Oral Health in the Family Health Strategy : analysis of articles published in the period 2004-2014

This study aimed to conduct an integrative review of scientific literature on the topic of Oral Health in the Family Health Strategy in the period 2004-2014. Articles published in national and international journals (n = 141) were consulted and selected from the electronic Library the Scientific Electronic Library Online (SciELO) and from electronic databases PubMed, Lilacs, BBO and Cochrane. The implementation process of oral health teams in the Family Health Strategy was the most frequent thematic variable (18%) of the 15 variables identified. The Northeast was the Brazilian macro-region where the largest number of published articles originated (n = 61). The studies were predominantly quantitative, and the highest number of publications occurred in 2010 (n = 26). We concluded that there is an increasing interest in investigating the context of oral health implementation in the Family Health Strategy, with particular emphasis on theme categories related to the micro-process work and the redefinition of professional identities arising from multidisciplinary work in primary care.


Introduction
In 1994 the Family Health Strategy (FHS) was established as a entry point to care for users into the Unified Health System (SUS) in Brazil.The FHS teamwork in specific geographic areas and is responsible for implementing actions for health promotion, disease prevention, treatment of common health conditions and rehabilitation 1,2 .
The insertion of the Oral Health Team (OHT) into the Family Health Strategy (FHS) starting in 2000 represented the possibility of introducing a change into the current oral health care model of the national Unified Health System (UHS), which emphasizes dental care with a clinical, individual, repairing, and biomedical focus 1 .This transformation would be possible through conceptual redefinition and reorientation of practices aimed at actions based on the principles of integrity, coordination, and continuity of care by the OHT, among other strategic actions 2 .
Researchers have investigated the role of the OHT/FHS, particularly in aspects related to the micro-process work, innovation in care models, and potential epidemiological impact on oral health [3][4][5][6][7] .These studies' findings are important as they can influence future practices and investment in resources and serve as a basis for the development of other studies 3,4 .Thus, this review and comment on the scientific literature concerning the oral health topic in FHS allows more insight into the working process and the results of the recent integration/expansion of OHT in primary care in Brazil 5,6 .
One of the methodological possibilities to accomplish this task is an integrative review.This approach is widely accepted and used in international literature because it allows researchers to summarize information while providing a critical evaluation of the results of multiple primary studies regarding a certain topic 8 .Given the above, this work aims to conduct an integrative review of the scientific literature on oral health of the FHS during the period 2004-2014.

Material and methods
An integrative review study was conducted on published works addressing the issue of oral health in the Family Health Strategy.The search for articles was performed electronically in in the library Scientific Electronic Library Online (Sci-ELO) and in the databases Public Medline (Pu-bMed), Latin American and Caribbean Health Sciences Literature (Lilacs), Brazilian Dental Library (BBO) and Cochrane Library (Cochrane).
In the electronic library SciELO and in the databases Lilacs, BBO the following search terms were used: 'saúde da família and saúde bucal' , 'odontologia em saúde pública and saúde da família' , and 'odontologia and saúde da família' , defined through consultation of Descritores em Ciências da Sáude (DeCS) (comparable to Medical Subject Headings -MeSH).In PubMed and Cochrane databases, the terms 'family health and oral health' and 'primary health care and oral health' were used, defined by the Medical Subject Headings (MeSH).
Only articles published in refereed journals were included in this integrative review, since they were subjected to the scrutiny of the editorial peer review process 9 .
The terms were searched in article titles, keywords, and abstracts.The inclusion criteria was articles from Brazil in English, Spanish, and Portuguese published in the period between 2004 and 2014.Only articles were selected; theses, dissertations and grey literature were excluded.When it was possible the inclusion criteria were adopt as searching filters for the articles according to the specificity of each database.The articles considered relevant were selected by reading the titles and abstracts.Three independent investigators read the titles and the abstracts and agreed that in case of disagreement over the inclusion or exclusion of any of the articles the divergence would be held to a vote.
To find and exclude duplicate articles, the reference manager EndNote X4 was used.After excluding duplicates, we selected those articles considered relevant to the review topic by reading the full texts.Three independent investigators read the full texts and agreed that in case of disagreement over the inclusion or exclusion of any of the articles, a new closed reading would be held, and the divergence remained would be held to a vote.
The collected information from the selected studies was processed using an instrument consisting of the following organizing elements: author, year of publication, title, journal of publication, location of the study, type of study, theme categories and the aims.The organizing elements were selected to facilitate the evaluation process.After extracting the information from the selected articles, results were analysed and discussed.

