IS EASIER WITH TELEDENTISTRY

Sažetak Uvod. Imperativ globalnog društva je promena. Najefikasniji način da savremeni čovek bude „u korak“ sa svakodnevnim promenama jeste primena informaciono-komunikacionih tehnologija. Ekspanzija i razvoj informatičke i telekomunikacione tehnologije brzo su pronašle primenu u sistemu zdravstvene zaštite unapređujući samu zdravstvenu praksu. Medicinska informatika sa svojom specifičnom podgranom – stomatološkom informatikom, bavi se razvojem, primenom i evaluacijom informacionih tehnologija u medicini i stomatologiji, tj. rešavanjem problema koji su u vezi sa informacijama i komunikacijom u zdravstvenoj zaštiti. Internet predstavlja najveću globalnu mrežu i sve više se koristi u medicini i stomatologiji. Korišćenje Interneta i drugih telekomunikacionih metoda omogućava nam da lakše održimo korak sa kontinuiranim širenjem baze znanja. Celokupna informaciona tehnologija je prepoznata kao sastavni deo zdravstvene zaštite i važan činilac dobre kliničke prakse, što je rezultiralo nastankom telemedicine, telestomatologije i telefarmakologije. Telemedicina predstavlja način da se uz korišćenje savremenih sistema komunikacije omogući prenos medicinskih podataka, čime se medicinske usluge mogu pružati bez obzira na fizičku lokaciju lekara i pacijenta. Zaključak. Telestomatologija je kombinacija telekomunikacije i stomatologije, uključuje razmenu kliničkih informacija i slika preko velikih razdaljina zbog specijalističkih stomatoloških konsultacija, postavljanja dijagnoze i planiranja terapije. Stubovi moderne telestomatologije su primena Interneta i brzog protoka informacija. Ključne reči: stomatologija, medicinska informatika, telemedicina, telestomatologija

E-zdravlje (e-health) je relativno nov ter min za zdravstvenu praksu koji podržava elektronske procese i komunikacije, a datira od 1999.godine.Neki bi ga izjednačili sa zdravst venom informatikom, a drugi bi ga u užem smi slu definisali kao korišćenje Interneta u zdra vstvenoj praksi.Intel ga definiše kao "napor preduzet od strane lidera u oblasti zdravstvene zaštite i hi-tech tehnologije, da u potpunosti iskoriste prednosti dostupne kroz konvergenci ju Interneta i zdravstvene zaštite" 3 .education and practice through a network of channels with all interested persons.In that way, we create a comprehensive "chamber"of knowledge that is sufficient to answer the re quirements of a new emerging global system of education.This way of fitting into modern world's trends is becoming necessary because most of data is unavailable.That is how pub lic education is formed, from which individuals and institutions can only have benefits, either as clients or service providers.Learning is always useful, especially in the fields of medicine and dentistry, where needs for information have be come an everyday necessity.

Application of information and communication technology in healthcare
Once acquired knowledge in the field of medicine is necessary to renew.Besides, medi cal knowledge is a subject to constant changes.The use of modern technology in the field of computer science is the most effeciant way to supplement the knowledge and at the same time to be available to all interested clients.There fore, information technologies are directly con ditioning the progress of the health system and medicine as a science.
Health informatics (medical informatics) is now accepted as a basic medical science that studies the laws of creation, transmission, pro cessing and use of information and knowledge to solve medical problems. 1(figure 1).
Health Information System (HIS) is an in tegrated communication computer system for information exchange in the process of health care, whose members are (all) medical staff and (all) users of health care. 2 HIS contains all in formation about health of the world population.
E-health is a relatively new term for health care practice, which supports electronic pro cesses and communication since 1999.Some would equate it with health informatics and oth ers would defined it as the use of the Internet in a medical practice.Intel defines it as "the effort taken by the leaders in the field of health care and hi-tech technology in order to use all avail able benefits through convergence of Internet and health care" 3 .

