Inequalities in the workforce distribution in the Brazilian Dentistry Desigualdades na distribuição da força de trabalho na Odontologia brasileira

This article aimed to describe the distribution of dental professionals in Brazil, through a narrative review. The approach is based on the assumptions which lead the individual in choosing such career and as well as their fragmented current practices due to the university educational curriculum process. Furthermore, data are revised on the geographical distribution of these individuals and the potential impacts, among others, in the epidemiological profile of the population oral health problems. It was evident that the workforce shifts as presented in different ways in society and influenced by social needs, public policy and market, play special roles. It discusses the urgency of socio-spatial redistribution of dentists, a role to be played collaboratively among different States in Brazil, regulatory and social control agencies. Finally, the role of dental courses in forming active subjects was highlighted, in the process of health improvement, aiming to build a more equitable and just society. Indexing terms: Dentistry. Mouth diseases. Workforce.


INTRODUCTION
The professional career choice is often made at a stage of life in which the young person can be influenced by the image of some professional of reference, by family pressure or even by the ideal of an activity which presents a certain social prestige.In the case of the choice by Dentistry it would be convenient to observe, in this preliminary problem, which professional inheritance will be updated by each dentist who chooses this career.
The surge of Dentistry as a modern profession, of higher-level, occurred in consonance with the social and commitment to health equity 10 .Efforts have been made in order to change this perspective.The Program for the Reorientation of Vocational Training in Health (Programa de Reorientação da Formação Profissional em Saúde -Pró-Saúde) 11 and the Program for Education through Work for Health (Programa de Educação pelo Trabalho para a Saúde -PET-Saúde) 12 are projects which could be examples which encourage multiprofessional experience, the use of technologies, in addition to the teaching-servicecommunity integration.Thus, the students are given the opportunity to approach the practices supported by SUS 13- 14 .
The SUS is nowadays the great workforce employer, and its growing association with the public service, both partially or integrally, has been relevant in Dentistry 5 .The inclusion of oral health actions in the Family Health Strategy, through Ordinance No. 1444, of December 28, 2000 15 , triggered dental care expansion through SUS 16 .Nonetheless, the public sector is not able to satisfactorily absorb the large number of professionals seeking for the stability offered by the system.Public contests have revealed that, in addition to newly trained professionals in search of the first job, there are those who have been in the market for years, however due to the current profession difficulties, they also dispute job opportunity in public services 17 .
These facts meet other studies which have questioned the role of the government in organizing the professions according to the role of university education 9 .Universities end up giving in to decisions based on the private world, determined by the laws of the market 18 due to economic and speculative pressure concerning the process of education and professional training together with the training apparatus expansion in dental area as part of the medical field 18 .Almeida-Filho 10 points out three facts which favor this situation: a) the immature young person, coming from expensive preparatory courses generally to enter undergraduate courses, such as Medicine, receives the imposition in career decision, is then part of an elitist higher education, based on individualistic values and actions; b) there is few incentive to promote a broad and humanistic view of diseases and health care; and c) curricula which focus on specialty, not interdisciplinary values.
This context reinforces the need for professionally training individuals who are able of critically understand their role within society, with a view to promote the population health improvement, supported health services enhancement, along with perceiving the changes introduced in the health sector and by overcoming the knowledge, even often mutilating ones.However, the National Curricular Guidelines for Dentistry undergraduate courses came precisely to boost the transformation process in the opposite direction to the model 2 .Thus, professionals with a general professional vision coming from Dentistry school disciplines and sociobiological factors which determine oral diseases as well as health promotion, these dental professional would be better suited to future trends, human and ethical aspects [2][3] .
In addition to this, the present narrative review aimed to describe the distribution of dental professionals in Brazil.

Dental professionals at present in Brazil
Brazil has been seeking to upgrade strategies in order to improve the oral health conditions, particularly proposed by government programs.As a consequence, pro-active professionals in the field of primary care, can have a promising career.
However, due to Brazil's development situation and the structuring of the health sector, which is still far from desirable, the country is characterized by inequalities both concerning diseases 4 and the distribution of health professionals in its territory [4][5] .
In the dental area, specifically, the private market has shown greater number of professionals enrolled in the Regional Council of Dentistry of the State of São Paulo, associated with better social indicators such as the Gini Index, the Condition of Life Index and the average per capita family income 6 .The same authors have stated that the principle of equity in public service has been followed, insofar as human and material resources are in accordance with the needs of the population.
It is observed that Brazil presents quantitative and qualitative imbalance in relation to oral health professionals, with marked consequences for the provision of services, either public or private.Quantitatively the country experiences a scenario of great disproportion concerning professional/inhabitants rate by regions 5 .In the qualitative aspect, university education does not offer adequate formation regarding the private market and the public sector needs [7][8][9] .According to the ideologies imposed by the higher education process itself, where private practice is stimulated, secondary employment is characterized by low paid though stable jobs 10 .Thus, the professionals working under the National Unified Health System (Sistema Único de Saúde -SUS) do not present the qualification profile, with actions based on evidence, training and medical hegemony posture in the health approach, so that the new professionals get involved in the search for justice and social equity 18 .
