e-Review of Tourism Research (eRTR), Vol. 18, No. 2, 2020 http://ertr.tamu.edu 290 Methawee Wongkit Prince of Songkla University, Trang Campus Watsida Boonyanmethaporn National Institute of Development Administration Dental Tourism Development in Thailand: A Perspective of Service Providers This study aimed to examine the perspectives of dental service providers on the supply side of dental tourism. Using Phuket as the study area, this research intended to understand how the dental service providers deal with dental tourists and why these patients decide to obtain dental treatment during their vacation in Thailand. A qualitative research approach was employed. In-depth interviews were the main instrument for collecting data. Content analysis was utilized to analyse the data. In total, five dentists and ten clinic staff were recruited. The results revealed that simple dental fillings, tooth bleaching, and dental prophylaxis were the most popular treatments. The success of a dental tourism business lies in the attentiveness of both employees and customers. In terms of hospitality, service, and standards of dentistry, the performance of staff in the dental clinic affects the feelings and needs of repeat travelers. Therefore, it is recommended for dental clinic owners to prepare and focus on staff training in terms of language, service quality, and standards of treatment as the quality of dental care services, reasonable costs, qualified dentists, time-saving treatment plans, and friendliness of the atmosphere are the main travel motivations for the successful development of dental tourism. Keywords: Dental Tourism, Dental Tourist, Service Providers, Thailand, Phuket Dr. Methawee Wongkit Department of Tourism Management Faculty of Commerce and Management Prince of Songkla University, Trang Campus 102 Moo 6 Kuanpring Mueang, Trang, 92000 THAILAND Phone: [66] 8 5965 1795 Email: methawee.w@psu.ac.th Asst. Prof. Dr. Watsida Boonyanmethaporn Graduate School of Tourism Management National Institute of Development Administration 118 Moo 3 Seri Thai Road, Klong-Chan, Bangkapi, Bangkok, THAILAND Phone: [66] 9 4241 5351 Email: worarak.suc@nida.ac.th http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 18, No. 2, 2020 http://ertr.tamu.edu 291 Dr. Methawee Wongkit is a lecturer of Tourism Management in the Faculty of Commerce and Management at Prince of Songkla University, Trang Campus, Thailand. Asst. Prof. Dr. Watsida Boonyanmethaporn is a full-time lecturer at Graduate School of Tourism Management, National Institute of Development Administration, where she currently serves as Associate Dean for Planning and Development and Director of Master of Management Program in Integrated Tourism and Hospitality Management. Introduction ‘Medical tourism’ seems to be a recent term, but it is not a new phenomenon, as people have been traveling to seek better hospitals for several years (Lagace, 2007). In the past, the flow of travel to receive medical care has been from less developed to more developed countries. However, recent trends show a reversal in this movement pattern to one of people intentionally undertaking the journey from wealthier countries to poorer ones (Jaapar, Musa, Moghavvemi, & Saub, 2017; Redlltz, 2015; Wilson, 2011). To a certain extent, medical tourism can be defined as the incidence of people traveling intentionally to seek a variety of medical treatments, which can include elective procedures or complex, specialized surgeries such as open-heart surgery, as well as dental care, cosmetic surgeries, and general health check-ups (Centers for Disease Control and Prevention, 2017; Connell, 2011; Connell, 2013; Crooks, Kingsbury, Snyder, and Johnson, 2010; Enderwick and Nagar, 2011). Countries such as Mexico, Hungary, Jordan, Lithuania, Malaysia, India, Singapore, and Thailand have all emerged as major medical tourism destinations, providing services for patients from around the world (Connell, 2006; Crooks et al., 2010; Horowitz and Rosensweig, 2007; Jaapar et al., 2017; Reed, 2008). However, among other tourist destinations, Momeni, Janati, Imani, and Khodayari-Zarnaq (2018) argued that Thailand, Singapore, and India have gained the largest share of the medical tourism market in Asia. http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 18, No. 2, 2020 http://ertr.tamu.edu 292 Thailand is not only a world-class tourist destination due to its rich bounty of natural attractions and heritage sites, but it is also well recognized as a popular destination for medical tourism as its world-class medical treatment is available at reasonable prices. (Thailand Board of Investment, 2019). According to the SCB Economic Intelligence Center report, Thailand is one of the leaders in international healthcare services, and the number of foreign patients is projected to grow at 9 percent per year by the end of 2021 (Amornvivat et al., 2016). The main reason that Thailand’s medical tourism sector has been expanding gradually is due to its advanced subsectors. For example, as of 2017, Thailand is one of the largest medical device producers in the Asia-Pacific Region. Also, Thailand has 65 hospitals and medical organizations accredited by the Joint Commission International (JCI), which was