Advocacy for a Digital Oral Health That Leaves No One Behind

The health, social, and economic consequences of the coronavirus disease 2019 (COVID-19) pandemic have already had a dramatic impact on the prevailing oral health care model and will continue to do so. This model, which all too often functions in isolation from the general health care system, relies on advanced technologies and is centered on dentistry as an independent health profession. According to Richard Watt (2020) in The Lancet, this dentist-centered model will require a profound reform to make it more efficient and capable of meeting people’s needs.

COVID-19 is forcing a paradigm shift at an accelerated pace. For example, it has now become essential to adopt more efficient infection prevention and control measures and to optimize the time spent by patients in dental services. Digital health, rightly presented as one of the solutions to the crisis, must be deployed more systematically and cover different dimensions of population health and patient care such as oral health promotion, prevention, diagnosis, surveillance, and treatment of oral diseases, as well as training of health providers, but not limited to them.

During the first wave of the pandemic, the lockdown enforced led to considerable disruption to the activities of dental services, even leading to closures (World Health Organization [WHO] 2020a). To mitigate the impact of the lockdowns, systems were quickly put in place in most countries to respond to dental emergencies, giving priority to distance screening, advice to patients by remote means, and treatment of urgent cases while ensuring continuous care. Digital health was widely adopted as a central component of this new approach, leading to new practices and tools, which in turn demonstrated it potential, limitations, and possible excesses.

In their daily interactions during the lockdowns, patients and oral health professionals adopted a range of communication tools, including videoconferencing and mobile applications, text messaging, telephone calls, and so on. The purpose of these tools was to maintain a link between patients in need of advice and care and oral health professionals, as well as to respond to urgent situations by remotely issuing prescriptions, for example. Gradually, however, new practices that are more business oriented and lacking a public health care approach have emerged. Private platforms for “oral consultation” via videoconferencing are one example of these new practices.

In this peculiar new world where webinars are replacing seminars, smartphone applications are thriving, and telehealth services are multiplying in all parts of the world, it has become critical to establish and/or reinforce digital health governance and to define norms and standards for digital oral health based on best practice and scientific evidence.

The Seventy-First World Health Assembly (2018) approved resolution WHA71.7 on digital health (WHO 2018). In this resolution, member states were urged to become involved in actions at the regional and national levels to foster the development of digital health, including “working towards interoperability of digital technologies for health.” The resolution also urged the director-general of WHO to adopt various measures to facilitate the development of digital health, including the creation of a digital health and innovation department and the elaboration of a global strategy on digital health for the 2020–2025 period. This strategy, whose aim is to reinforce the governance of digital health at the national level and to improve the development of national strategies on digital health (WHO 2020b), has now been launched.

More recently, the 74th World Health Assembly adopted on May 31, 2021, a comprehensive resolution on oral health (WHO 2021). The resolution requests the WHO director general to develop a global strategy to tackle oral diseases by 2022 and to further translate this strategy into a global action plan by 2023 in considering the use of provisions that modern digital technology provides in the field of telemedicine and teledentistry.

All those involved in digital health, including operators in the field and high-level decision makers, agree that now is the time to act decisively to break down barriers. Several barriers have been already identified all over the world considering domestic specificities: fears over data protection, licensure issue, patient liability, insurance coverage for telehealth appointments, ethical concerns, and adaptation of dental practices to embrace telehealth. The idea shared by multiple experts in the digital health field is to move forward toward safe and universal access and use of digital health.

The use of digital health necessarily leads to a new way of understanding health in general and oral health more specifically. “We must ensure that the digital health revolution is safe, sustainable and leaves no one behind,” stated Bernardo Mariano Jr., director of Digital Health & Innovation at WHO, at the launch of the new directorate he was heading. The global oral health community must address these issues before solutions are enforced or imposed by other sectors. Digital health should be global public goods for health made available to health care professionals to improve, first and foremost, the health of the most vulnerable members of society, who are often excluded from the dominant oral health care system.