Dental informatics
In the mid 80`s of last century, in dental practice, computers were used for keeping fi nancial records, medical and dental histories, follow up of treatment and type of insurance.Today, in over 90% of dental offices computers are involved in most aspects of dental practice.Our base of knowledge dobles every two years.The use of the Internet and other telecommu nication methods makes it possible to keep up with expanding base of knowledge (figure 2).
Dental informatics uses computers and in formation science in order to improve dental practice.Primarily, it is focused on research, development and evaluation of information models and computer applications, which con tributes to the education and management. 4ental informatics is a separated area from in formation technology.first of all, it is focused on implementation and application of computer technology and telecommunications.However, these two areas overelap in some parts.
Dental informatics includes: -manage of information -keeping dental records, work organisation and managing den tal office;

Telemedicine
A few years ago, the term telemedicine was replaced with the term "telehealth", which is considered as politically correct.During 2007, this term was replaced with the modern terms, online health and ehealth 6 .
Although the principle of telemedicine is a relatively simple -data are accepted from va rious sensors and transferred to other centers for processing, analysis and diagnosis, the im plementation is not simple, because of highly complex technical requirements, especially in regard to the processing, transmission, archi ving and search a huge number of extremely large files, such as medical images.A marked development of hardware and software in the recent years has provided an unimagined po ssibilities in the field of telemedicine.Main ad vantage of telemedicine is to exclude or reduce the need for physical movement of patients and medical staff to the appropriate medical center.It also allows the examination of patients with modern appliances wherever they are, such as rural hospital, clinic or ambulance, while the signal analysis and diagnosis is performed in a remote center, which has a superb medical staff and a complete diagnostic equipment 7 .Slika 3. Telestomatologija / Figure 3. Teledentistry (downloaded from: http://www.dental.ufl.edu/offices/teledentistry/)lnih bolesti, impaktiranih umnjaka, planiranja i ugradnje dentalnih implantata i drugo, iako ova oblast još uvek nije dovoljno ispitana (slika 3).

Teledentistry
Modern teledentistry is based on Internet where you can with easiness and great savings funds use on-line systems for the transmission of digital information for patients on small and large distances.Excellent results have been ob tained with the Internet teledentistry oral dise ases, impaction of wisdom teeth, planning and dental implants and more, although this area has not been tested sufficiently (figure 3).
Teledentistry system allows dentists to share information about the patient, X-rays, graphical representation of periodontal and solid tissue, the applied treatments, notes, photos and other information that can be transported through multiple providers.
Teledentistry will be new clinical dimension in doctor-patient relationship.Although the term has not yet entered in everyday vocabu lary, it should become a cornerstone of modern dental practice, very soon.That will improve the efficiency and effectiveness of oral health care services.
The initial concept of teledentistry is deve loped as part of the plan for dental informatics and the application of techniques and techno logy in all areas of oral health.Teledentistry is a combination of telecommunication and den tistry, including the exchange of clinical infor mation and images over long distances for den tal consultation and plan of treatment.This new form of dental practice is seeking to provide support for dental care in areas without dental practitioners, overcoming social, geographical and cultural barriers 8 .

Classification of teledentistry
Teledentistry applications analogue to tele medicine applications include: • telediagnostic, teleconsultation, telemoni toring, telecare, teleconsulting and remote ac cess to information applied in dental practice.
Currently, there are two basic techniques used for teledentistry: 1. Videoconferences in real time; 2. Technique "store and forward" 9 .
Both techniques involve digitization of pro fessional dental care and electronic transmis sion of videos, drawings, diagrams, X-rays.Then, we prepare information for the transfer and that is how data is transmitted to remote locations.
Lak pristup informacijama i uverenjima o vrednosti takvih informacija dramatično utiče Videoconferences in real time allow people at two or more locations to communicate with each other using a digital screen to display vi deo images of the person or people at one or more locations.These systems use a video ca mera and speakerphone, so that site users can hear and see each other.Both parties settle time of meeting and they exchange information si multaneously in real time between two loca tions.Users can verbally clarify objectives and comments physically pointing at specific deta ils and modify already entered data during the consultation to throughly discuss and establish personal contacts.
Technique "store and forward" uses less complicated equipment and can operate over the Internet.Dentists collect information and store them in a file that is transmitted via elec tronic mail as encoded file.A consultant takes over a file and examine its content, after that he/she returns recomandations in the same way.This technique is the cheapest one, it provides enough benefits for a wide range of applications and it is equally efficient as image of object in real time.

