughout the analysis, memo writing was used to record coder reflections, track emerging themes, and document the rationale behind coding decisions, thereby enhancing transparency. Intercoder reliability was addressed through a negotiated agreement strategy: coders had established procedures for resolving discrepancies in advance, and when disagreements occurred, they revisited the transcript, discussed interpretations, and reached consensus. The principal investigator (BH), who observed all interview sessions, was available to provide input when needed to ensure consistency. A hybrid coding framework was applied, combining deductive codes derived from the research questions and the TAM [27] with inductive codes that captured novel insights arising directly from the data. This flexible approach allowed the team to systematically examine anticipated themes while incorporating unexpected findings that enriched understanding of participants’ experiences [33,37]. After all interviews were completed, the research team convened via Zoom to review the transcripts collectively, identify recurring themes, and extract supporting evidence, including descriptive terms and illustrative quotes from participants. The transcripts and findings were not shared with interviewees for review.

A total of 4 interviews were conducted. All 10 dental professionals participated, 4 from the United States (coded U1-U4) and 6 from Thailand (coded T1-T6). Although U1 to U4 were initially intended to be interviewed together, scheduling constraints led to U1 and U4 being interviewed individually and U2 and U3 together, whereas T1 to T6 were all available simultaneously and, as affiliates of the same institution in Thailand, participated in a single group interview. Table 1 lists the interview sessions, professions, genders, and countries of the dental professionals.

The thematic analysis process, in which patterns or themes are identified within qualitative data revealed 2 main themes from the interviewees’ responses: professional familiarity and confidence with mHealth technology, and patient reactions to smartphone imaging in dental care (Table 2).

A total of 9 out of 10 dental professionals reported feeling comfortable using the mHealth app and taking dental photos. Several dental professionals attributed this to their familiarity with smartphones, as U4 and T4 noted they use mobile phones daily. U4 also expressed ease with both the app and photography process. Factors such as having a newer phone (stated by T4) and proper lighting and retraction (stated by U1) contributed to the feasibility of the process. However, U2 mentioned challenges with consistency, requiring a refresher before using the app due to infrequent use.

Despite overall comfort, 3 dental professionals highlighted specific concerns. U2, based in the United States, described using a cell phone in a dental setting as “invasive,” particularly when working with privacy-conscious patients. This discomfort stemmed from introducing the phone and ensuring patients understood their data were secure, as stated by U2:

U2 also noted a lack of prior experience with intraoral photography. T4 emphasized the importance of restricting data access to the research team, while T3, another dental professional based in Thailand, worried about appearing less competent in front of the patient when relying on an app for diagnosis.

The majority of dental professionals observed no noticeable discomfort among patients during photo-taking. T1 suggested that dentists can help patients become accustomed to photography as part of dental examinations by adopting the approach of “we take a photo and show it to them.” U2 noted observing minimal discomfort, describing patients as “fine” but acknowledged some initial hesitancy, especially among immigrant patients who might harbor concerns about privacy or identification. U2, a US-based dental professional, noted that immigrant patients sometimes fear being photographed, even when assured they won’t appear in the image (see Table 2).

Despite this, U2 mentioned that some patients viewed technology integration as a necessary advancement. U3, acting as a research recruiter at the Minnesota State Fair, observed that patients were generally comfortable by the time they arrived, perhaps because they volunteered or were not in a dental facility for dental care. However, recruiting participants posed a challenge, echoing common issues with dental appointment attendance. U4 found that providing more detailed information and setting clear expectations reduced patient discomfort, making them “less anxious” and “more willing” to participate.

Dental professionals also speculated why patient discomfort was minimal. T1 noted that patients in emergency trauma situations were generally uncooperative and preferred faster tools such as intraoral cameras. Conversely, patients with nonemergency issues were described as “very comfortable.” T2 and T4 believed that obtaining informed consent and explaining the photo-taking process alleviated patient concerns. They emphasized that the procedure was painless and less invasive than standard dental examinations. T4 noted that patients seemed comfortable, particularly when dental photos were shared with them afterward to facilitate treatment discussions.