the highest number in ASEAN in 2018 (Thailand Board of Investment, 2019). Since the market for medical tourism is projected to grow worldwide and medical tourists are becoming an important source of tourism income due to their high average spending per head, as they usually seek high-quality amenities including accommodation, food, and transportation, during their recovery period; the Thai Government has attempted to develop the country as a global center for medical tourism (Karnjanatawe, 2019; Noree et al., 2016). The kingdom has recently positioned itself to target the premium tourist market by establishing medical tourism, which was introduced to foreign markets as part of the government’s 2014 action plan (Amornvivat et al., 2016; Oxford Business Group, 2015). Typically, Thailand has been recognized as a medical tourism destination due to its quality of treatment at reasonable prices, short waiting times, and the variety of medical treatments available (Amornvivat et al., 2016; The International Medical Travel Journal, 2013). In addition, the country has also established a strong reputation for orthopedic surgery, cardiovascular disease treatment, cosmetic surgery, and gender reassignment surgery along http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 18, No. 2, 2020 http://ertr.tamu.edu 293 with general health check-ups and dental care (Cohen, 2008; Connell, 2006; Horowitz et al., 2007; Wongkit and McKercher, 2016). Medical tourism in Thailand is mostly concentrated in Bangkok and other key tourist destinations, namely, Pattaya, Chiang Mai, and Phuket, where medical services and tourism- related infrastructure is available (Moghavvemi et al., 2017). However, recently, Phuket has been promoted as a medical tourism spot in southern Thailand. One of the medical tourism products that many medical tourists tend to seek out is dental care (Wongkit and McKercher, 2016, pp. 19). Although dental treatment in Phuket has become popular among foreign tourists, previous studies did not pay attention to this area. Many of them appeared to highlight medical travelers' motivations that led them to travel abroad for medical care (i.e., Connell, 2006; Jotikasthira and Cox, 2010; Singh, 2013). Some studies have examined the effects of medical tourism development in regards to the country's health system (i.e., Cohen, 2008; NaRanong and NaRanong, 2011; Wibulpolprasert and Pengpaibon, 2003), while others have focused on hospital management issues and problems when hospitals consider to becoming involved and participating in this industry (i.e., Cohen, 2008; James, 2012). A recent study conducted by Jaapar et al. (2017) seems to be a kick-off on dental tourism, as it attempts to determine the profiles, motivations, and satisfaction of dental tourists. In other words, they are looking at the demand side. Therefore, this study aims to examine the supply side, which is the dental service providers. Using Phuket as the study area, this study intends to gain a comprehensive understanding of how the dental service providers deal with their dental tourists and why these patients decide to receive dental treatment during their vacation in Thailand. Also, this research attempts to provide suggestions for dental tourism development in Thailand. http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 18, No. 2, 2020 http://ertr.tamu.edu 294 Literature review Overview of the medical tourism industry Medical tourism has been discussed among scholars for many years. Initially, many researchers (e.g., Laing and Weiler, 2008, Sheldon and Bushell, 2009; Smith and Kelly, 2006) argued that medical tourism should be located under the umbrella of wellness tourism, as its activities range from spiritual experiences that refresh the soul, to medical surgery that improves the body, and many others in between. However, Smith and Puczko (2009) proposed that wellness tourism should not include medical treatments because wellness tourists needed to be in good enough physical health to embark on a journey, and they also needed to be affluent because of the pursuit of wellness activities is time-consuming and expensive. As a result, medical tourism can be explained as a phenomenon in which an individual intentionally travels to receive specific medical treatment outside his or her usual place of residence, and medical tourists should be defined as travelers who are combining his or her vacation trip with obtaining medical care at the same time (Brotman, 2010; Connell, 2006; Heung et al., 2010; Horowitz and Rosensweig, 2007; Lunt et al., 2011; Smith and Puczko, 2009). According to Wongkit and McKercher (2013), treatments in medical tourism can range from preventative medical care, such as general health check-ups or general diagnostics, and minor procedures, such as cosmetic and dental surgery, to major invasive procedures, such as cardiology/cardiac surgery, orthopedic surgery, and gender reassignment surgery. According to Shahijan et al. (2015, pp. 476), medical tourism has seen rapid growth globally. It is expected that this tourism sector’s total market size will reach USD 165 billion by 2023 (Thailand Board of Investment, 2019). Therefore, many countries have attempted to develop themselves as medical