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National analysis of dental teleconsulting of the Brazilian Telehealth Program

Abstract

This cross-sectional study nationally evaluated asynchronous dental teleconsulting services offered by the Telehealth Brazil Networks Program, using the 2019 Telehealth Results Monitoring and Evaluation System database and considering Brazilian regional differences. The following teleconsulting variables were collected: dentist’s sex and specialty, date/time of question and answer, response time; dental specialty, professional satisfaction, and patient referral. Five Brazilian regions were socioeconomically characterized according to the Human Development Index, estimated population, Gini coefficient, coverage of dental specialty centers, oral health teams in Family Health Strategy, and oral health teams in primary health care (PHC). In total, 2,703 teleconsulting sessions occurred in Brazil in the analyzed period. The Southeast exhibited the highest demand (49.1%). Most dentists were female (60.6%) and were dental surgeons from the Family Health Strategy (61.3%). Most teleconsulting sessions occurred during working hours (85.5%) and questions were answered within 72 hours (66.7%). Level of satisfaction and avoidance of referral yielded rates of 90.9% and 66.8%, respectively, among dentists who answered about these topics. Semiology was the most frequently demanded area in teleconsulting (33.9%). The different demands from the regions reflected regional differences. The most frequently demanded specialties represent the Brazilian PHC scenario. Professionals incorporated teleconsulting into their work routine and most teleconsultants responded within the stipulated timeframe. Professional feedback should be encouraged.

Telemedicine; Primary Health Care; Dentistry

Introduction

Telehealth provides services and shares information on healthcare. 11. Celes RS, Rossi TR, de Barros SG, Santos CM, Cardoso C. [Telehealth as state response strategy: systematic review]. Rev Panam Salud Publica. 2018 Aug;42:e84. Portuguese. https://doi.org/10.26633/RPSP.2018.84
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It has fosters the continuing education of health professionals and supports multidisciplinary care, especially in underserved areas. 22. Brito TDLV, Baptista RS, Lopes PRL, Taylor A, Haddad AE, Messina LA, et al. Collaboration between medical professionals: special interest groups in the Brazilian telemedicine university network (RUTE). Telemed J E Health. 2019 Oct;25(10):902-10. https://doi.org/10.1089/tmj.2018.0075
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Also, it has considerably improved quality, efficiency, and costs, expanding point-of-care options and diagnosis and decreasing inequalities in the provision of oral health services. 33. Ministério da Saúde (BR). Nota técnica nº 50/2015-DEGES/SGTES/MS. Diretrizes para oferta de atividades do Programa Nacional Telesaúde Brasil Redes. Brasília, DF: Ministry of Health; 2015 [cited 2016 Nov 21]. Available from: http://189.28.128.100/dab/docs/portaldab/notas_tecnicas/Nota_Tecnica_Diretrizes_Telessaude.pdf
http://189.28.128.100/dab/docs/portaldab...

Likewise, teledentistry facilitates remote dental care, via information technologies, 44. Khan SA, Omar H. Teledentistry in practice: literature review. Telemed J E Health. 2013 Jul;19(7):565-7. https://doi.org/10.1089/tmj.2012.0200
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and has allowed earlier diagnosis than regular tests. 55. Alabdullah JH, Daniel SJ. A systematic review on the validity of teledentistry. Telemed J E Health. 2018 Aug;24(8):639-48. https://doi.org/10.1089/tmj.2017.0132
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Teledentistry presents a wide range of applications, such as teleconsultations (remote communication between dental professionals and patients), telediagnosis, teletriage, and telemonitoring, in which the progress of treatment outcomes and disease progression are monitored remotely. 66. Mariño R, Ghanim A. Teledentistry: a systematic review of the literature. J Telemed Telecare. 2013 Jun;19(4):179-83. https://doi.org/10.1177/1357633x13479704
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Therefore, teledentistry has been used to improve people’s access to specialized oral healthcare 55. Alabdullah JH, Daniel SJ. A systematic review on the validity of teledentistry. Telemed J E Health. 2018 Aug;24(8):639-48. https://doi.org/10.1089/tmj.2017.0132
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, 77. Costa CB, Peralta FD, Mello ALF. How has teledentistry been applied in public dental health services? An integrative review. Telemed J E Health. 2020 Jul;26(7):945-54. https://doi.org/10.1089/tmj.2019.0122
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and has been efficiently applied in teleassistance and tele-education in dental public health services. 77. Costa CB, Peralta FD, Mello ALF. How has teledentistry been applied in public dental health services? An integrative review. Telemed J E Health. 2020 Jul;26(7):945-54. https://doi.org/10.1089/tmj.2019.0122
https://doi.org/10.1089/tmj.2019.0122...
In the current scenario of the COVID-19 pandemic, the importance of teledentistry has become even more noticeable, because it may reinforce social distancing, offering remote triage of patients for dental treatment, avoiding their unnecessary exposure. 88. Ghai S. Teledentistry during COVID-19 pandemic. Diabetes Metab Syndr. 2020 Sep - Oct;14(5):933-5. https://doi.org/10.1016/j.dsx.2020.06.029
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In Brazil, a developing country with continental dimensions, there is heterogeneous distribution of healthcare infrastructure, varying professional training levels, and socioeconomic and cultural contrasts, leading to unequal access to healthcare across its five regions. 99. Ministério da Saúde (BR). Portaria nº 2.546, de 27 de outubro de 2011. Redefine e amplia o Programa Telessaúde Brasil, que passa a ser denominado Programa Nacional Telessaúde Brasil Redes (Telessaúde Brasil Redes) 2011. Diário Oficial União, 2011 Oct 28; Section 1. p 50-52. , 1010. Ministério da Saúde (BR). Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial União, 2017 Sep 20. Public dental care services are also included in this scenario, with differences in its geographical distribution and in the availability of dental supplies and equipment, 1111. Scalzo MT, Matta-Machado AT, Abreu MH, Martins RC. Structural characteristics of oral health services in Brazilian Primary Health Care. Braz Oral Res. 2021;35e023:1-10. https://doi.org/10.1590/1807-3107bor-2021.vol35.0023
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and the epidemiological aspects of the Brazilian population reflect the country’s contrasts. 1212. Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Secretaria de Vigilância em Saúde. Pesquisa nacional de saúde bucal: resultados principais. Brasília, DF: Ministério da Saúde; 2012 [cited 2020 Nov 26]. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/pesquisa_nacional_saude_bucal.pdf
https://bvsms.saude.gov.br/bvs/publicaco...