Digital tools must be made accessible to everyone, everywhere, to contribute to empower people and communities through health literacy and improve the skills of health professionals by means of e-training. The mOralHealth program, led by the WHO oral health program and that is part of the “Be He@lthy Be Mobile” initiative, reflects this dynamic. The program aims to contribute to the achievement of better oral health as part of the 2030 Sustainable Development Agenda, including universal health coverage, as well as to tackle the burden of noncommunicable diseases. More specifically, its objective is to enable countries to include digital oral health in their health policy and implement programs and interventions aimed at health workers and at the population at large. The mOralHealth program is structured in 4 modules. These modules are designed as flexible components, which can be implemented individually or collectively, according to a country’s specific needs. Similarly, the mOralHealth program can also be implemented as a stand-alone intervention to improve oral health or integrated into existing initiatives targeting other noncommunicable diseases. The first module (the mOralHealth literacy module) aims to improve oral health literacy of individuals and communities, as well as oral health awareness and advocacy among policy and decision makers, the media, and civil society organizations. A practical example of the type of activity that can be implemented is the dissemination of oral health information using short text messages. While not everyone has access to running water or electricity, the mobile phone market penetration globally (WHO 2021) means that almost anyone can now be reached via text messaging. The second module (mOralHealth training module) aims to encourage the employment of mobile technologies for training approaches to enhance knowledge and skills of general health professionals as well as raise awareness on the global oral health agenda and prioritize oral health interventions among health professionals. The third module (mOralHealth early detection module) provides information on the potential, as well as helpful considerations, for using remote diagnostics tools, which are increasingly being used to facilitate access to and quality of health care services. Last, the fourth module (the mOralHealth surveillance module) aims to use mobile technology in the context of strengthening oral health surveillance systems and collection of epidemiological data, as well as monitoring of quality patient care and service delivery. A handbook will be published soon to help policy makers and stakeholders to develop digital oral health policies and to get the more relevant information on how to implement the mOralHealth program (World Health Organization and International Telecommunication Union 2019).

Political leaders must become aware of the universal availability of digital technology and make use of it as an additional, safe means of providing services to the public. In view of the multiple uses of digital technologies in health—health literacy, teaching, prevention, early detection, therapeutics, and public health policies—deployment of a comprehensive program of digital oral health will require the adoption of a multifaceted approach:

Digital oral health should focus on promoting oral health and preventing oral illnesses and on reaching as many people as possible, especially the most fragile population groups. Deployment strategies should take into consideration accessibility and skills requirements to be usable by most of the population.

Teachers and students in dental schools should be able to improve their understanding of digital oral health and its impact on their daily practice and public health in general. Courses on this subject must be available in digital format as an extension and/or a replacement of traditional in-person classes during exceptional times—like the current pandemic, thus becoming accessible to as many as possible. It will be essential that oral health professionals be more open to the new technologies and processes to avoid the creation of a generational gap. The next generation of oral health professionals should be able to evaluate the clinical, regulation, and public health aspects of a digital oral health tool to use it in their daily practices.

Digital oral health has the potential to improve early detection of oral pathologies, facilitate referral and access to oral health care professionals, optimize health care processes, prioritize treatments, and support guidance for patients with fatal pathologies such as noma and oral cancer. Its growth would benefit from a strong legislative framework. All sectors of dentistry would also gain from substantial research and development investments in artificial intelligence (AI), including improving health care policies by analyzing public health data.

At present, specialized digital technologies such as digital impression, intraoral sensors, 3-dimensional scanning, and printing are widely used in highly specialized dental services that are not available to the majority because of their cost and complexity. Only an intersectoral approach associating engineering, researchers, health care professionals, and policy makers could lead to the development of innovative technical solutions that benefit all.

It has been said that data are the new oil of the 21st century (Arthur 2013). Digital technologies collect and use huge quantities of data that may be personal and highly sensitive, which raises several ethical issues. Correctly managed, use of that data can lead to highly optimized health care, where prevention, treatments, and follow-up are tailored to the health condition and needs of a population, community, or even an individual. Misuse may lead to all forms of exploitation and even data colonialism (Couldry and Mejias 2019a, 2019b). Reaching a balance between access and protection of health data is a crucial issue that remains to be solved in most countries.

Digital tools should be designed to reduce, not increase, inequalities in access to health care. It offers an opportunity to improve healthy behavior, lower risk factors common to oral diseases and other noncommunicable diseases, and contribute to reducing oral health inequalities. It can accelerate the implementation of universal health coverage and help achieve the 2030 Sustainable Development Agenda for sustainable development, leaving no one behind. Digital oral health should be one of the pillars of oral health care after COVID-19. Universal access to digital oral health should be promoted globally. The WHO’s mOralHealth program aims to do that.

Author Contributions

N. Giraudeau, contributed to conception and design, drafted the manuscript; B. Varenne, contributed to conception and design, critically revised the manuscript. Both authors gave final approval and agree to be accountable for all aspects of the work.