The Brazilian government, motivated by the concern to minimize the barriers generated by the marked inequalities in oral health, has launched proposals with this objective, as in the case of the Smiling Brazil Program, 2004 19 .Its objectives were to increase the number of oral health teams composed by dentists, auxiliaries and hygienists, and the acquisition of dental offices which resulted in coverage increase 19 .
Another aspect to be pointed out in this discussion refers to the increasing number of Dentistry courses in Brazil.In 1991, there were 83 presential courses; in 2004 this number rose to 174, representing an increase of 109.64% 17 .In 2009, the Federal Council of Dentistry (Conselho Federal de Odontologia -CFO) registered 191 colleges in the country 20 .The greatest concentration of openings for new courses and new vacancies occurred in the Southeast and South regions, followed by the Northeast 17 .Current data have shown that both public and private education courses are mostly concentrated in the Southeast region It is wise to observe the responsibility that the universities have in the presented context.The opening of Dentistry courses is a debatable and worrying topic in Brazil since the promulgation, in 1961, of the Law on the Guidelines and Bases of National Education, established financial and legal support for the private unviersities 17 .In order to understand the size of the Brazilian disproportion, a country like the United States of America (USA) in the years 2008/2009 had 57 Dentistry schools 21 , where the organization policy performs a certain "control" in the education, and what can be called "import" or "export" of professionals according to local needs.A survey of 35,000 dental professionals evaluated how this process really takes place in the USA, a process in which a number of conditions may determine whether graduates remain in the State where the course was completed.This analysis is essential for coping with labor-power problems in the country, characterized by irregular professional distribution 22 .In Australia, Canada and in European countries the highest concentration of professionals also occurs in urban areas [23][24][25] .
At the same time, Brazil faces a serious problem regarding the establishment of the professional and concentration of courses in certain regions, which could be remedied through organizational strategies in order to maintain professionals in the socially and economically disadvantaged regions, as well as a containment policy to open new courses in more developed regions.
Population aging is also an essential fact concerning changes related to the profession.Accumulated diseases, such as periodontal alterations as well as the teeth absence can impair the clinical condition that will be prevalent in the future.These facts do not occur exclusively in Brazil, as reported in other studies [26][27] .The European Union, for example, has for a long time been suffering from a decline in caries disease in the 12-year old group, in addition to the clear population aging.These facts change oral diseases scenario where the focus was on caries increase.Professionals have sought different alternatives to overcome the market crisis should be emphasized.Health care plans that include Dentistry cooperatives, insurance companies, so-called "Dentistry group", among others, have been increasing.These modalities tend to continue on the market as they become attractive to the client who considers them less expensive and in many cases even health benefit offered by many companies to their employees.All these facts add up and become highly profitable for the entrepreneurs of this branch [28][29] .
In 1998, 42.3% of the Dentistry course graduates stated that they intended to look for a stable job, instead of their own private dental clinics.This rate increased to 70.7% in 2003, revealing that the search for more stable jobs has been increasing 17 .
The last decade showed that 47.6% of the 614 professionals interviewed in a 2003 survey, developed by the CFO together with the Brazilian Institute of Socio-Economic Studies and Research, stated having had more profitably while working in dental cooperatives.The statement accounted for 14.7% of respondents 30 .
While discussing the labor market in Dentistry, it is necessary to point out possible private and public sector peculiarities.The private sector can be influenced by the patient's direct search for services both by financial situation and by educational and behavioral factors, such as the fear of the dental treatment.On the other hand, the public sector would be subject to the governmental organization, which follows a hierarchy of priorities, job functions, wages and adjustments according to the epidemiological scenario and the population needs.One of the greatest problems faced by this sector is due to the instability of the supply-service-demand ratio.
The issues mentioned above are in line with those highlighted by the CFO survey 30 .The major problems faced by dental surgeons working in the private/liberal sector are: material costs (40.8%), payment of fees (30.3%), social Inequalities in the workforce distribution in the Brazilian Dentistry level of patients (28.4%), and treatment prices (24.7%).In the public sector the main problems are related to wages (53.4%) and working conditions (36.0%) 30 .
Regarding the dental market in several neo-liberal countries, it can be observed a professional concentration in large urban centers, contrary to the popular mass without dental treatment access [22][23][24][25]31 , similar to Brazil. Pesonal characteristics and lifestyle choice 32 , added to geographical characteristics of the chosen place, family issues, leisure, earnings and job opportunities 25,33 are factors which influence the choice for services in a given locality 25,33 .