The telehealth project was implemented in Brazil in 2006 33. Ministério da Saúde (BR). Nota técnica nº 50/2015-DEGES/SGTES/MS. Diretrizes para oferta de atividades do Programa Nacional Telesaúde Brasil Redes. Brasília, DF: Ministry of Health; 2015 [cited 2016 Nov 21]. Available from: http://189.28.128.100/dab/docs/portaldab/notas_tecnicas/Nota_Tecnica_Diretrizes_Telessaude.pdf
http://189.28.128.100/dab/docs/portaldab...
by the Ministry of Health. 1313. Haddad AE, Rendeiro M, Correira AD, et al. Brazilian teledentistry network experience. J Bras Tele. 2013;2(2):81-3. https://doi.org/10.12957/jbrastele.2013.8133 .
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The program, currently known as the Telehealth Brazil Networks Program, 33. Ministério da Saúde (BR). Nota técnica nº 50/2015-DEGES/SGTES/MS. Diretrizes para oferta de atividades do Programa Nacional Telesaúde Brasil Redes. Brasília, DF: Ministry of Health; 2015 [cited 2016 Nov 21]. Available from: http://189.28.128.100/dab/docs/portaldab/notas_tecnicas/Nota_Tecnica_Diretrizes_Telessaude.pdf
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was expanded to include the entire country and was redefined to strengthen and increase the resolution ability of primary health care (PHC) services and improve access to specialized healthcare. 33. Ministério da Saúde (BR). Nota técnica nº 50/2015-DEGES/SGTES/MS. Diretrizes para oferta de atividades do Programa Nacional Telesaúde Brasil Redes. Brasília, DF: Ministry of Health; 2015 [cited 2016 Nov 21]. Available from: http://189.28.128.100/dab/docs/portaldab/notas_tecnicas/Nota_Tecnica_Diretrizes_Telessaude.pdf
http://189.28.128.100/dab/docs/portaldab...
, 99. Ministério da Saúde (BR). Portaria nº 2.546, de 27 de outubro de 2011. Redefine e amplia o Programa Telessaúde Brasil, que passa a ser denominado Programa Nacional Telessaúde Brasil Redes (Telessaúde Brasil Redes) 2011. Diário Oficial União, 2011 Oct 28; Section 1. p 50-52.

One of the Program’s strategies is teleconsulting, which consists of bidirectional communication between PHC professionals and teleconsultants (experts in a specific area) for assistance or advanced information on clinical care, health promotion actions, or work process. Teleconsulting is offered by telehealth centers and take place via synchronous messaging, videoconferences, or asynchronous messages that must be answered within 72 h. 33. Ministério da Saúde (BR). Nota técnica nº 50/2015-DEGES/SGTES/MS. Diretrizes para oferta de atividades do Programa Nacional Telesaúde Brasil Redes. Brasília, DF: Ministry of Health; 2015 [cited 2016 Nov 21]. Available from: http://189.28.128.100/dab/docs/portaldab/notas_tecnicas/Nota_Tecnica_Diretrizes_Telessaude.pdf
http://189.28.128.100/dab/docs/portaldab...
, 77. Costa CB, Peralta FD, Mello ALF. How has teledentistry been applied in public dental health services? An integrative review. Telemed J E Health. 2020 Jul;26(7):945-54. https://doi.org/10.1089/tmj.2019.0122
https://doi.org/10.1089/tmj.2019.0122...
Brazilian regulations state that teleconsulting must only occur between professionals rather than directly between patients and health professionals. 22. Brito TDLV, Baptista RS, Lopes PRL, Taylor A, Haddad AE, Messina LA, et al. Collaboration between medical professionals: special interest groups in the Brazilian telemedicine university network (RUTE). Telemed J E Health. 2019 Oct;25(10):902-10. https://doi.org/10.1089/tmj.2018.0075
https://doi.org/10.1089/tmj.2018.0075...
However, Resolution no. 226/2020 published in 2020, by the Brazilian Federal Council of Dentistry, allows telemonitoring (remote monitoring of patients undergoing treatment by dentists), and teleadvice with the application of a preclinical questionnaire to decide on the best time to attend to them, considering COVID-19 pandemic restrictions. 1414. Conselho Federal de Odontologia. Resolução nº 226, de 4 de junho de 2020. Dispõe sobre o exercício da Odontologia a distância, mediado por tecnologias, e dá outras providências.. Brasília, DF: Conselho Federal de Odontologia; 2020.

The Program was has been evaluated by some studies, 1515. Rezende EJ, Tavares EC, Alves HJ, Santos AF, de Melo MC. Teleconsultations in public primary care units of the city of belo horizonte, Brazil: profile of patients and physicians. Telemed J E Health. 2013 Aug;19(8):613-8. https://doi.org/10.1089/tmj.2012.0179
https://doi.org/10.1089/tmj.2012.0179...

16. Paixão LC, Costa VA, Ferreira EF, Ribeiro Sobrinho AP, Martins RC. Analysis of the asynchronous dental teleconsulting of Telehealth Brazil Networks in Minas Gerais. Braz Oral Res. 2018 Dec;32(128):e128. https://doi.org/10.1590/1807-3107bor-2018.vol32.0128
https://doi.org/10.1590/1807-3107bor-201...
- 1717. Bavaresco CS, Hauser L, Haddad AE, Harzheim E. Impact of teleconsultations on the conduct of oral health teams in the Telehealth Brazil Networks Programme. Braz Oral Res. 2020 Feb;34 e011:e011. https://doi.org/10.1590/1807-3107bor-2020.vol34.0011
https://doi.org/10.1590/1807-3107bor-202...
but none has nationally explored dental teleconsulting. Thus, the present study aimed to nationally describe regional differences in dental teleconsulting provided by the Telehealth Brazil Networks Program.

The null hypothesis was that Brazilian regions have a similar demand for teleconsulting.

Methodology

This cross-sectional and exploratory study evaluated a secondary database of asynchronous dental teleconsulting of the Telehealth Brazil Networks Program during 2019. Telehealth centers are deployed in almost every state of the country 1818. Ministério da Saúde (BR). SMART - Sistema de Monitoramento e Avaliação dos Resultados do Telessaúde. Brasília, DF: Ministério da Saúde; 2021 [cited 2021 Feb 20]. Available from: https://smart.telessaude.ufrn.br/webapp/nucleos_telessaude/?show_all=1
https://smart.telessaude.ufrn.br/webapp/...
but not all of them actively use telehealth services. The services provided by each center vary in terms of structure and capacity, and some centers book teleconsulting sessions with other telehealth centers. For example, the telehealth center platforms of the states of Rio Grande do Sul and Minas Gerais are also used for requests from other telehealth centers, thus helping meet the heavy demand. 1919. Oliveira TC, Oliveira Junior JG, Tavares G, Rigato AFG, Pereira FWA, Carvalho FFB. The National Program Telehealth Brazil Networks: a historic and situational perspective. Latin Am J Telehealth. 2017 Ago;4(2):104-13. The distribution of teleconsulting is shown in Figure .