Teledentistry in practice
Communication and information technolo gy provide a channel of information for patients and for dentists.Models of usage include office Web sites, e-mail communications, computeri zed management systems with office, electro nic health records, digital images and teleden tistry 10 .
Schleyer et al. classified the CIT (com munications and information technology) applications in 3 categories of applications: applications based on Internet, clinical and ad ministrative applications.

Applications based on Internet (Internet applications)
Internet category includes applications and interfaces, such as World Wide Web.We can approach it through any personal computer or other electronic devices, such as mobile phone or other wireless device.Applications based on Internet will not replace the "hands-on" care or treatment at the dentist and also it will not re place the quality of social interactions "face-toface".However, this new technology affects the quantity and quality of health information that patients can receive and a number of aspects of dental care that is provided and the nature of the doctor-patient relationship, too 11 .na odnos doktor-pacijent.Neki doktori stoma tologije i medicine su zabrinuti zbog pacijenata koji dođu u ordinaciju sa informacijama dobi jenim sa Interneta, dok drugi doktori prihvataju ulogu Interneta zajedno sa svojim pacijentima i pružaju im zdravstvene informacije i linkove kako bi unapredili izvore zdravstvenih informa cija na njihovim ličnim Web sajtovima.Kad po seduju određeni nivo pristupa informacijama, pacijenti mnogo aktivnije učestvuju u svojoj zdravstvenoj nezi.Odnosno, kad su pacijenti upućeni u spektar mogućnosti lečenja (imaju informacije o svim raspoloživim mogućnostima lečenja), tada sarađuju sa svojim stomatologom u donošenju odluke o toku lečenja.
Easy access to information and beliefs about the value of such information dramati cally influence the doctor-patient relationship.Some dentists and medical doctors are concer ned about patients who come into the office with information from Internet.But some other doctors accept the role of Internet and provide health information and links to enhance health information sources on their personal Web si tes.When patients have a certain level of access to information they can participate more active ly in their health care.Then, when patients are informed about the range of treatment options (with information about available treatment op tions), they can cooperate with his/her dentist in decision for treatment.
Internet applications used in dental practice include: e-mail or secure messaging; a practice Web site or portal; on-line scheduling; pre-regi stration; pre-visit preparation; patient`s access to their medical records and teledentistry.Email communication can show as extremly im portant builder of doctor-patient relationship. 12enefits, communications, personal knowledge and confidence can positively affect the use of Internet applications.
Despite of increasing popularity of using email, some clinicians and researchers do not believe that it can positevely affect the doctorpatient relationship.Instead, they believe that this will reduce interpersonal nonverbal com munication as a positive trend that enhances this relationship 13 .
Web site of dental practice is the second one in creating the doctor-patient relationship.The se Web sites offer general information about a doctor, medical staff and dental practice.Besi des, dental health offices associate with other re levant health care Web sites.Philosophy of den tal practice, preventive health care information and other dental health knowledge are available for existing and potential patients.A potential patient may feel that his/her values and prefe rences fit with dentist`s, when Web site includes relevant information about the dentists and the philosophy and politics of practice.The initial communication can lay the foundation for the doctor-patient relationship through potential of providing a sense of trust and shared values.
Među kliničkim komunikacionoinformaciono-tehnološkim (CIT) aplikacijama, EOHR se smatra centralnim delom informaci ja.EOHR može doprineti odnosu stomatologpacijent obezbeđivanjem standardizovanog centralnog skladišta informacija o pacijentu i kliničkim podacima koji se odnose na paci jentovo oralno zdravlje kao i na psihosocijalne i demografske informacije o pacijentu.Ovaj set informacija može da pruži kontekst o paci jentu, kao što je njegov socijalni status, želje i vrednosti u odnosu na njegovu stomatološku negu ili stanje.Izrazita kontekstualizacija može olakšati smisao komunikacije, poboljšavajući patients feel that they have more control, which lead to the development of more trust in the relationship.Studies have shown that patients have better communication with their doctors when they have access to to their dental records.Other studies have shown that patients who had access to their medical records now have incre ased confidence and trust in their doctors. 14dministrative applications on Internet allows patients the interaction with the orga nizational aspects of dental practice.On line scheduling of appointments, pre-registration and pre-visit preparation are bases for better communication and comfort.They also provi de contextual knowledge of patient, which can support integration and continuity of dental care.If the patient has more control and sense of parcipitation in administrative process, he/ she will have more trust in general dental prac tice and they will also have better relationship with the dentist.

