Desenvolvimento e implementação de um programa de telemonitoramento odontológico para pacientes oncológicos pediátricos

Abstract

Antineoplastic therapies often present toxicity to the oral mucosa, particularly in children and adolescents, due to the high mitotic index characteristic of this age group. Oral health monitoring is crucial for the early diagnosis and treatment of oral comorbidities in these patients. However, the physical distance between patients and healthcare professionals during periods when patients are not attending therapeutic centers can hinder the continuity of care. In this context, telemonitoring emerges as a promising strategy to ensure continuous care and proper monitoring of these patients' oral conditions. This thesis aimed to develop and implement a Pediatric Dentistry Telemonitoring application for an Oncology service – TON. Two methodological stages were outlined to achieve this: mobile application development and implementation analysis, resulting in three outputs: a technical product (application) and three scientific articles. The application was developed using a Design Thinking approach comprising three stages: immersion, ideation, and prototyping. During the immersion stage, a panel of experts was assembled to identify key gaps in face-to-face dental care for pediatric oncology patients and to investigate the target audience's profile for the application. In the ideation stage, four main remote solutions were proposed: remote examination, oral hygiene diary, health education, and instant messaging. These solutions were operationalized in the prototyping stage through a simplified navigation flow and a visual identity designed to build user trust. The implementation process of TON was evaluated using the RE-AIM framework, focusing on effectiveness (E) and adoption (A). Effectiveness was assessed through a diagnostic accuracy study comparing remote oral mucosa examinations conducted via TON by three evaluators with in-person clinical examinations (diagnostic gold standard) for outcomes of oral mucositis (OM) and severe oral mucositis (SOM). The study's sample units were oral mucosa site examinations (n=120). Accuracy parameters and the Kappa coefficient were calculated for each outcome (α=5%). Remote mucosa examinations showed satisfactory accuracy for diagnosing SOM across all three evaluators: 100% sensitivity, specificity above 92.3%, and accuracy ranging from 92.5% to 97.5%. For OM detection, test performance was lower: sensitivity between 25% and 45%, specificity between 85% and 98%, and accuracy between 78% and 85.8%. Overall performance of remote examinations, combining results from the three evaluators and consolidating OM and SOM into a single clinical outcome, demonstrated limited discriminatory capacity, with an AUC of 0.60, accuracy of 82.7%, sensitivity of 36.6%, and specificity of 92%. Adoption of the intervention at the collective level was assessed through usability analysis of the application. This was conducted using a mixed-methods study with a convergent parallel approach, assigning equal weight to the quantitative phase, which employed the System Usability Scale (SUS), and the qualitative phase, which utilized a semi-structured interview guide. Data collection for the qualitative phase continued until theoretical saturation (n=14), while the quantitative phase used a non-probabilistic convenience sample (n=20). Data analysis integrated inferential statistics, including correlation tests and the Mann-Whitney U test (α=5%), alongside Bardin’s content analysis technique. Regarding intervention adoption, the average usability score for TON was 86.6 (±10.4). Analysis of 14 interviews revealed that users acknowledged TON's utility, highlighting its user-friendly interface, professional support, and data security as key facilitators. However, technical issues, caregivers' exhaustive routines, and children's lack of cooperation during examinations were identified as barriers. Suggested improvements included notifications, gamification, and video call integration. The TON application represents a significant advancement in pediatric oncology dental care, offering a feasible and well-accepted solution for the target population. It demonstrates potential for assisting in the identification of oral mucosa changes, particularly SOM lesions, in children and adolescents undergoing cancer treatment.