Figure
Flowchart of the order of teleconsulting distribution process.

*BHU: Basic health unit

** PHC: Primary health care


Data were collected from the Monitoring and Evaluation System of the Telehealth Results (in Portuguese, Sistema de Monitoramento dos Resultados do Telessaúde ― SMART) database, which integrates information on telehealth centers into the Program. 2020. Ministério da Saúde (BR). Telehealth: technology for the health care benefit. Brasília, DF: Ministério da Saúde; 2018 [cited 2018 April 28]. Available from: https://smart.telessaude.ufrn.br/
https://smart.telessaude.ufrn.br/...

In the SMART database, International Classification of Diseases (ICD-10) and the International Classification of Primary Care 2 (ICPC-2) codes applied to dentistry were used to filter asynchronous teleconsulting data. 2121. Ministério da Saúde (BR). Modelo de Interoperabilidade de Dados do Telessaúde Brasil Redes. Brasília, DF: Ministério da Saúde; 2021 [cited 2021 Feb 20]. Available from: https://smart.telessaude.ufrn.br/webapp/api_docs/
https://smart.telessaude.ufrn.br/webapp/...
As inclusion criteria, only teleconsulting requested by dentists was analyzed. Teleconsulting services extracted without any information about the state of origin (n=19) and duplicates were excluded (n=665). The theoretical model used considered that factors related to service, professionals, demand for healthcare, and socioeconomic issues may interfere in telehealth programs. 2222. Nepal S, Li J, Jang-Jaccard J, Alem L. A framework for telehealth program evaluation. Telemed J E Health. 2014 Apr;20(4):393-404. https://doi.org/10.1089/tmj.2013.0093
https://doi.org/10.1089/tmj.2013.0093...
The following teleconsulting variables were used: dentist’s sex and specialty and date/time of question and answer, to determine whether teleconsulting was requested between 8 a.m. and 6 p.m. or outside working hours; response time in hours; professional satisfaction (satisfied, neither satisfied nor dissatisfied, or dissatisfied); and whether teleconsulting avoided patient referral (yes, no, or not informed). The fields of teleconsulting questions were categorized as per ICD-10 or ICPC-2 into clinical dentistry, which encompasses some dental specialties, such as dentistry, endodontics, and periodontics; health promotion and prevention (prophylactic measures and oral health education); pharmacology (prescription of medications and adverse effects); semiology (diagnosis in general and systemic disorders such as diabetes and hypertension); stomatology (oral lesions); and service (dental issues that do not fit into dental specialties, related to the health system, health service operation, administrative process, and patient referral). Five Brazilian regions were socioeconomically characterized according to the Human Development Index (HDI), 2323. Brazil. Pnud Brazil, Ipea e FJP. Atlas do desenvolvimento humano no Brasil. Brasília, DF; 2020 [cited 2020 Oct 22]. Available from: http://www.atlasbrasil.org.br/ranking
http://www.atlasbrasil.org.br/ranking...
estimated population, 2424. Instituto Brasileiro de Geografia e Estatística. Estimativas da população residente no Brasil e Unidades da Federação com data de referência em 1º de julho de 2019. Brasília, DF: Instituto Brasileiro de Geografia e Estatística; 2019 [cited 2021 Jan 6]. Available from: https://ftp.ibge.gov.br/Estimativas_de_Populacao/Estimativas_2019/estimativa_dou_2019.pdf
https://ftp.ibge.gov.br/Estimativas_de_P...
Gini coefficient, 2525. Instituto Brasileiro de Geografia e Estatística. Brasil. Panorama. Brasília, DF: Instituto Brasileiro de Geografia e Estatística; 2019 [cited 2020 Jun 19]. Available from: https://cidades.ibge.gov.br/brasil/panorama
https://cidades.ibge.gov.br/brasil/panor...
and coverage of the dental specialty centers (DSCs), 2626. Ministério da Saúde (BR). Secretaria de Atenção Primária à Saúde. Cidades atendidas com laboratórios regionais de prótese dentária. Brasília, DF; 2021 [cited 2021 Feb 17]. Available from: http://aps.saude.gov.br/ape/brasilsorridente/cidadesatendidas
http://aps.saude.gov.br/ape/brasilsorrid...
oral health teams in Family Health Strategy (OHT/FHS), and OHT in PHC (OHT/PHC). 2727. Ministério da Saúde (BR). Secretaria de Atenção Primária à Saúde. Cobertura de saúde bucal. Brasília, DF: Ministério da Saúde; 2020 [cited 2020 Jun 23]. Available from: https://egestorab.saude.gov.br/paginas/acessoPublico/relatorios/relHistoricoCoberturaSB.xhtml
https://egestorab.saude.gov.br/paginas/a...

The results were descriptively analyzed by frequency and stratified by Brazilian regions using the IBM Statistical Package for Social Sciences, v 22.0 (IBM SPSS Statistics for Windows, Armonk, NY, USA). For variables with missing data, the statistical analysis considered all valid information, and losses are explained in the tables.

The study was approved by the Research Ethics Committee of Universidade Federal de Minas Gerais (UFMG) under protocol Nº 3.662.611 (CAAE 17400319.9.0000.5149).

Results

A total of 2,703 teleconsulting sessions were conducted in Brazil in 2019, with the highest demand from the Southeast (49.1%), followed by the Midwest (23.5%). The South had the highest HDI and lowest Gini coefficient. The Southeast was the most populated region. DSC, OHT/FHS, and OHT/PHC coverages were better for the Northeast ( Table 1 ).

Table 1
Socioeconomic analysis of the Brazilian regions concerning the demand for teleconsulting. Brazil, 2019.

Most dentists requesting teleconsulting were female (60.6%) and the most significant demand was for dental surgeons from the FHS (61.3%) and generalists (31.3%). Most teleconsulting sessions occurred during working hours (85.5%) and were answered within 72 hours (66.7%). Regarding professional satisfaction, 90.9% were satisfied (question answered by 53.3% of professionals). Concerning patient referral, 66.8% said teleconsulting avoided it (67.1% of professionals answered this question) ( Table 2 ).

Table 2
Descriptive analyses of the profile of dental teleconsulting by region. Brazil, 2019.

Regarding dental specialties, a large number of questions were related to semiology (33.9%), followed by clinical dentistry (31.6%) ( Table 3 ).

Table 3
Descriptive analysis of dental teleconsulting by field of issue per region. Brazil, 2019.

Discussion

Different issues were addressed in teleconsulting across the five Brazilian regions, in line with their socioeconomic and cultural contrasts, invalidating the null hypothesis.