Results
Initially, 6,803 publications were obtained: 5,607 in PubMed, 501 in Lilacs, 198 in BBO, 291 in the Cochrane database, and 206 in SciELO.After applying search filters appropriate in each database for the purpose, 451 studies considered relevant were selected.After reading the titles and abstracts, 271 duplicate articles and 39 theses and dissertations were excluded, resulting in 141 articles that met all the inclusion criteria.Reading of the articles text in full was done independently by two investigators and the data of the 141 articles was summarized by the integrative review method 10 .Chart 1 provides a list of selected studies.The flow diagram of articles selection is presented in Figure 1.Fifteen thematic categories were identified in the 141 selected articles (Table 1).The most discussed thematic category in the analysed production was the implementation process of oral health teams in the FHS follow by teamwork process.The highest number of publications was found in 2010 with 26 articles focused on the review topic.The distribution of articles according to publication year is presented in Figure 2. The majority of the articles were published in national journals; only five were published in international journals.The journal with the largest number of published articles was 'Ciência e Saúde Coletiva' (n = 28) in the period between 2004 and 2014.The majority of the articles were published by authors from public universities (n = 114).Only eighteen articles had professionals working in primary care teams participating as authors.
The region in which the largest number of published articles originated was the Northeast (n = 61), followed by the Southeast (n = 37) and the South (n = 22).The regions with the lowest number of publications were the North (n = 2) and Mid-west (n = 5).Of the 141 articles, three were nationally based studies, and 11 were lit-Table 1. Absolute and relative frequency of articles on oral health in the Family Health Strategy (FHS), according to the topic covered, Brazil, 2004-2014.erature reviews on the topic, not representing any region.The categorization of the studies by Brazilian states is shown in Figure 3. Two articles presented information regarding only the region where they were conducted, not the state.As for the research method used, 42% were qualitative (n = 59), 57% quantitative (n = 80), and 1% qualitative and quantitative (n = 2).There was recently an increasing interest in investigating the context of oral health implementation in the FHS.Thus the years 2010, 2011 and 2012 had the highest number of publications, with the sum of articles published in that period being higher than the sum of publications in other years in the evaluated period and the majority of the authors are affiliated with public universities.

