Health systems of the 21st century have to cope with the challenges posed by their rapidly changing socioeconomic, ecological, technological, demographic and epidemiological environment. The revolution of information and communication technologies (ICT) has the potential to make contemporary health systems more effective, efficient and equitable at the same time, but represents an external challenge on their own right, as well, which health systems have to adapt to. The use of digital health solutions, therefore, is not just an opportunity to make health systems better, but a compelling force to change, which disrupts the traditional organizational and operational framework of medical care.
Digital health solutions, such as eHealth, mHealth, Big and Long Data, are ICT based medical and management technologies to improve the performance of health systems [1–5]. The ICT based administration of service delivery in health care has, in itself, a great potential to increase efficiency (appointment management, patient notification, patient information, documentation of services, e-prescribing, communication of test results, etc) [6], but new technologies go beyond simply replacing paper-based with electronic documentation. Telemedicine utilizes advanced communication technologies to enable distance diagnosis, therapy and monitoring, in which the participants of the health procedure are at different geographical locations and connected electronically. Teledentistry is one subgroup of telemedicine defined by the medical specialization, dentistry, and in addition to dental practice, it extends to dental research, education and management, as well [7, 8]. The common to all telemedicine solutions is that they make the data, the information travel instead of the patient, relatives and health workers, with the data being processed real time (e.g. in the case of videoconferencing), or at different time points (store-and-forward systems). Typical teledentistry solutions include tele-consultation, when the patient-doctor encounter is managed through videoconferencing (D2P) and tele-support, when the doctor treating a particular patient receives support from another doctor, who is at a different location (D2D). The technological development has made it possible to perform not just diagnostic, but therapeutic procedures, such as surgical interventions, from a distance, and while the doctor being present with the patient is only for reassurance, the opportunity can also be used for training purposes [7, 9, 10].
According to the available literature, teledentistry solutions have been successfully implemented in Australia, the USA and England [7, 11, 12]. They delivered improved access to services in rural, remote areas and reduced travel for patients and their families. For instance, in Australia, the government has an ongoing struggle to provide access to high quality dental services for the population of remote geographical areas [13]. Although the dental care of school-age children is fully covered, human resources shortages have created large regional disparities manifested in long waiting times [14, 15]. According to a study by the Clinical Department of the University of Melbourne, the introduction of a cloud-based, store-and-forward teledentistry system was able to reduce unnecessary patient visits, waiting times, and could save 275.75 hours of work (i.e. 36.7 days) per year, while 95% of the patients was satisfied with the service and found the software user friendly [16]. Further, dentists in rural areas with backward infrastructure and unfavorable working conditions could receive on the job training in the form of telesupport [16].
The experiences suggest that one of the most important advantages of teledentistry is the more efficient use of human resources, which has recently become a critical factor of health systems performance all over the world [17, 18]. The recent COVID-19 pandemic has shown, how even relatively well staffed health systems can easily be overwhelmed with a sudden surge of critical condition patients, and the bottleneck of upscaling meaningful health care capacities is not necessarily the special pieces of equipment needed, but the appropriately trained health care workers to operate them [19]. Digital health solutions has been widely used to support coping with the challenges posed by the COVID-19 pandemic in this respect [20–23]. Hungary also exemplifies the importance of the health workforce, as the country has been experiencing a serious human resources crisis in the health sector, due to the massive emigration of doctors and other health professionals into the higher income countries of the EU, especially Germany, the UK and the Scandinavian countries [24–26]. The shortage is even more worrisome, if we consider that Hungary had a substantial surplus of physicians during the communist era [27].
As far as dentistry is concerned, the situation is not at all better, despite the fact that the number of dental graduates are increasing (Table 1). According to WHO guidelines, no more than 2,000 inhabitants should be cared for by 1 dentist. Theoretically Hungary meets this criterion, as on the basis of the number of licensed dentists and the size of the population, there were 1,708 inhabitants per dentist in 2015. However, if we take into account the number of publicly financed dental practices only, this figure was as high as 3370 [28]. The almost twofold difference is attributable to fact that there is a sizeable private sector in Hungary, which a huge percent of the population cannot afford to utilize.
Table 1
The state of human resources in dental care in Hungary, 2015
Indicator | Figure for 2015 |
Number of inhabitants per dentist | 1,708 |
Number of inhabitants per publicly financed dentist | 3,370 |
WHO recommendation | 2,000 |
Number of vacant practices | 280 |
Number of permanent vacancies | 42 |
Average age of dentists (year) | 50.5 |
Share of dentists over the pension age (%) | 20 |
Source: [28] |
Further, the averages hide large regional disparities. In terms of dental primary care, there are currently 280 vacant practices, and the number of permanent vacancies (practices, which have been unoccupied for over 10 years) is as high as 42 [28]. The trends are also worsening, despite that universities supply close to 300 new dentists in each year. Fresh graduates are reluctant to work in deprived rural areas and migration also takes its toll. Patients living in these remote locations are forced to travel, sometimes for hours, to central dental providers, which are also responsible for specialist dental care, such as periodontal and orthodontic care, oral medicine or dental surgery, as well as the care for patients with special needs, such as multiple chronic diseases, or disabilities [29]. As a result, central dental providers are jammed, dentists struggle with lack of time, while waiting times are increasing and unacceptably long.
The human resources crisis in dental care is further aggravated by aging. The average age of dentists is 50.5 years, and 20% of dental professionals are over the pension age [28]. Sudden external shocks, such as the COVID-19, further amplify these tensions [30]. In this paper, we have studied how teledentistry could be applied to ease the performance problems created by the shortage of dental health professionals, using the example of a university clinical department (Department of Community Dentistry, Semmelweis University, Budapest), which provides the full spectrum of dental health services from primary to tertiary care.