The highest demand for teleconsulting from the Southeast was due to its larger population, 2424. Instituto Brasileiro de Geografia e Estatística. Estimativas da população residente no Brasil e Unidades da Federação com data de referência em 1º de julho de 2019. Brasília, DF: Instituto Brasileiro de Geografia e Estatística; 2019 [cited 2021 Jan 6]. Available from: https://ftp.ibge.gov.br/Estimativas_de_Populacao/Estimativas_2019/estimativa_dou_2019.pdf
https://ftp.ibge.gov.br/Estimativas_de_P...
when compared to other regions, and to its higher percentage of telehealth centers, when compared to those in other states. 1818. Ministério da Saúde (BR). SMART - Sistema de Monitoramento e Avaliação dos Resultados do Telessaúde. Brasília, DF: Ministério da Saúde; 2021 [cited 2021 Feb 20]. Available from: https://smart.telessaude.ufrn.br/webapp/nucleos_telessaude/?show_all=1
https://smart.telessaude.ufrn.br/webapp/...
In addition, the Southeast has the second highest HDI of Brazil, 2323. Brazil. Pnud Brazil, Ipea e FJP. Atlas do desenvolvimento humano no Brasil. Brasília, DF; 2020 [cited 2020 Oct 22]. Available from: http://www.atlasbrasil.org.br/ranking
http://www.atlasbrasil.org.br/ranking...
suggesting a better infrastructure of healthcare services, facilitating the communication between PHC professionals and teleconsultants.

The Midwest, with the third highest HDI, 2323. Brazil. Pnud Brazil, Ipea e FJP. Atlas do desenvolvimento humano no Brasil. Brasília, DF; 2020 [cited 2020 Oct 22]. Available from: http://www.atlasbrasil.org.br/ranking
http://www.atlasbrasil.org.br/ranking...
the second lowest Gini coefficient, 2525. Instituto Brasileiro de Geografia e Estatística. Brasil. Panorama. Brasília, DF: Instituto Brasileiro de Geografia e Estatística; 2019 [cited 2020 Jun 19]. Available from: https://cidades.ibge.gov.br/brasil/panorama
https://cidades.ibge.gov.br/brasil/panor...
and the second highest coverage of DSC, 2626. Ministério da Saúde (BR). Secretaria de Atenção Primária à Saúde. Cidades atendidas com laboratórios regionais de prótese dentária. Brasília, DF; 2021 [cited 2021 Feb 17]. Available from: http://aps.saude.gov.br/ape/brasilsorridente/cidadesatendidas
http://aps.saude.gov.br/ape/brasilsorrid...
OHT/FHS, and OHT/PHC 2727. Ministério da Saúde (BR). Secretaria de Atenção Primária à Saúde. Cobertura de saúde bucal. Brasília, DF: Ministério da Saúde; 2020 [cited 2020 Jun 23]. Available from: https://egestorab.saude.gov.br/paginas/acessoPublico/relatorios/relHistoricoCoberturaSB.xhtml
https://egestorab.saude.gov.br/paginas/a...
exhibited the second highest demand for teleconsulting. 2727. Ministério da Saúde (BR). Secretaria de Atenção Primária à Saúde. Cobertura de saúde bucal. Brasília, DF: Ministério da Saúde; 2020 [cited 2020 Jun 23]. Available from: https://egestorab.saude.gov.br/paginas/acessoPublico/relatorios/relHistoricoCoberturaSB.xhtml
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Another possibility is that professionals from the Midwest are more aware of the use of the Program. Teleconsulting is a crucial tool for this region, not only for filtering secondary healthcare demand, 2828. Martins RC, Reis CM, Matta Machado AT, Amaral JH, Werneck MA, Abreu MH. Relationship between Primary and secondary dental care in Public Health Services in Brazil. PLoS One. 2016 Oct;11(10):e0164986. https://doi.org/10.1371/journal.pone.0164986
https://doi.org/10.1371/journal.pone.016...
but especially for supporting PHC, given that the Midwest has one of the worst oral health indices. 1212. Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Secretaria de Vigilância em Saúde. Pesquisa nacional de saúde bucal: resultados principais. Brasília, DF: Ministério da Saúde; 2012 [cited 2020 Nov 26]. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/pesquisa_nacional_saude_bucal.pdf
https://bvsms.saude.gov.br/bvs/publicaco...

The Northeast had the third highest demand for teleconsulting. This ranking position might have resulted from its better PHC coverage 2727. Ministério da Saúde (BR). Secretaria de Atenção Primária à Saúde. Cobertura de saúde bucal. Brasília, DF: Ministério da Saúde; 2020 [cited 2020 Jun 23]. Available from: https://egestorab.saude.gov.br/paginas/acessoPublico/relatorios/relHistoricoCoberturaSB.xhtml
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, providing the population with better support. However, this region has the second most significant population, with the lowest socioeconomic status 2323. Brazil. Pnud Brazil, Ipea e FJP. Atlas do desenvolvimento humano no Brasil. Brasília, DF; 2020 [cited 2020 Oct 22]. Available from: http://www.atlasbrasil.org.br/ranking
http://www.atlasbrasil.org.br/ranking...
and the highest amount of social inequalities. 2525. Instituto Brasileiro de Geografia e Estatística. Brasil. Panorama. Brasília, DF: Instituto Brasileiro de Geografia e Estatística; 2019 [cited 2020 Jun 19]. Available from: https://cidades.ibge.gov.br/brasil/panorama
https://cidades.ibge.gov.br/brasil/panor...
Moreover, despite the better DSC coverage 2626. Ministério da Saúde (BR). Secretaria de Atenção Primária à Saúde. Cidades atendidas com laboratórios regionais de prótese dentária. Brasília, DF; 2021 [cited 2021 Feb 17]. Available from: http://aps.saude.gov.br/ape/brasilsorridente/cidadesatendidas
http://aps.saude.gov.br/ape/brasilsorrid...
, Northeasterners have limited access of OHTs to DSC 2828. Martins RC, Reis CM, Matta Machado AT, Amaral JH, Werneck MA, Abreu MH. Relationship between Primary and secondary dental care in Public Health Services in Brazil. PLoS One. 2016 Oct;11(10):e0164986. https://doi.org/10.1371/journal.pone.0164986
https://doi.org/10.1371/journal.pone.016...
and one of the greatest needs for restorations, endodontic treatments, and tooth extractions. 1212. Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Secretaria de Vigilância em Saúde. Pesquisa nacional de saúde bucal: resultados principais. Brasília, DF: Ministério da Saúde; 2012 [cited 2020 Nov 26]. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/pesquisa_nacional_saude_bucal.pdf
https://bvsms.saude.gov.br/bvs/publicaco...
Accordingly, teleconsulting could help solve PHC problems, as patients at health units where the referral of more complex cases is difficult have to be assisted in the PHC setting.