Discussion
The first finding is that there was recently an increasing interest in investigating the context of oral health implementation in the FHS.This investigative movement is most likely correlated with the more than a decade already spent in national trials with this type of care.In other words, the increasing national experience on the subject likely led to a deeper scrutiny and appreciation of its capabilities and limitations, justifying the greater frequency of publications in the years 2010, 2011 and 2012.
Three Brazilian regions originated the largest number of published articles (Northeast, Southeast and the South) and this distribution of the articles is characterized by geographical inequalities.Perhaps this can be justified by the local experience on the subject and distribution of dentists in Brazil, varies greatly by region 11 .
Analysis of the publications showed that the majority of the authors are affiliated with public universities; fewer professionals working in primary care teams participated as authors.The inclusion of professionals from the OHT/FHS as authors and not only as participants in the research is something to be considered in future studies as it would promote greater knowledge ownership in the scenarios studied, avoiding unilaterality of the knowledge produced 12,13 in addi-tion to stimulating the integration of education and health services (one of the guidelines for the paradigm shift in terms of professional training in health).
The second most discussed thematic category in the analysed production was the micro-process work of OHT/FHS.Perhaps this can be justified by the difficulties that teams still find in the practices recommended by the National Oral Health Policy in addition to the challenge of breaking with a working process marked since its formation by a clinical focused fragmentation [13][14][15] , suggesting the adoption of a model for comprehensive care centred on the families and people's needs 1,16,17 .Despite these difficulties, there are initiatives of professional oral health practices based on health education 17,18 and health promotion [19][20][21] .These produce improvements in health conditions and practices (20-22) as they are effective in reducing the weaknesses of specific groups and health inequity 22 , despite reduced intersectoriality [21][22][23][24][25][26][27][28] .
Another important theme evaluated was the insertion of OHT into the FHS, certainly a contentious process for most professionals as it involves the dynamic of the encounter between two not well resolved dimensions of a dentist's identity: academic training often focused on individual action and work in a multidisciplinary team of which he/she must be a part 14,22,29,30 .Studies show that these professionals are forced to reconstruct their identities, a paradoxical process marked by difficulties in breaking paradigms and incorporation of new practices 31 .In this sense, it is worth remembering that the OHT were inserted late in the FHS when compared to medical professionals and nurses 2,4 .
According to Chaves 32 , many dentists who work with the FHS experience this professional identity crisis determined by the conflicts generated by the need to rebuild their corporate identity and markedly influenced by the dentistry market and the challenging environment of the public space to be built in oral health services in the country.Real work experiences in Brazilian social spaces should be the starting point for the search of theoretical frameworks in academic training; this could be obtained if students were encouraged following graduation to take responsibility and perform caring interventions that overcome the fragmentation of professional acts, providing a critical exercise of the dimensions involved in public health work 33 .
From this perspective, it is noteworthy that dentists represent a contradiction between the initial perspectives related to the profession and the reality of the FHS 34 , which may result from professional training that did not favour the SUS, implying an inadequate profile [35][36][37] and justifying the need for permanent health education (oral) for both dentists 30,[35][36][37][38] and community health agents 39,40 .
Understanding the complex relationships in health requires the use of qualitative and quan-titative methods 41 .In the present study, despite identification of a higher number of quantitative studies, an increased interest and performance of qualitative research was found in addition to an increase in the space for their publication in biomedical journals.Some studies call themselves qualitative-quantitative, while to Turato 42 the epistemological constructions disallow this terminology; in most cases, these studies are quantitative, because the mere inclusion of literal quotations from the participants without use of coherent interpretive epistemology does not automatically legitimize the study as qualitative for the simple methodological allusion.
In this regard, we must stimulate critical reading of the literature, given that some fundamental misconceptions can be committed with the pretext of obtaining a publication, skewing results or making them at least biased 5,7 .As an example, in some studies equity of access to oral health services was evaluated through questionnaires and interviews with users.It is known that, to obtain more accurate information, the design of future studies should allow a direct approach to the access of services, which can be made possible through the inclusion of conceptual distinctions and of validated access/accessibility/utilization indicators.Equity of access to oral health services is not consolidated by the implementation of the OHT/FHS; it requires studies to establish the real expansion of access to/accessibility of services by different groups and the differential use of public resources 43 .
In any case, the impact of OHT/FHS's expansion in the growth (at least potential) of access to services and the corresponding impact on oral health conditions are important thematic categories, because they refer to the possibility of effective change in reality.However, these categories were addressed by reports of user satisfaction and analysis of clinical indicators (OHT productivity), thus limiting aspects, considering that impact studies would be more effective in assessing the effects of the strategy on the population 44 , which could be obtained based on other study designs and with the use of distinct indicators of epidemiological basis.
Regarding users, the majority seeking oral health services in the FHS is still women whose main motive is pain, a reflection of the high prevalence of dental cavities 45 , and they have reported being satisfied with the performance of the oral health team 36,46 .
Of the selected studies, we found only three of national basis [47][48][49] and two at the macro-regional level 49,50 showing the need for broad and specific research in this direction, especially when considering the size of Brazil and, therefore, its important contextual differences regarding population needs and the profile of the working process of the OHT/FHS in the various scenarios.
Studies indicate that FHS has positively impacted some health indicators in general terms 43,46,47 .However, the impact of the integration of OHT into the FHS on oral health indicators at the local and national levels is not yet defined.From this perspective, we point out that only one of the selected studies addressed this issue on a national level, in the so-called Family Health Program 29 .
Regarding access to dental care, it is observed that study results conflict, revealing that, while the current model of dental care has improved the access 30,36,51,52 , this is still considered an obstacle to overcome 51,53 .Some weaknesses of the care model were listed such as the limited universal access 50 , integrity of actions 54 , lack of epidemiological basis of the OHT work and of monitoring/actions evaluation 24,55 , and limitations in the reference and counter-reference process 24,36,38,55 .
Such paradoxes and limitations can be explained by the inconclusive nature of the reorganization of oral health care 56,57 and by the places where the studies were conducted (Brazilian states and municipalities), considering the continental dimensions of Brazil, certainly a reflection of what the cultural diversity and social determinants of health produce in the oral health-disease process.
It is possible that the inclusion of only published studies and only electronic search in this review may be a limitation as it could have excluded many studies.Despite of these limitation, with a critical analysis of the publications included in this study, it is shown that there are still thematic categories poorly explored by the published sci-entific literature, such as aspects related to financing/investment in oral health and its relationship with social inequities or in-depth analysis of the real impact of OHT/FHS actions on oral health indicators.Considering the thematic categories poorly explored, the lack of validated indicators to assess the efficacy of health care practice accurately could be a limitation faced by researcher, as well as the implementation process of public oral health policies in Brazil is not well-established, due to the later incorporation of Oral Health Teams into the Family Health Strategy and the issues of resource allocation, costs, and financing that still need to be overcomed 58 .
Future research should also look more deeply into the issue of the quality of the articles published with the aim of clarifying which research designs can provide the most valid and useful answer to the institutional and evaluative needs of oral health care in FHS.