Clinical applications
Clinical applications include a wide range of devices and software programs which involve: Electronic Oral Health Records (EOHR) with medical and dental patient`s history, plan of tre atment, charting, oral health status; nano-denti stry; dental images; diagnostic applications and applications that support the decision 15 .
Among the CIT applications, EOHR is con sidered, as a central part of information.EOHR may contribute to the dentist-patient relation ship by providing and standardized central sto rage of information about patient and clinical data related to patient`s oral health, as well as psychosocial and demographic information about the patient.This set of information can provide context about the patient, such as his/ her social status, wishes and values in relation to their dental care or condition.The expresive meaning of contextualization facilitate com munication, improving and building personal treatment and trust.Digital images can have a strong impact on the dentist-patient relation ship because of its immediacy and simplicity of understanding through recognizable visua lizations, which causes their increasing break among dentists.Specifically, intraoral and ex traoral images allow the patient to see exactly what is going on in his/her oral environment.i gradeći lični tretman i poverenje.Digital ne slike mogu imati najdublji uticaj na odnos stomatolog-pacijent, zbog svoje neposrednosti i jednostavnosti razumevanja kroz prepoznatlji ve vizuelizacije, što uslovljava njihov sve veći prodor među stomatologe.Konkretno, intra-i ekstra-oralne slike omogućavaju pacijentu da vidi šta se upravo dešava u njegovoj oralnoj sredini.Pored slike trenutnog stanja, manipu lacija digitalnom slikom omogućava pacijentu da vidi moguće efekte različitih tretmana una pred.Ovaj tip intra-oralnih slika duboko utiče na otvorenu komunikaciju, znanje pacijentovih sklonosti, vrednosti i izgradnju poverenja.
Other clinical CIT applications, such as diagnosis, plan of treatment and support of ma king decisions, may also positively influence the dentist-patient relationship.The use of this technology enables communication focusing on more appropriate and more effective treat ment and prevention of dental diseases.The patient will probably gain additional contex tual knowledge when technology implements on transparent common approach that attracts patients that is not "black box" that can be kept outside the conversation.The patient who feels that he's/she's more involved in the process of care and making decisions will probably deve lop more reliable and cooperative relationship with the dentist.