The South had the best socioeconomic indices and the second lowest demand for teleconsulting. This might be due to the better oral health epidemiological characteristics of its population and the greater demand by teenagers, adults, and seniors for preventive oral health consultations. 1212. Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Secretaria de Vigilância em Saúde. Pesquisa nacional de saúde bucal: resultados principais. Brasília, DF: Ministério da Saúde; 2012 [cited 2020 Nov 26]. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/pesquisa_nacional_saude_bucal.pdf
https://bvsms.saude.gov.br/bvs/publicaco...
This could result in fewer complex treatments (e.g., restorations, endodontic treatments, and surgeries). 1212. Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Secretaria de Vigilância em Saúde. Pesquisa nacional de saúde bucal: resultados principais. Brasília, DF: Ministério da Saúde; 2012 [cited 2020 Nov 26]. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/pesquisa_nacional_saude_bucal.pdf
https://bvsms.saude.gov.br/bvs/publicaco...
Thus, if the population requires less complex procedures and diagnosis, PHC dentists will probably have fewer concerns.

The North had the lowest demand for teleconsulting, with huge socioeconomic challenges just as the Northeast. 2828. Martins RC, Reis CM, Matta Machado AT, Amaral JH, Werneck MA, Abreu MH. Relationship between Primary and secondary dental care in Public Health Services in Brazil. PLoS One. 2016 Oct;11(10):e0164986. https://doi.org/10.1371/journal.pone.0164986
https://doi.org/10.1371/journal.pone.016...
The population from the northern states, just as that of the Northeast and Midwest, have worse oral health status and require more complex treatments. 1212. Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Secretaria de Vigilância em Saúde. Pesquisa nacional de saúde bucal: resultados principais. Brasília, DF: Ministério da Saúde; 2012 [cited 2020 Nov 26]. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/pesquisa_nacional_saude_bucal.pdf
https://bvsms.saude.gov.br/bvs/publicaco...
Also, the North has the lowest DSC coverage, 2626. Ministério da Saúde (BR). Secretaria de Atenção Primária à Saúde. Cidades atendidas com laboratórios regionais de prótese dentária. Brasília, DF; 2021 [cited 2021 Feb 17]. Available from: http://aps.saude.gov.br/ape/brasilsorridente/cidadesatendidas
http://aps.saude.gov.br/ape/brasilsorrid...
suggesting a lack of support for secondary healthcare. Teleconsulting could provide this support by assisting in the decision to treat patients in the PHC setting or refer them to other services. 1414. Conselho Federal de Odontologia. Resolução nº 226, de 4 de junho de 2020. Dispõe sobre o exercício da Odontologia a distância, mediado por tecnologias, e dá outras providências.. Brasília, DF: Conselho Federal de Odontologia; 2020. , 2020. Ministério da Saúde (BR). Telehealth: technology for the health care benefit. Brasília, DF: Ministério da Saúde; 2018 [cited 2018 April 28]. Available from: https://smart.telessaude.ufrn.br/
https://smart.telessaude.ufrn.br/...
Telehealth is likely to be underused in this region and should be stimulated to improve the healthcare of the population.

Eliminating regional differences in access to dental care is a daunting challenge. Integrated care is considered to provide higher-quality and more cost-effective care 2828. Martins RC, Reis CM, Matta Machado AT, Amaral JH, Werneck MA, Abreu MH. Relationship between Primary and secondary dental care in Public Health Services in Brazil. PLoS One. 2016 Oct;11(10):e0164986. https://doi.org/10.1371/journal.pone.0164986
https://doi.org/10.1371/journal.pone.016...
, 2929. Amorim LP, Senna MI, Alencar GP, Rodrigues LG, Paula JS, Ferreira RC. Public oral health services performance in Brazil: influence of the work process and service structure. PLoS One. 2020 May;15(5):e0233604. https://doi.org/10.1371/journal.pone.0233604
https://doi.org/10.1371/journal.pone.023...
and is often related to characteristics embraced by telehealth such as integrated ICTs, population-focused care, professional development, and innovation. 2828. Martins RC, Reis CM, Matta Machado AT, Amaral JH, Werneck MA, Abreu MH. Relationship between Primary and secondary dental care in Public Health Services in Brazil. PLoS One. 2016 Oct;11(10):e0164986. https://doi.org/10.1371/journal.pone.0164986
https://doi.org/10.1371/journal.pone.016...
The importance of telehealth has also been reported for rural America, where increased provision of high-quality telehealth services may minimize disparities and enhance the connection between clinicians. 3030. National Quality Forum. Rural Telehealth and Healthcare System Readiness Measurement Framework: Final Report. 2021 [cited 2021 Dez 04]. Washington, DC: National Quality Forum; 2021 [cited 2021 Dez 4]. Available from: https://www.qualityforum.org/Publications/2021/11/Rural_Telehealth_and_Healthcare_System_Readiness_Measurement_Framework_-_Final_Report.aspx
https://www.qualityforum.org/Publication...

The primary demand for teleconsulting in all Brazilian regions was from female dentists, as observed elsewhere, 1515. Rezende EJ, Tavares EC, Alves HJ, Santos AF, de Melo MC. Teleconsultations in public primary care units of the city of belo horizonte, Brazil: profile of patients and physicians. Telemed J E Health. 2013 Aug;19(8):613-8. https://doi.org/10.1089/tmj.2012.0179
https://doi.org/10.1089/tmj.2012.0179...
, 1616. Paixão LC, Costa VA, Ferreira EF, Ribeiro Sobrinho AP, Martins RC. Analysis of the asynchronous dental teleconsulting of Telehealth Brazil Networks in Minas Gerais. Braz Oral Res. 2018 Dec;32(128):e128. https://doi.org/10.1590/1807-3107bor-2018.vol32.0128
https://doi.org/10.1590/1807-3107bor-201...
, 3131. Alkmim MB, Marcolino MS, Figueira RM, Sousa L, Nunes MS, Cardoso CS, et al. Factors associated with the use of a teleconsultation system in Brazilian primary care. Telemed J E Health. 2015 Jun;21(6):473-83. https://doi.org/10.1089/tmj.2014.0112
https://doi.org/10.1089/tmj.2014.0112...
and that may reflect the higher prevalence of females in healthcare services, 1515. Rezende EJ, Tavares EC, Alves HJ, Santos AF, de Melo MC. Teleconsultations in public primary care units of the city of belo horizonte, Brazil: profile of patients and physicians. Telemed J E Health. 2013 Aug;19(8):613-8. https://doi.org/10.1089/tmj.2012.0179
https://doi.org/10.1089/tmj.2012.0179...
, 1717. Bavaresco CS, Hauser L, Haddad AE, Harzheim E. Impact of teleconsultations on the conduct of oral health teams in the Telehealth Brazil Networks Programme. Braz Oral Res. 2020 Feb;34 e011:e011. https://doi.org/10.1590/1807-3107bor-2020.vol34.0011
https://doi.org/10.1590/1807-3107bor-202...
their greater adherence to the Program, or a more significant concern with women’s professional conduct. 1616. Paixão LC, Costa VA, Ferreira EF, Ribeiro Sobrinho AP, Martins RC. Analysis of the asynchronous dental teleconsulting of Telehealth Brazil Networks in Minas Gerais. Braz Oral Res. 2018 Dec;32(128):e128. https://doi.org/10.1590/1807-3107bor-2018.vol32.0128
https://doi.org/10.1590/1807-3107bor-201...
The primary demand from FHS dental surgeons and general dental practitioners was expected thanks to the Brazilian PHC profile.