Clear communication was a recurring theme in reducing patient discomfort. T4 and U1 highlighted the importance of explaining the exclusion of identifiable features in photos. U1 stated the following:

Transparency about the process helped foster trust and alleviate initial apprehension.

The overall consensus from dental professionals was that patients did not experience discomfort during smartphone-based dental photography. Although the telesupport function of some mHealth technologies could reduce patient discomfort [13], this study demonstrated that the asynchronous telediagnosis function of the mHealth technology could also minimize patient discomfort. Of further note, a prior study has reported a low level of dental patient anxiety from synchronous video consultation [24]. Thus, both synchronous and asynchronous teledentistry can decrease patient discomfort when dental professionals use these practices to communicate and examine patients.

One of the reasons for this finding is likely to include the physical safety characteristics of the mHealth model. Earlier studies have suggested that the use of X-rays in dental treatment increased patient anxiety, most likely due to the procedure’s uncomfortable nature [5], apprehension toward radiation exposure [5], and the perceived lack of control during image acquisition [10]. Compared to X-rays, taking photos using a smartphone does not inflict any pain and is not invasive. Hence, patients become less uncomfortable when receiving a teledentistry procedure than undergoing a radiographic examination. Another possible reason patients did not express discomfort may have been the communication provided by dental professionals before the teledentistry procedure. Dental professionals informed patients about what the dental photos would include and how they would be used, which likely contributed to patient comfort. This aligns with the recommendation from literature, which emphasizes obtaining clear informed consent and ensuring confidentiality, particularly regarding who would have access to recorded materials and how they would be used, can enhance patient comfort [38] and support the effectiveness of psychotherapy [2]. Furthermore, dental professionals could show patients the images of their teeth after photography to help strengthen patient trust. These highlight the importance of health care provider–patient communication and carry significant clinical implications for mHealth and teledentistry.

Beyond the clinical context, the findings of this study can also be interpreted through the lens of informatics and digital health system design. The TAM provided a useful framework for understanding how familiarity with smartphones influenced dental professionals’ confidence and ease of adoption [27]. From a systems perspective, the mHealth model used here illustrates key principles of human-technology interaction: usability [39], transparency [40], and trust [40]. Prior informatics reviews have emphasized that clear communication of data flows and privacy safeguards is essential for user acceptance of digital health tools [40,41]. Integrating these insights into system design suggests that teledentistry platforms should prioritize intuitive interfaces [40], explicit consent protocols [41], and secure data management to enhance both health care provider and patient comfort [40,41]. In this way, the study contributes not only to clinical practice but also to broader discussions on how digital health systems can be designed to balance efficiency, accessibility, and patient-centered care.

In teledentistry procedures, smartphones and intraoral cameras are often used as alternatives to each other. A recent study found that patients reported greater comfort with smartphone-based teledentistry compared to intraoral cameras, although smartphone photography required more time to complete a similar procedure [42]. Using a smartphone for diagnostics may cause less discomfort than an intraoral camera because smartphones are familiar devices used daily by many people. In contrast, intraoral cameras are only found in clinical settings and can feel more intrusive. In cases of traumatic dental injuries, high-quality photographs during the initial visit are essential for long-term follow-up, which may be required for up to 5 years [43]. Patients will need to undergo photography during most follow-up visits. As mHealth apps on smartphones feel less intimidating than intraoral photography, they could help reduce patient discomfort and encourage regular checkups.

Only 1 interviewee raised a unique concern regarding the potential discomfort that smartphone-based photography might cause among immigrant patients. Although all patient photos were deidentified during the research process and patients were reassured about privacy and confidentiality protections, maintaining anonymity in photography-based research involving migrant minority groups remains an important consideration [44]. To address this, patient education programs could help reassure patients about the safety of teledentistry, while professional development for clinicians and administrators could reinforce best practices for protecting patient privacy. Additionally, dental photographs captured through mHealth approaches should be securely integrated into electronic health records to ensure confidential access and long-term storage. For patients who are uncomfortable with teledentistry, in-person appointments should remain an option to ensure continued access to dental care.