tourism destinations, as they see this niche tourism as an opportunity to boost the countries’ revenue. A report produced by Lunt et al. (2011, pp. 13) http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 18, No. 2, 2020 http://ertr.tamu.edu 295 asserted that medical tourism destinations in the global map include Asia (India, Malaysia, Singapore, and Thailand); South Africa, South and Central America (including Brazil, Costa Rica, Cuba, and Mexico); the Middle East (particularly Dubai), and some European destinations (e.g., Western, Scandinavian, Central and Southern Europe, and the Mediterranean). Nonetheless, Crooks et al. (2010) argued that India, Singapore, and Thailand have become the global leaders in this industry. Dental tourism: a subset of medical tourism The pursuit of dental treatment abroad has become part of an increasingly important part of the medical tourism industry (Lovelock et al.,2018). Turner (2008) also argues that dental treatment is, perhaps, one of the main reasons people travel abroad for medical care. While the demand for other types of health care is unpredictable and occurs suddenly, dental care is less emergency dominated. In addition, people tend to obtain the same, or similar, dental treatments more than once in their lifetime. Hence, people have more opportunities to learn from past experiences, collect and evaluate information, and plan the time and place for undergoing dental treatments and selecting providers (Österle et al., 2009, pp. 425). According to the American Dental Association (ADA), dental tourism can be described as the act of traveling to another country to receive dental treatment (ADA, 2009). Previous studies exhibited that traveling for dental care is fairly common in Europe and that Hungary has become a popular dental tourism destination for foreign patients over the last two decades (e.g., Balázs and Oesterle, 2008; Kamath et al., 2015; Kovacs and Szocska, 2013; Lunt et al., 2011; Österle et al., 2009). Crossing national borders and obtaining dental care at low-cost clinics in Hungary has become the best solution for many patients since the cost of treatment costs less than 50 percent of the same treatment in Western European countries (Österle et al., 2009; Turner, 2008). Another well-known dental tourism destination http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 18, No. 2, 2020 http://ertr.tamu.edu 296 is Mexico, which arises from its nearness to the United States, where 25 percent of the worldwide dental tourists are from (Kamath et al., 2015; Turner, 2009). To a certain extent, India and Thailand are the two leaders in dental tourism for the Asian continent (Kamath et al., 2015). Turner (2009, pp. 117) emphasized that dental tourists generally travel for treatment when the total cost of dental care, meals, accommodations, transportation, and other expenses is less than the price of local dental services. In addition, Panteli et al. (2015) noticed that the high cost of dental care in their home countries is one of the main factors that motivate many people to look for alternative dental clinics overseas. Österle et al. (2009, pp. 425) also asserted that many countries have excluded large parts of dental care from social health insurance or national health service coverage and that a large number of countries require substantial co-payments from the patients. Therefore, some specific dental interventions, such as removable prosthetic treatments, may require a co-payment of up to 20 percent if they provided by contract doctors; others, such as implant treatments and crowns or bridge treatments, which are not covered in the social health insurance plans, have to be paid for out- of-pocket by the patient (Österle et al., 2009). Furthermore, Kamath et al. (2015) revealed that the cost for a dental filling in the US and Europe is about USD 300-400, but it costs only USD 30-40 for the same treatment in India. Although the cost and quality of dental treatment in the dental tourism industry are often discussed, as people tend to associate low prices with poor quality, studies conducted by Kovacs and Szocska (2013) and Österle et al. (2009) have demonstrated that many dental tourists decide to receive dental care abroad because they trust the quality of dental professionals in their preferred destinations. Thus, affordable prices and high quality of dental care seem to be the key determinants for dental tourism (Österle et al., 2009). Shorter waiting periods are another reason many people decide to become dental tourists (Barrowman et al., http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 18, No. 2, 2020 http://ertr.tamu.edu 297 2010). In India, the dentist-to-population ratio is about 1:9,000 dentists in urban and semi- urban areas and around 1:200,000 dentists in rural areas. Therefore, there are enough dentists to service international patients (Kamath et al., 2015). Nevertheless, for many patients, combining their dental treatment with some leisure activities is their primary reason for traveling abroad and becoming dental tourists (Barrowman et al., 2010; Lovelock et al., 2018; O'Connell and O’Sullivan, 2007). Medical tourism in Thailand Thailand has long held the crown as one of the most famous