Administrative application
Applications from category of administra tion include most aspects of a comprehensive computerized practice management system.These systems have greater impact on patient`s experience with dental practice as a whole, al though they are related to the relation dentistpatient.Characteristics, such as patient registra tion, billing, insurance processing procedures, reminder call and re-appointment, when used in a manner that the patient is in the center, can positively affect the patient`s attitude towards politics and procedures of dental practice.This attitude, on the other side, adds a positive basis for the dentist-patient relationship.Exploring the importance of all applications for the den tist-patient relationship, there is need for tech nology education on both sides.Every medical profession, including dentistry, is suddenly fa ced with an entirely new force of revolutionary proportions.This is a digital transformation of health care and it will practically redefine every dimension of clinical practice and related ac tivities (for example, management of practice, marketing, payment).This new force has been widely published on the fair side of doctors and hospitals under item telemedicine and recently, as electronic health.Lessons and promises of digital transformation now can be applied in prakse, marketing, plaćanje).Ova nova sila je bila široko objavljena na tržišnoj strani lekara i bolnica pod stavkom telemedicina i nedavno kao elektronsko zdravlje.Lekcije i obećanja digitalne transformacije sad se mogu primeniti u stomatologiji, a rezultat su alata koji su tek nedavno usavršeni -umreženi kompjuteri i di gitalizovane informacije.Kompjuteri nameću praksi disciplinu, povećavaju efikasnost i stoga i profitabilnost.Dobar stomatološki kompjuter ski sistem omogućiće osoblju da provede više vremena sa pacijentima i obezbeđuje da stoma tolozi imaju veću svest o potrebama pacijenata.Korišćenje IT (informacione tehnologije) tre ba da unapredi kvalitet života i za pacijente i za praktičare.Stomatologija može da izbegne većinu neželjenih efekata upravljene nege (ma naged care) i vladinih regulativa, ali ona neće pobeći digitalnoj transformaciji.Dobre vesti su da će na kraju i pacijenti i stomatolozi imati koristi od dva glavna rezultata ove revolucije: telestomatologija i elektronska trgovina ili etrgovina (e-commerce).
Multimedija je aplikacija koja pruža in formacije koristeći nekoliko formi medija, uključujući zvuk, tekst, grafike, animacije i vi deo.Ona ima za cilj da poboljša komunikaciju i razumevanje.Multimedija ima brojne apli kacije za stomatologe koje služe da učine sto matološke bolesti i tretmane razumljivijim za pacijente istovremeno, na nivou stomatološke klinike i na nivou zajednice; da pokaže preven tivne stomatološke mere za decu (tehnike pranja zuba i efikasnije korišćenje zubnog konca); da procesuira demonstracije interaktivne hirur dentistry and they are the results of networked computers and digitized information that have been perfected recently.Computers provide di scipline of practice and increase efficiency and therefore profitability.Good dental computer system will allow staff to spend more time with patients and ensure that dentists have greater awareness of the patient`s needs.Use of IT (in formation technology) should improve quality of life for patients and practioners, too.Den tistry can avoid most of the unwanted effects of directed care (managed care) and goverment regulation but it won`t escape from digital tran sformation.Eventually, patients and dentists will have benefits from two main results of re volution: teledentistry and e-commerce.
The necessary ICT (information and com munication technology) for contemporary prac tice: It takes one computer`s platform, that which will integrate a computerized diagnostic equip ment, tools, treatment and electronic system of patient`s records, in order to achieve the neces sary holistic approach to treatment in dentistry.Computerized diagnostic devices are computer systems introduced by products, such as pe riodontal probe, electromyography (EMG) for analysis of mandibular movement, radiovisio graphy (RVG), digital radiography and dental imaging systems, including digital intraoral and extraoral camera.These devices provide diag nostic information, that previously were unava ilable.
Advantages of using multimedia in dental practice: Multimedia is an application that provides information using several forms of media, in cluding sound, text, graphics, animation and video.It aims to improve communication and understanding.Multimedia has many applica tions for dentists, in order to make dental dise ases and treatments more understandable for patients at two levels at the same time (dental clinic level and community level); to demon strate preventive dental measures for children (brushing techniques and more efficient use of dental floss); to process interactive demonstra tion surgery during the live e-learning; to have interactions in real time through teledentistry.In short, multimedia educates patients and practitioners in dentistry.It also helps to impro ve patient`s awareness and at the same time im proves professional development in dentistry 16 .
A few things are very important for pro per performing of teledentistry, such as: pro per software set up and the same basic type of hardware and software, peripheral devices and telecommunication links with the appropriate bandwith.Videoconferences in real time requi re more sophisticate equipment and faster con nection.In order to start implementation of te ledentistry in practice, it is necessary to initiate consultation with dental software companies.It is also necessary to establish cooperation with a company specialized in hardware.The com pany or an individual should determine tech nical requirements for this system in order to learn users how to use hardware and to provi de technical support for unpredicted difficul ties that may arise in the work.It is important that technologies in practice are compatible so the information about the patient are properly transferred.
If all previous conditions are met, people who live in rural and undeveloped areas will have the most benefits from teledentistry.Be sides, providing health care in these areas will also overcome the barriers of access to dental care and financial problems.Patients who live in rural areas are referred to receive dental care in urban areas and have to travel, which is usu ally expensive and takes time.Teledentistry can close this gap in distance in any country of the world, including Serbia.Consultations with a specialist can be conducted without the patient`s presence and that can save one preli minary meeting with the patient, at least.Te ledentistry has an important role for general dentists.They can examine a patient using te leconsultation with a collegue dental specialist and in case of urgent situations they can also give necessary prescriptions for medecines and therapy.In this way, we can reduce or eliminate pain and save time for next treatments.
During work with the dental laboratory, it is often necessary that dentist and technician share information.Teledentistry facilitates communi cation between dentists and dental laboratories, for example, tooth color images can be sent to dental technician, dentist can make suggestions and detailed instructions about the specifics of the teeth and jaw during the development of dental restorations, they can also make agre ament about phases of dental work, about the time of scheduling of patients, financial mo ment, etc.This would reduce chances for ma king errors during the dental preparations.