Conclusion
It was concluded that, in the national scientific production, there has been a growing importance of the analysis of OHT performance inserted in the FHS.Future studies should not only include FHS workers in the authorship but also perform more conceptually in-depth approaches and with robust methodologies and analysis (multivariate analysis, multilevel logistic regression, analysis by triangulation of methods, mix methods), appreciating thematic categories such as the impact of OHT inclusion on the expansion/equity of access and use of services as well as the specific indicators of oral health conditions.For this, one must invest in differentiated methodologies that are sensitive to the proposed topic and that bring reliable subsides for planning/re-orientation of the OHT/FHS actions.

Collaboration
CE Dalazen was responsible for searching the bases data analysis, data interpretation and interpretation of the manuscript; AD De-Carli and SJ Moyses were responsible for the conception of the research, interpretation data and critical review of the final manuscript.
Cruz et al., 2009.Working process in the family health strategy: a perspective from the oral health team.Baldani; Antunes, 2011.Inequalities in access and utilization of dental services: a cross-sectional study in an area covered by the Family Health Strategy.Barbosa et al., 2007.Oral health care in the family health program, from its implementation to today's moment: Perceptions of dentists and assistants in municipality context.Stocco; Baldani, 2011.The control of babies' dental visits through the vaccines card: evaluating a pilot program developed at the Family Health Strategy at Ponta Grossa (PR, Brazil).Pires et al., 2007.Knowledge of oral health by community health agents: a perspective of educational deficiencies in the family health program.Ditterich et al., 2009.The work with family carried through for academics of dentistry in the family health strategy in Curitiba-PR: an experience practice.Cericato et al., 2010.A inserção do cirurgião-dentista no PSF: uma revisão crítica sobre as ações e os métodos de avaliação das Equipes de Saúde Bucal.Oliveira et al., 2012.The community health agents and oral cancer prevention.Medeiros et al., 2007.Dentist expectation about the insertion of oral health in the family health program.Carvalho et al., 2011.Dental pain in the previous 3 months in adolescents and Family Health Strategy: the comparison between two areas with different to oralhealth care approaches Viana et al., 2012.Analysis of access to dental services through the first dental programmatic appointment indicator in Pernambuco: a comparative study between the years 2001 and 2009.Soares et al., 2013.Inequalities in oral health care use in the primary care setting and associated factors in two Brazilian municipalities.Nascimento et al., 2013.Oral health in the context of primary care in Brazil.Silva et al., 2011.Analysis of the progress of the oral health teams inserted in the Family Health Strategy in Pernambuco, Northeast Region, Brazil, 2002 until 2005.Padilha et al., 2005.DENTAL Planning in the Family Health Program of the State of Paraíba: A qualitative study Busato et al., 2011.Evaluation of the perception of the oral health teams of the municipal health department of Curitiba, Paraná State, regarding atraumatic restorative treatment (ART).Neto et al., 2007.Restaurações diretas na ESF em Teresina.Direct restorations in the family health program in Teresina (PI).

Chart 1 .
Cavalcanti et al., 2012.Evaluation of users of basic attention healthcare about the implantation of an integral dental assistance protocol.Martello et al., 2012.Dental caries and factors associated in children aged three years enrolled in Family Health Units in the Municipality of Rondonopolis, Mato Grosso, Brazil.Macedo et al., 2008.Evaluation of the surgeon-dentists placed in the Family Health Strategy of the cityof Recife as for how appropriate is their knowledge concerned the actions in thisstrategy.Rodrigues; Bomfim, 2010.Oral health in the family health program of a municipality of the semi-arid region of Bahia (Feira de Santana): organization and micropolitics.Silva et al., 2011.Study on oral health of elderly patients linked to a Family Health Program, who take antihypertensive medication Marin; Leite, 2011.Prevalence of dental caries in 5-6-year-old schoolchildren assisted by the family health program in a medium-sized city of Minas Gerais -Brazil.Farias; Sampaio, 2011.Role of the dental surgeon in the family health team.Anjos et al., 2011.Brazilian oral health crew: advances and challenges.Author, Publication Year.Article title.

Figure 1 .
Figure 1.Flow diagram of selection of articles.

Figure 2 .Figure 3 .
Figure 2. Number of articles on oral health in the Family Health Strategy published in the period between 2004 and 2014.

Author, Publication Year. Article title Author, Publication Year. Article title.
Pimentel et al., 2012 1 .Characterization of the work process by oral health teams in municipalities in Pernambuco State, Brazil, according to population size: from community links to organization of clinical care.Melo et al., 2011.Accessibility to Oral Health Services in Primary Care: Unveiling the Absenteeism in a Family Health Unit of João Pessoa-PB.Lenzi et al., 2010.Profile of the dentists members of Family Health Program in a city in the South part of Brazil.