medical tourism destinations since it specialized in transgender surgery in the 1970s, although it later moved into cosmetic surgery (Connell, 2006). Heung et al. (2011) noticed that medical tourism in Thailand gained competitive advantages due to a combination of its strong tourism attributes, affordable prices, and the positive reputation of its healthcare industry. Medical tourism in Thailand began after the Asian Financial Crisis of 1997, as the private hospitals were faced with the number of their local patients dropping dramatically. Therefore, they had to generate more revenue by attracting international patients. Bumrungrad International Hospital in Bangkok was the pioneer in promoting this campaign (Connell, 2006; Cohen, 2008; Maung and Walsh, 2014; Yeoh et al., 2013). The medical tourism industry expanded significantly after the Thai government promoted the country as a medical hub in 2004 (Economic and Social Commission for Asia and the Pacific [ESCAP], 2009). In 2006, the Thai Ministry of Commerce estimated that 1.2 million medical tourists received healthcare services in Thailand and generated an estimated revenue of approximately USD 1.1 billion. In other words, this was about 9 percent of Thailand's total estimated revenue from the overall tourism sector in 2006 (Noree et al., 2016). According to Oxford Business Group (2015), it was estimated that medical tourism in Thailand could generate earnings in excess of three billion US dollars in 2015, representing http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 18, No. 2, 2020 http://ertr.tamu.edu 298 revenue growth of up to 15 percent year-on-year. According to data provided by the National Statistical Office (2019b), the number of medical tourists was officially recorded starting in 2018. The total number of international tourists who visited Thailand in 2018 was 38,178,194, with 95,251 traveling to Thailand to seek medical treatment (National Statistical Office, 2019b). Therefore, it is expected that this is a promising tourism sector for sustainable growth. Medical tourism in Thailand has expanded into a wide range of medical procedures, from various dental treatments, cardiac surgery and transplant operations, and the rising importance of medical screening (Connell, 2011, pp. 64). Amornvivat et al. (2016, pp.28) argued that foreign patients coming to Thailand are either looking for lower costs or higher quality. Specifically, foreign patients seeking cheaper medical services often come from developed countries with high income per capita and costly healthcare. Whereas those patients from developing countries generally come for medical treatment higher in quality and safer than in their home countries, medical facilities are inadequate. Noree et al. (2016, pp.34) also asserted that medical tourists in Thailand are heterogeneous. They are a combination of patients who travel with serious health issues and those seeking minor treatments while taking a vacation. At present, Thailand seems to be the largest medical tourism service provider (Arunanondchai and Fink, 2006). Thailand as a destination for dental tourism According to the Thai Dental Council (2017), the number of licensed dentists in Thailand is 15,951. In 2018, a report conducted by the Ministry of Public Health (National Statistical Office, 2019a) revealed that Thai dentists' ratio to population was one per 8,472 persons. Although 2,545 dentists (approximately 16 percent) work in private hospitals, the number of dentists working in private clinics is still unclear (National Statistical Office, 2018). http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 18, No. 2, 2020 http://ertr.tamu.edu 299 Since private healthcare providers tend to be key players in Thailand’s medical tourism industry, it is very common to see many international patients undergo dental treatments in private hospitals and private dental clinics (Connell, 2011; Lunt et al., 2011; Wongkit and McKercher, 2016). The availability of general and specialty dental services at a lower cost and the plentifulness of beautiful tourist attractions makes Thailand one of the most popular destinations for dental tourists who prefer to combine saving on dental care and enjoying a holiday at the same time (Sangkularb, 2017). Hence, the Ministry of Health aims to promote Thailand as a world-class dental destination. Furthermore, Bangkok and Phuket appear to be the main dental tourism destinations in Thailand, as these two cities combine great travel opportunities and affordable prices for dental treatments at the same time (Cohen, 2008; Sangkularb, 2017; Turner, 2008). Previous research studies (i.e., Jaapar et al., 2017; Lovelock et al., 2018; Lunt et al., 2011; Turner, 2008) attempted to find out why people decided to receive dental care overseas, sometimes in destinations that do not speak their languages, have a similar culture, or understand their religious beliefs. Although the cost of treatment seems to be a primary consideration for many dental tourists (Panteli et al., 2015; Turner, 2008; Turner, 2009), a study by Wongkit and McKercher (2016) revealed that people who obtain dental care in Thailand emphasized factors related to the quality of dentists, medical facilities, service