Dental professionals also found the mHealth teledentistry model to be feasible, reporting a high level of comfort with its use. This aligns with findings in medical education, where students with prior exposure to telemedicine tend to feel more confident using such technologies [45]. On the basis of these insights, we recommend integrating comprehensive teledentistry training into dental education and ongoing professional development. These programs should prioritize building core competencies in teledentistry, such as obtaining informed consent and maintaining patient confidentiality during virtual encounters. Incorporating teledentistry training into dental curricula and clinical protocols could enhance practitioner readiness and improve patient care in remote settings. Standardizing communication protocols and ethical practices, such as consent and confidentiality, can help establish trust and ensure quality care. As teledentistry becomes more widespread, these educational and policy shifts will be essential for ensuring its effective and responsible implementation in clinical practice.

The interpretation of this study’s findings is subject to certain limitations. First, the small sample size of interviewees may restrict the ability to draw generalized conclusions, as a larger cohort might reveal additional perspectives. The pool of participants, consisting of 4 US-based and 6 Thailand-based dental professionals, may have introduced biases shaped by their unique clinical experiences, cultural backgrounds, patient populations, and photo-capturing environments. For instance, dental professionals assigned to the Minnesota State Fair research facilities were unlikely to encounter patients with emergency trauma cases, as such patients would typically seek care in clinics or hospitals rather than visiting the State Fair. Conversely, those working in clinical settings were more likely to manage patients presenting with pain, bleeding, or injuries and may have been more confident and experienced in clinical dentistry. Notably, privacy concerns among immigrant patients were raised by American dental professionals, whereas Thai dental professionals reported image concerns about appearing less competent in front of patients. These differences may reflect broader cultural expectations. An earlier study suggested that Thais were inclined to accommodate audience expectations, while Americans often balanced personal goals with audience interests [46]. Such cultural norms likely shaped how dental professionals perceived patient concerns and articulated their views. Given these contextual influences and the small, convenience-based sample, the transferability of findings is limited. Future research should purposely recruit larger and more diverse cohorts of dental professionals working with similar mHealth models to strengthen the depth, cultural breadth, and applicability of insights.

Another limitation of this study is its focus on patient discomfort as perceived by dental professionals, rather than directly assessing patient discomfort from the patients’ perspectives. Given the small sample size and the varied clinical experiences of the interviewees, interpretations of patient discomfort may reflect biases stemming from dental professionals’ subjective perceptions. While indirect assessments of patient discomfort from clinicians’ viewpoints may not capture the full scope and intensity of patients’ experiences, dentists are well positioned to observe and interpret discomfort [25], and they can also be affected by their patients’ discomfort [26]. Therefore, investigating patient discomfort from dental professionals’ perspectives remains a practical and informative approach, despite its limitations.

Future directions based on this study include exploring patient discomfort from the perspectives of both patients and caregivers, as well as identifying the factors contributing to discomfort associated with different teledentistry technologies. Additionally, developing and evaluating effective strategies to alleviate such discomfort is a critical area for future research. This study also underscores the importance of defining and cultivating core competencies in teledentistry, particularly in understanding and managing patient discomfort. Refining training curricula for current and future clinicians to incorporate these competencies will better prepare them to address patient concerns and maximize the effectiveness of teledentistry practices.

This study highlights the feasibility of smartphone-based photography for teledentistry, with dental professionals expressing comfort in using the mHealth app. Familiarity with smartphones and clear communication helped facilitate the process, although minor challenges such as maintaining consistency in app use and concerns about smartphone introduction in clinical settings were noted. Patients exhibited minimal discomfort, likely due to the noninvasive nature of smartphone photography and the role of informed consent in setting expectations.

Clinically, integrating smartphone-based photography into teledentistry requires clear communication strategies to enhance patient comfort and trust. Future research should directly assess patient discomfort during teledentistry encounters and explore strategies to further minimize discomfort. Expanding teledentistry training in dental education and professional development will better equip dental professionals to use this technology effectively, ultimately improving accessibility and patient-centered care in dentistry.