Publication Year. Article title Author, Publication Year. Article title.
Pimentel et al., 2010.Analysis of oral health attention in the Family Health Strategy of the Sanitary District VI, Recife, Pernambuco State.Moura et al., 2010.Profile and procedures of the community health agents regarding oral health in the countryside of Piauí State, Brazil.Faccin et al., 2010.Work process in oral health: seeking different looks to understand and transform the reality.Fonseca et al., 2013.The oral health of seniors in Brazil: addressing the consequences of a historic lack of public health dentistry in an unequal society.Moretti et al., 2010.Intersectoriality in health promotion actions carried out by the oral health team of Curitiba, Paraná State.Tonello et al., 2007.Assessment of oral health status of pregnant women participating in a family health program in the city of Lucas do Rio Verde -MT -Brazil Pereira et al., 2009.Inclusion of oral health teams in the Family Health Program and its impact on the use of dental services.Godoi et al., 2014.An oral health care network organized by large municipalities in Santa Catarina State, Brazil.Frazão; Marques, 2009.Effectiveness of a community health worker program on oral health promotion.Moura et al., 2013.Oral health in the family health strategy in a regional management territory of the state of Piaui.Nascimento et al., 2009.Oral health in the family health strategy: a change of practices or semantics diversionism.Palmier et al., 2012.Socioeconomic indicators and oral health services in an underprivileged area of Brazil.Almeida et al., 2009.The dental health of preschoolaged children resident in areas covered by the Family Health Program, in the city of Salvador, in the State of Bahia, Brazil.Martins et al., 2011.How primary health care professionals and residents assess issues related to the oral health of older persons?Koyashiki et al., 2008.The work in oral health of the Community Health Agent in Family Health Units.Lindoso et al., 2005.Caries active white spots and dental biofilms prevalences in children from 0 to 36 months of age, assisted by Family Health Program in Camaragibe -PE, Brazil.Author, Publication Year.Article title.
Lima et al., 2006.Early oral health care : family health team task.Santos; Assis, 2005.Relation net of buccal health practice's protagonist in the family health program in Alagoinhas-Bahía.Chart 1. Author, Publication Year.Article title.it continues Author,

Publication Year. Article title Author, Publication Year. Article title.
Martelli et al., 2008.Analysis of the oral health care model in cities of the state of Pernambuco.Carnut et al., 2011.Initial validation of the index of oral healtcare needs for oral health teams in the family healthcare strategy.Emmi; Barroso, 2008.Evaluation of oral health actions in the Family Health Program in the Mosqueiro district, Pará State, Brazil.Costa et al., 2010.Working Process of Dentist in the Family Health Strategy of Parnamirim-RN: Facing the Challenges of a New Care Model Santos et al., 2007.Conflicting situations in the reception of oral health teams from the Family Health Program in Alagoinhas, Bahia, Brazil.Almeida et al., 2010.Preventive action in oral health development in the Family Health Strategy: how are the dentists evaluating the results in its work process?Chaves; Vieira da Silva, 2007.Oral health care and health decentralization in Brazil: two case studies in Bahia State.Rodrigues et al., 2009.Dental health in feira de santana (BA) family health program: the surgeon dentist profile.Santos; Assis, 2006.From fragmentation to integrality: constructing and reconstructing the practice of buccal health in the Alagoinhas (BA) Family Health Program.Freire, 2013.The Family Health Strategy workers' perception of the oral health team performance in Goiânia-GO, Brazil, 2009: a qualitative study.Fakhouri, 2004.The real situation of the dentist inside the family health program.Soares et al., 2013.Constructing public oral health policies in Brazil: issues for reflection.Fischer et al., 2010.Primary dental care indicators: association with socioeconomic status, dental care, water fluoridation and Family Health Program in Southern Brazil.Rocha; Araujo, 2009.Working conditions of oral health teams in the Family Health Program: the case of North Health District in Natal, RN, Brazil.Mello; Moysés, 2010.Best practices in local health systems: focusing on the elderly's oral health.Turrioni et al., 2012.Assessment of educational actions on the oral health of adolescents within the Family Health Strategy.Melo et al., 2012.Oral healh National Policy and bioethics of protection by the integral care.França et al., 2007.Therapeutic with medicinal plants in the oral diseases: the perception of the professionals in the program of family health of Recife.

Publication Year. Article title Author, Publication Year. Article title.
Melo et al., 2012.Level of Information and Preventive Behavior of Patients Attending the Family Health Program of Aracaju-SE Regarding Oral Cancer.