providers, and the reputations of service providers. Those factors related to the cost of treatment, privacy considerations, and the opportunity to avoid long waiting times did not play a key role among these people. Methodology This exploratory study aimed to discover the perspective of dental tourism service providers to gain an in-depth understanding of dental tourism development by employing a qualitative research approach. Recently, Phuket has been promoted as a medical tourism http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 18, No. 2, 2020 http://ertr.tamu.edu 300 destination in southern Thailand, and the most popular tourist attraction in Phuket is Patong Beach, which was selected as the study area. According to the Phuket Provincial Administration Organization (2015) statistics, there are 86 registered dental clinics in Phuket, with 15 of them being located in the Patong Beach area. Purposive sampling was used to assure the participants’ qualifications for having knowledge about dental tourism. To be eligible to be recruited in this study, interviewees must be either dentists or dental assistants who work for the clinics or the owners/ managers of the dental clinics, and they must have been working in the clinic for more than one year. Also, pre-screening questions regarding the concept of dental tourism and dental tourists were employed to confirm that all of the participants were knowledgeable about this issue. All of the participants passed these criteria. The draft of the interview questions was vetted by a Thai dentist and three tourism academics. The pilot testing was conducted before the main study at ten dental clinics in Phuket Town to verify the trustworthiness of the interview questions. Five dentists and ten clinic staff were recruited and participated in the main data collection from August 2016 to February 2017. All participants gave informed consent prior to the interview as the study involved participants who worked with patients; hence they could choose whether they would participate in the interviews. Conducting the survey ethically was given the highest priority; the participants’ names remained anonymous to ensure confidentiality, with only the results being presented. All in-depth interviews were conducted in the Thai language, and the average interview time was between 20 and 45 minutes. Data were analysed using content analysis. Certain limitations of this study are recognized, such as the shortage of time and budget; thus, data collection was only conducted in the Patong Beach area. Therefore, the findings of this study may not be generalizable to other dental tourism destinations in Thailand. http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 18, No. 2, 2020 http://ertr.tamu.edu 301 Findings Background information about the Dental Clinics in Patong Beach The participants were Thai and consisted of ten clinic staff and five dentists from 15 dental clinics in the Patong Beach area. The clinics were typically open Monday to Saturday between 10 a.m. until 8 p.m., with most closed on Sunday and public holidays. Generally, an appointment for dental care was required. However, most first-time foreign tourists tended to be walk-in patients who inadvertently passed by dental clinics and requested dental treatments or appointments. In cases where there was a free time slot, the tourists could receive the treatment. Otherwise, the appointments would be made, the as same as for regular patients. For tourists who had previously used the clinics to receive dental treatments had made advanced reservations via phone or email, where they were informed of the exact dental treatment schedule. Once these tourists become repeat patients, and they are awaiting their next treatment trip, they now understand what dental care services are available and how the clinic’s reservation system works. Many of them appear to highlight the dental care services they are awaiting to arrange on their lists for their next medical trip to the same dental clinic, as they now know how to approach the dentists and make an appointment for their preferred dental treatments. Type of dental services The highest number of international tourists arriving to receive dental treatment in Patong Beach were European and Australian, whereas Asian patients were the smallest group. Simple dental fillings, tooth bleaching, and dental prophylaxis were the most popular treatments. Other dental care sought included non-emergency treatments such as teeth whitening, scaling and polishing, and routine examination and consultation. Also, tooth extraction, dental crowns, endodontic, dental bridges, or repair of a prosthesis were respectively less prevalent. Orthodontics was the least popular treatment since the long-term http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 18, No. 2, 2020 http://ertr.tamu.edu 302 treatment required consecutive appointments with dentists, which may cause travel inconvenience. The foreign patients who received dental care from the dental clinics in Patong Beach were generally highly satisfied with the treatment results. As such, they tended to become repeat customers. The major reasons are the reliability of dental services and the quality of dental