According to the SMART, teleconsulting is the second most offered service by telehealth centers, and asynchronous activities are used mainly by PHC professionals, 1919. Oliveira TC, Oliveira Junior JG, Tavares G, Rigato AFG, Pereira FWA, Carvalho FFB. The National Program Telehealth Brazil Networks: a historic and situational perspective. Latin Am J Telehealth. 2017 Ago;4(2):104-13. probably because of the convenient time schedule. 1515. Rezende EJ, Tavares EC, Alves HJ, Santos AF, de Melo MC. Teleconsultations in public primary care units of the city of belo horizonte, Brazil: profile of patients and physicians. Telemed J E Health. 2013 Aug;19(8):613-8. https://doi.org/10.1089/tmj.2012.0179
https://doi.org/10.1089/tmj.2012.0179...
While most teleconsulting sessions took place during working hours (South: 92.3%, Northeast: 88.0%, Southeast: 84.5%, Midwest: 83.4%, and North: 72.7%), 14.8% were requested after hours. As observed earlier, 1616. Paixão LC, Costa VA, Ferreira EF, Ribeiro Sobrinho AP, Martins RC. Analysis of the asynchronous dental teleconsulting of Telehealth Brazil Networks in Minas Gerais. Braz Oral Res. 2018 Dec;32(128):e128. https://doi.org/10.1590/1807-3107bor-2018.vol32.0128
https://doi.org/10.1590/1807-3107bor-201...
, 3232. Marcolino MS, Alkmim MB, Assis TG, Sousa LA, Ribeiro AL. [Telehealth support for primary health care in remote municipalities in the state of Minas Gerais, Brazil]. Rev Panam Salud Publica. 2014 May-Jun;35(5-6):345-52. Portuguese. some questions were submitted at night, suggesting professionals incorporated asynchronous teleconsulting into their routines. 3232. Marcolino MS, Alkmim MB, Assis TG, Sousa LA, Ribeiro AL. [Telehealth support for primary health care in remote municipalities in the state of Minas Gerais, Brazil]. Rev Panam Salud Publica. 2014 May-Jun;35(5-6):345-52. Portuguese. However, this raises some concern because, outside working hours, professionals have other obligations to attend to and may forget or not have enough time for teleconsulting, and, therefore, their needs are eventually underreported. Evening requests may have occurred due to connectivity failures or difficulty accessing the platform during working hours because of work overload. 1515. Rezende EJ, Tavares EC, Alves HJ, Santos AF, de Melo MC. Teleconsultations in public primary care units of the city of belo horizonte, Brazil: profile of patients and physicians. Telemed J E Health. 2013 Aug;19(8):613-8. https://doi.org/10.1089/tmj.2012.0179
https://doi.org/10.1089/tmj.2012.0179...

Another possible reason may be that some managers do not allow access to the platform during working hours for streamlining professional production. Services should facilitate health professionals’ access to the telehealth platform as a work routine, 1515. Rezende EJ, Tavares EC, Alves HJ, Santos AF, de Melo MC. Teleconsultations in public primary care units of the city of belo horizonte, Brazil: profile of patients and physicians. Telemed J E Health. 2013 Aug;19(8):613-8. https://doi.org/10.1089/tmj.2012.0179
https://doi.org/10.1089/tmj.2012.0179...
and the government should improve the training of telehealth professionals to achieve more efficient PHC.

Most teleconsulting questions were answered within 72 h, showing telehealth centers reply within the stipulated time. 33. Ministério da Saúde (BR). Nota técnica nº 50/2015-DEGES/SGTES/MS. Diretrizes para oferta de atividades do Programa Nacional Telesaúde Brasil Redes. Brasília, DF: Ministry of Health; 2015 [cited 2016 Nov 21]. Available from: http://189.28.128.100/dab/docs/portaldab/notas_tecnicas/Nota_Tecnica_Diretrizes_Telessaude.pdf
http://189.28.128.100/dab/docs/portaldab...
However, 33.2% of the requests were answered after 72 h, raising a concern, since it may compromise patient’s assistance. In the Northeast and North, telehealth centers answered the questions within the stipulated time (86.8% and 81.8%, respectively), while in the Midwest, this rate was lower (53.1%). It is important to enhance the commitment of teleconsultants on providing PHC professionals with feedback.