Zaključak
Digitalna praksa 21. veka biće bolja od filma-i-papira, zbog toga što će informacije In oral and maxillofacial surgery teledenti stry is used in remote planning of implants ex cept in videoconferencing and transfer of ope rations on Internet.
When medically compromised patient ap pears in dental office, it is necessary to provide consultation between different medical specia lists.In this way, we could achieve an interdi sciplinary approach to holistic health care.for example, if patient has bad blood analysis, you can ask medical doctor to check the patient's clotting time before dental treatment.
Teledentistry may also be of great help for hospital consultations, in which patients are ta ken care of for medical reasons, such as trans plantation when oral status is an imperative.
In the identification procedures the availa bility of data can contribute and speed up the process of identifications 17 .
The final width and depth of teledentistry are more likely limited by the imagination rat her than technology.It is estimated that the si tuation will change in the future.for example: one day, the telepresence surgery may allow a remote specialist to manipulate with the surgi cal instruments in primary dental care using the computer commands, so the patient immediate ly recieves the specialist`s care without going to surgery.Dentists will also be able to partici pate in large clinical trials of new materials and procedures.Soon, teledentistry will become more than just a mechanism of the interaction between general dentists and dental specialists.

Conclusion
Digital practice of the 21 st century will be better than its precursor, film-and-paper, be cause information will immediately flow to the place where it is necessary.That will have a positive impact on improving skills and kno wledge of dental professionals.However, two perceptual barriers are care about security and costs.They seem to disturb many dentists about serious consideration of digitizing their practi ces.These concerns were based in the past, but recent progress in both areas indicates that digi tal transformation should be a key element for planning practice in the comming years.
Dentists will be able to add a new dimen sion of services for the growing number of pa tients who manage their lives with the help of the on-line world.They can also join an electro nic community formed around the philosophy teći odmah do mesta gde je to potrebno, čime će se pozitivno uticati na poboljšanje veština i znanja dentalnih profesionalaca.Međutim, dve perceptivne prepreke -brige o bezbednosti i troškovima -izgleda da ometaju mnoge stoma tologe o ozbiljnom razmatranju digitalizacije njihovih praksi.Ove zabrinutosti su bile osno vane u prošlosti, ali skorašnji napreci u obe ob lasti ukazuju na to da bi digitalna transformaci ja trebalo da bude ključni element za planiranje prakse narednih godina.