treatment. With some treatments completed in one visit, i.e., tooth bleaching or dental filling, the tourists may not revisit the clinics unless a promotion is launched to attract them. Accessibility to dental services of international tourists Many treatments are completed in a single visit; hence the ratio of returning tourists is relatively low. Redemption of an attractive promotion is one of the main reasons for the re- use of dental services. However, even if dental clinics do not offer any promotions, the tourists can still negotiate dental treatment rates, which are fair to local Thai people. Word of mouth promotion from those treated in the clinic is a minor factor in seeking out a clinic for dental treatment. Some dental tourists revealed that they chose to receive dental care at a dental clinic because it is more convenient, and they asserted that the dental clinics provided the treatment with high standards, which they would not have received from their hometown hospitals. The most important factors motivating international tourists to choose a dental clinic are convenience, quality of treatment, guaranteed treatment standards, and is located in a tourism area, such as Patong beach, making travel and treatment more convenient for the tourists. Future trends of dental treatment for international tourists According to the interviews, the clinic owners and the dental clinics' staff reported that the number of foreigners treated at the dental clinics in the future is largely dependent upon the travel season. If the number of international tourists keeps increasing continuously, each clinic has different management guidelines. Most of the dental clinics argued that http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 18, No. 2, 2020 http://ertr.tamu.edu 303 training programs for clinical staff to be more proficient in customer service and increasing foreign language proficiency, which is of paramount importance when servicing international tourists, are essential. Another approach is to employ more clinical staff. The majority of dental clinics argued that, if they have more foreign patients, they will attempt to arrange the schedule of their dentists to fit with the times the patients would be available, or that they would extend the clinic hours in order to serve the needs of their customers in each day. To employ a new dentist is the last option for these dental clinics, as their busines sizes are relatively small, and dentists' salary carries a high cost of investment. Discussion and conclusion This research aimed to study the potential of tourism business development for dental treatment, the trends in the use of dental services, and the types of dental treatments tourists use in Patong Beach, Phuket. This study was conducted at one of the most popular tourist destinations in Thailand, so most dental patients were Europeans and Australians, whereas Asian patients were the smallest group in the Patong Beach clinics. As most foreign patients did not plan to receive dental treatment at the destination during their travels, many of them, especially the first-time foreign tourists, tended to be walk-in patients who inadvertently passed by dental clinics and requested dental treatments or appointments. Therefore, most dental treatments they tended to obtain were less complicated, such as dental checkups, teeth whitening, and scaling. These findings are similar to the study of Wongkit and McKercher (2013), who investigated tourists’ motivation in Thailand and found that the respondents mentioned that the main travel motivation was for a holiday and that about 40% of them did not plan to undergo medical treatment until after they had arrived in Thailand. Regarding the dental tourists’ procedures in this study, dental check-ups were the most popular treatment that people obtained. Additionally, a study conducted by Jaapar et al. (2017), which explored http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 18, No. 2, 2020 http://ertr.tamu.edu 304 dental tourists’ travel motivation and satisfaction in Malaysia, revealed that the dental tourists chose three dental clinics due to offering free check-ups and examinations, which encouraged general tourists who had come for a holiday, or to visit friends and relatives, to take the opportunity to get dental care from the dentists. In addition, since most dental tourists in Patong Beach are from Europe and Australia, they tended to receive dental treatments that could be completed during a single visit, such as scaling and polishing, simple fillings, and tooth whitening. These findings are similar to the study of Jaapar et al. (2017), which found dental tourists tended to obtain general dental care, which includes scaling and polishing, simple fillings, and tooth whitening. Compared with the study by Österle et al. (2009), however, Hungary's dental tourists were involved with more complicated dental care, such as dental implants and partial denture procedures. This might be because of the country's location, which allows foreign patients to easily access the dentists for long-term treatment. This study found that the dental care quality standards, the cost-savings, the referral of friends or family, and the testimonials about