Although most professionals answered the question about their satisfaction with the service, 46.7% did not, which limited the study and hindered the evaluation process. 1717. Bavaresco CS, Hauser L, Haddad AE, Harzheim E. Impact of teleconsultations on the conduct of oral health teams in the Telehealth Brazil Networks Programme. Braz Oral Res. 2020 Feb;34 e011:e011. https://doi.org/10.1590/1807-3107bor-2020.vol34.0011
https://doi.org/10.1590/1807-3107bor-202...
This low response rate occurred in the Southeast, South, and Northeast regions (36.9% and 42.5%). The Midwest and North presented higher response rates (95.0% and 81.8%, respectively). Among the professionals who answered that question, almost all reported being very satisfied or satisfied. Satisfaction with the teleconsulting service has also been reported in previous studies 1616. Paixão LC, Costa VA, Ferreira EF, Ribeiro Sobrinho AP, Martins RC. Analysis of the asynchronous dental teleconsulting of Telehealth Brazil Networks in Minas Gerais. Braz Oral Res. 2018 Dec;32(128):e128. https://doi.org/10.1590/1807-3107bor-2018.vol32.0128
https://doi.org/10.1590/1807-3107bor-201...
, 1717. Bavaresco CS, Hauser L, Haddad AE, Harzheim E. Impact of teleconsultations on the conduct of oral health teams in the Telehealth Brazil Networks Programme. Braz Oral Res. 2020 Feb;34 e011:e011. https://doi.org/10.1590/1807-3107bor-2020.vol34.0011
https://doi.org/10.1590/1807-3107bor-202...
, 3131. Alkmim MB, Marcolino MS, Figueira RM, Sousa L, Nunes MS, Cardoso CS, et al. Factors associated with the use of a teleconsultation system in Brazilian primary care. Telemed J E Health. 2015 Jun;21(6):473-83. https://doi.org/10.1089/tmj.2014.0112
https://doi.org/10.1089/tmj.2014.0112...
and points to the importance of telehealth in assisting PHC professionals. The ability of teleconsulting to help solve daily problems is related to greater utilization of the system 3131. Alkmim MB, Marcolino MS, Figueira RM, Sousa L, Nunes MS, Cardoso CS, et al. Factors associated with the use of a teleconsultation system in Brazilian primary care. Telemed J E Health. 2015 Jun;21(6):473-83. https://doi.org/10.1089/tmj.2014.0112
https://doi.org/10.1089/tmj.2014.0112...
, thus underscoring the importance of feedback from professionals 1616. Paixão LC, Costa VA, Ferreira EF, Ribeiro Sobrinho AP, Martins RC. Analysis of the asynchronous dental teleconsulting of Telehealth Brazil Networks in Minas Gerais. Braz Oral Res. 2018 Dec;32(128):e128. https://doi.org/10.1590/1807-3107bor-2018.vol32.0128
https://doi.org/10.1590/1807-3107bor-201...
, 1717. Bavaresco CS, Hauser L, Haddad AE, Harzheim E. Impact of teleconsultations on the conduct of oral health teams in the Telehealth Brazil Networks Programme. Braz Oral Res. 2020 Feb;34 e011:e011. https://doi.org/10.1590/1807-3107bor-2020.vol34.0011
https://doi.org/10.1590/1807-3107bor-202...
to render the program more effective. 3333. Ellimoottil C, An L, Moyer M, Sossong S, Hollander JE. Challenges and opportunities faced by large health systems implementing telehealth. Health Aff (Millwood). 2018 Dec;37(12):1955-9. https://doi.org/10.1377/hlthaff.2018.05099
https://doi.org/10.1377/hlthaff.2018.050...

Regarding patient referral to other care levels, the response rate was a little higher, and 66.8% of the professionals who answered that question said teleconsulting avoided patient referral. The South and Southeast exhibited, once again, the lowest response rates (66.7% and 49.1%, respectively). The highest response rates were obtained from the Midwest and South (98.3% and 84.8%, respectively), whereas the Southeast had the highest rate (57.6%) relative to not avoiding patient referral. Various studies have suggested the efficacy of telehealth in avoiding unnecessary patient referral to secondary and tertiary care 1515. Rezende EJ, Tavares EC, Alves HJ, Santos AF, de Melo MC. Teleconsultations in public primary care units of the city of belo horizonte, Brazil: profile of patients and physicians. Telemed J E Health. 2013 Aug;19(8):613-8. https://doi.org/10.1089/tmj.2012.0179
https://doi.org/10.1089/tmj.2012.0179...

16. Paixão LC, Costa VA, Ferreira EF, Ribeiro Sobrinho AP, Martins RC. Analysis of the asynchronous dental teleconsulting of Telehealth Brazil Networks in Minas Gerais. Braz Oral Res. 2018 Dec;32(128):e128. https://doi.org/10.1590/1807-3107bor-2018.vol32.0128
https://doi.org/10.1590/1807-3107bor-201...
- 1717. Bavaresco CS, Hauser L, Haddad AE, Harzheim E. Impact of teleconsultations on the conduct of oral health teams in the Telehealth Brazil Networks Programme. Braz Oral Res. 2020 Feb;34 e011:e011. https://doi.org/10.1590/1807-3107bor-2020.vol34.0011
https://doi.org/10.1590/1807-3107bor-202...
, 3131. Alkmim MB, Marcolino MS, Figueira RM, Sousa L, Nunes MS, Cardoso CS, et al. Factors associated with the use of a teleconsultation system in Brazilian primary care. Telemed J E Health. 2015 Jun;21(6):473-83. https://doi.org/10.1089/tmj.2014.0112
https://doi.org/10.1089/tmj.2014.0112...
, 3232. Marcolino MS, Alkmim MB, Assis TG, Sousa LA, Ribeiro AL. [Telehealth support for primary health care in remote municipalities in the state of Minas Gerais, Brazil]. Rev Panam Salud Publica. 2014 May-Jun;35(5-6):345-52. Portuguese. and in increasing PHC effectiveness. 1717. Bavaresco CS, Hauser L, Haddad AE, Harzheim E. Impact of teleconsultations on the conduct of oral health teams in the Telehealth Brazil Networks Programme. Braz Oral Res. 2020 Feb;34 e011:e011. https://doi.org/10.1590/1807-3107bor-2020.vol34.0011
https://doi.org/10.1590/1807-3107bor-202...
Telehealth can be used as a supporting tool for the referral and counterreferral systems, integrating them. Again, feedback from professionals is fundamental for the evaluation of the Program in the PHC setting. 1616. Paixão LC, Costa VA, Ferreira EF, Ribeiro Sobrinho AP, Martins RC. Analysis of the asynchronous dental teleconsulting of Telehealth Brazil Networks in Minas Gerais. Braz Oral Res. 2018 Dec;32(128):e128. https://doi.org/10.1590/1807-3107bor-2018.vol32.0128
https://doi.org/10.1590/1807-3107bor-201...
The perception of the usefulness of telehealth is related to the fulfillment of users’ needs, being extremely important for program planning and for incorporation of teleconsulting into daily practice. 3131. Alkmim MB, Marcolino MS, Figueira RM, Sousa L, Nunes MS, Cardoso CS, et al. Factors associated with the use of a teleconsultation system in Brazilian primary care. Telemed J E Health. 2015 Jun;21(6):473-83. https://doi.org/10.1089/tmj.2014.0112
https://doi.org/10.1089/tmj.2014.0112...

The higher demand for semiology (Southeast: 55.4%) and clinical dentistry (Midwest: 55.8%, South: 44.9%, and Northeast: 27.9%) issues was expected since they are constantly present in PHC. The highest demand for issues related to semiology indicated some difficulty of professionals in diagnosing and managing patients with systemic disorders. Endodontics, minor oral surgery, and periodontics are constantly present in the daily practice of Brazilian PHC and are an integral part of clinical dentistry. They are the most common specialties that require referral to DSCs. 2828. Martins RC, Reis CM, Matta Machado AT, Amaral JH, Werneck MA, Abreu MH. Relationship between Primary and secondary dental care in Public Health Services in Brazil. PLoS One. 2016 Oct;11(10):e0164986. https://doi.org/10.1371/journal.pone.0164986
https://doi.org/10.1371/journal.pone.016...
In this context, the support provided by teleconsulting may reduce unnecessary referrals and shorten the waiting time for secondary care. 2828. Martins RC, Reis CM, Matta Machado AT, Amaral JH, Werneck MA, Abreu MH. Relationship between Primary and secondary dental care in Public Health Services in Brazil. PLoS One. 2016 Oct;11(10):e0164986. https://doi.org/10.1371/journal.pone.0164986
https://doi.org/10.1371/journal.pone.016...
Also, teledentistry could improve dental care through diagnostic collaboration between dental professionals. 55. Alabdullah JH, Daniel SJ. A systematic review on the validity of teledentistry. Telemed J E Health. 2018 Aug;24(8):639-48. https://doi.org/10.1089/tmj.2017.0132
https://doi.org/10.1089/tmj.2017.0132...
In the northern region, stomatology issues accounted for the highest demand (55.0%). This higher demand for stomatology issues has also been observed in other studies 1616. Paixão LC, Costa VA, Ferreira EF, Ribeiro Sobrinho AP, Martins RC. Analysis of the asynchronous dental teleconsulting of Telehealth Brazil Networks in Minas Gerais. Braz Oral Res. 2018 Dec;32(128):e128. https://doi.org/10.1590/1807-3107bor-2018.vol32.0128
https://doi.org/10.1590/1807-3107bor-201...
- 1717. Bavaresco CS, Hauser L, Haddad AE, Harzheim E. Impact of teleconsultations on the conduct of oral health teams in the Telehealth Brazil Networks Programme. Braz Oral Res. 2020 Feb;34 e011:e011. https://doi.org/10.1590/1807-3107bor-2020.vol34.0011
https://doi.org/10.1590/1807-3107bor-202...
and may reveal the difficulty of PHC professionals in identifying and diagnosing oral lesions.

Accessing telehealth services is associated with better-quality health care 3434. Santos AF, Fonseca Sobrinho D, Araujo LL, Procópio CD, Lopes EA, Lima AM, et al. [Incorporation of information and communication technologies and quality of primary healthcare in Brazil]. Cad Saude Publica. 2017 Jun;33(5):e00172815. Portuguese. https://doi.org/10.1590/0102-311x00172815
https://doi.org/10.1590/0102-311x0017281...
and could increase the problem-solving capacity of the OHT. 2929. Amorim LP, Senna MI, Alencar GP, Rodrigues LG, Paula JS, Ferreira RC. Public oral health services performance in Brazil: influence of the work process and service structure. PLoS One. 2020 May;15(5):e0233604. https://doi.org/10.1371/journal.pone.0233604
https://doi.org/10.1371/journal.pone.023...
Nevertheless, a low rate of utilization of teledentistry services has been observed. 1717. Bavaresco CS, Hauser L, Haddad AE, Harzheim E. Impact of teleconsultations on the conduct of oral health teams in the Telehealth Brazil Networks Programme. Braz Oral Res. 2020 Feb;34 e011:e011. https://doi.org/10.1590/1807-3107bor-2020.vol34.0011
https://doi.org/10.1590/1807-3107bor-202...
Factors such as service infrastructure, difficult access to computers, and internet speed and connection, 1919. Oliveira TC, Oliveira Junior JG, Tavares G, Rigato AFG, Pereira FWA, Carvalho FFB. The National Program Telehealth Brazil Networks: a historic and situational perspective. Latin Am J Telehealth. 2017 Ago;4(2):104-13. , 3535. Souza CH, Morbeck RA, Steinman M, Hors CP, Bracco MM, Kozasa EH, et al. Barriers and benefits in telemedicine arising between a high-technology hospital service provider and remote public healthcare units: a qualitative study in Brazil. Telemed J E Health. 2017 Jun;23(6):527-32. https://doi.org/10.1089/tmj.2016.0158
https://doi.org/10.1089/tmj.2016.0158...
, 3636. Santos AF, Mata-Machado AT, Melo MD, Fonseca Sobrinho D, Araújo LL, Silva ÉA, et al. Implementation of telehealth resources in primary health care in Brazil and its association with quality of care. Telemed J E Health. 2019 Oct;25(10):996-1004. https://doi.org/10.1089/tmj.2018.0166
https://doi.org/10.1089/tmj.2018.0166...
experience in the use of technology, 3535. Souza CH, Morbeck RA, Steinman M, Hors CP, Bracco MM, Kozasa EH, et al. Barriers and benefits in telemedicine arising between a high-technology hospital service provider and remote public healthcare units: a qualitative study in Brazil. Telemed J E Health. 2017 Jun;23(6):527-32. https://doi.org/10.1089/tmj.2016.0158
https://doi.org/10.1089/tmj.2016.0158...
and high turnover of PHC professionals 2020. Ministério da Saúde (BR). Telehealth: technology for the health care benefit. Brasília, DF: Ministério da Saúde; 2018 [cited 2018 April 28]. Available from: https://smart.telessaude.ufrn.br/
https://smart.telessaude.ufrn.br/...
can influence the adherence to the Program.

Data from the SMART secondary databases were a limitation of this study, as the information depends on the PHC professionals and telehealth centers. SMART is still underused by many telehealth centers, hindering the evaluation of the Program’s impact in Brazil. 1919. Oliveira TC, Oliveira Junior JG, Tavares G, Rigato AFG, Pereira FWA, Carvalho FFB. The National Program Telehealth Brazil Networks: a historic and situational perspective. Latin Am J Telehealth. 2017 Ago;4(2):104-13. Integrating information systems 1919. Oliveira TC, Oliveira Junior JG, Tavares G, Rigato AFG, Pereira FWA, Carvalho FFB. The National Program Telehealth Brazil Networks: a historic and situational perspective. Latin Am J Telehealth. 2017 Ago;4(2):104-13. and encouraging professionals are challenges to be overcome.

Conclusions

Regions had different demands because of regional differences. The specialties that most demanded teleconsulting reflect the Brazilian PHC profile. Professionals incorporated teleconsulting into their work routine and most teleconsultants responded within the stipulated time. Feedback from professionals should be encouraged. The professionals’ input and SMART use could help understand the impact of teleconsulting on the PHC support system.

Ackwnoledgments

We would like to express our thanks to the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES 001), Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Fundação de Amparo à Pesquisa do Estado de Minas Gerais (FAPEMIG), Pró-Reitoria de Pesquisa da Universidade Federal de Minas Gerais (PRPq-UFMG), Brazilian Ministry of Health, and Coordenação Geral de Política e Inovação em Saúde Digital (CGPIN). APRS thanks CNPq for the fellowship grant.

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Publication Dates

  • Publication in this collection
    08 Aug 2022
  • Date of issue
    2022

History

  • Received
    24 Sept 2021
  • Reviewed
    2 May 2022
  • Accepted
    16 May 2022
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