treatment were the most important factors among dental tourists that influenced them to become repeat customers. This is consistent with the study conducted by Rerkrujipimol and Assenov (2011), which found that maintaining high service standards is required to compete with the competition emerging from new dental clinic service centers. Like other types of treatment, the dental services’ quality and cost are among the main reasons for dental tourists choosing a provider when searching for treatments abroad (Zhang, Seo, & Lee, 2013). To attract more dental tourists, therefore, the dental tourism service providers, whether dental clinics or the dental departments in the hospitals, have to reach and maintain a high standard of quality care in line with international standards while maintaining an affordable price (Kovacs & Szocska, 2013). http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 18, No. 2, 2020 http://ertr.tamu.edu 305 This study also found that time-saving, relaxed environment and the dentists and staff's Thai hospitality culture appeared as factors that motivated foreign tourists to become repeat dental tourists. This supports the contribution of Ahmadimanesh, Paydar, and Asadi- Gangraj (2019) held that dentists; kindness, humility, speed, and a comfortable and friendly environment were emphasized as the main motivations in dental tourism. Therefore, the success of the service business lies in the attentiveness of both employees and customers. In terms of hospitality, service, and standards of dentistry, the performance of staff in the dental clinic affects the feelings and needs of repeat travelers. These factors are very important for a dental clinic to be a viable business. The survey results also found that some clinics do not have staff training programs and do not make service standards a priority. As a result, the dental clinic owners need to prepare and focus on staff training in terms of language, service quality, and standards of treatment as the quality of dental care services, reasonable costs, qualified dentists, time-saving treatment plans, and friendliness of the atmosphere are main travel motivations for the successful development of dental tourism in Patong Beach. Recommendations In terms of dental service providers, to attract more foreign tourists to receive dental treatments, the priority messages are that they should communicate the details of dental treatments, especially the fair prices and time for treatment, to their potential customers when they do a marketing activity, as many foreign tourists, particularly who are in the vacation mode, tend to decide to receive dental treatment as walk-in patients. Providing these details, including the information about the dentists' qualifications, can enhance the confidence in the treatment quality of the dentists and the clinics or hospitals. Since word of mouth plays a vital role in this industry, the dental clinics and hospitals should employ testimonials from previous and revisit patients; this information can be presented via their official websites and http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 18, No. 2, 2020 http://ertr.tamu.edu 306 different social networks sites that their potential customers use. By delivering a newsletter and special treatment package promotions via email or another preferred channel of communication, patients who have obtained dental treatments can help the patients remember them and prompt them to receive more dental care when they travel to the destination again. Moreover, dental clinics and dental departments in the hospitals should be improving the skills of staff and clinicians in the area of services and proficiency in foreign languages. The customers who come to the treatment are mostly foreign tourists, so communication is considered very important, as well as the ability to provide good service and impress tourists. In terms of facilitating tourists to travel to the service, maps, and lists of things to do and places to visit locally should be prepared to attract more dental tourists. In terms of the government sector, since medical tourists seem to spend more money in the destination than other types of tourists, this is a great opportunity for many countries to promote this industry to increase tourism revenue. In this study, if the Thai government wants to promote Phuket as a world-class dental tourism destination, the accommodation facilities, transportation systems, tourist facilities, and tourist attractions should be developed to serve tourists who have different needs. Furthermore, the government should update their database regarding the information for each dental clinic and hospital, and the information of the registered dentists, in order to ensure that the dentists and the dental service providers continue to maintain their quality of dental treatment and provide dental care according to the set of laws and regulations of the Thai Dental Council. Researchers who wish to research similar topics should study the opportunities for tourism development for dental treatment from the perspectives of public and private hospitals or research related to the study of visitor trends. 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