This irregularity of professional distribution was highlighted by the CFO survey 30 .The Southeast region accounted for 60.6% of the respondents, followed by the South and Northeast regions, with 14.5% and 12.4%, respectively.The urban area retained 96.9% of dentists.Another data showed that 89.6% of the professionals were self-employed, compared to 26.2% under public service, however 47.7% of the individuals would like to participate in some internalization program 30 .
Current research showed a significant concentration of professionals in the South and Southeast regions, with the State of São Paulo comprising 33.08% of the total number of dentists in Brazil 5 .However, a new and relevant data of this same research was the internal migration of dentists to population growth areas mainly on the North and Central-West regions.The Brazilian States that stood out for job transfer enrollment were Acre, Roraima and Amapá.The Federal District was also sought because of the greater concentration of public jobs and the high local per capita income 5 .
Unequal and markedly self-employed professional distribution is influenced by social and economic factors, with repercussions on the inadequate organization of services, whether in the public or private scenario.In this context, besides the professionals it is the user of the dental care who is in disadvantage, since he is often in a condition where he can not afford the treatment, but also can not access the public service network.
As for the provision of dental services, public policies aimed at increasing access are fundamental to overcome the stigma that Dentistry is a practice aimed at few, marked by social exclusion.
Professional disbelief in the government's performance in relation to health policies aimed at Dentistry was reported by 59.9% of respondents 30 .What role does the State play in this process, that is what kind of working conditions does the government offer for dental workers?First of all, the state government must be able to promote the regulation of labor relations and the practice of professions, considered as "critical nodes" for adequate sector management and for the protection of the consumers 34 .From there, the principles of efficiency and equity in health services can be reached.
It is important to clarify that there is no preestablished definition as to the proportion of ideal number of dentists according to the number of inhabitants.The World Health Organization states that this distribution varies according to socioeconomic, cultural and epidemiological factors 32.Some studies illustrate the different forms of professional distribution and performance in the country 17,[35][36][37] .Regarding the spatial distribution, the highest concentration of professionals is in the following order: Southeast, Center-West, South, Northeast and North, a pattern that follows the distribution of per capita income in the country 17 and is reinforced by the Survey of Medical-Sanitary Assistance of 2005 37 , which highlighted the professional concentration in the Southeast and South regions, followed by the Center-West of the country for any type of public or private health establishment.These distribution data corroborate with other findings, where the Southeast and South regions have emerged 5 .
Regarding the type of care provided, which characterizes the type of service, the 1998 National Household Sample Survey (Pesquisa Nacional de Amostra por Domicílios -PNAD) revealed that 69% of the dental services were private, against 24% public and 17% for other healthcare plans 35 .
In 2003, PNAD did not show very different data 38 .There was a predominance for private dental care by 67% of the population, however this was not repeated when the data were global for the search of health care, whose predominance was for care through SUS 38 .This last point is in line with what Girardi et al. 36 concluded, after analyzing national data, that from 1995 to 2000, unlike other workers, the health professions were the ones that most participated in the public sector at the same time that wages presented a considerable growth.
The public network was the one that most absorbed dentists, with emphasis on the municipalities 37 .In order to exemplify the professional importance in relation to the use of dental services, the increase of a professional to 1,000 inhabitants represents a 46.6% reduction in the chance that the individual will ever have a dental appointment, which also represents more service provision 39 .
Regarding the presence of the dental professional, the greater number of professionals may represent more access to the service 40 and to preventive collective strategies 41 .Another relevant point is that routine visits to the dentist have a very positive effect on reducing dental losses 42 .However, it is essential to highlight that the real impact of the professional action against oral diseases is controversial, since dental services represented only 3% of the reduction of dental caries in industrialized countries, against 65% relating to social and economic factors 43 .Furthermore, not even access to the dental service, where restorative treatments increased oral health improvement, still characterized by mutilating procedures 44 .Davenport et al. 45 reported that frequent visits to the dentist are related to a greater amount of filled teeth.
The impact that dental care has on the prevalence of oral diseases shows that the reduction of inequalities in oral health is not being addressed by public services, since individuals assisted in private and union services reported better health conditions concerning tooth appearance, masticatory capacity and perceived need for treatment 46 .
The importance of the training process in Dentistry is emphasized, so that the subjects are aware of the health sector improvement.A socio-spatial redistribution of professionals under favorable conditions is essential so as to provide dental service establishment and maintenance, a role to be played by the State, in partnership with the supervisory fiscal bodies of the profession and social control institutions.
It was concluded that the workforce in Dentistry is distributed with inequality, under the influence of social needs, public policies and the market scene, therefore resulting in the prevalence of oral diseases.

Collaborators
MCL GABARDO collaborated in the design of the study in the article.RG DITTERICH collaborated in the writing of the article.MR CUBAS collaborated on critical review of the content.ST MOYSÉS collaborated in the bibliographic survey and in the article.SJ MOYSÉS collaborated on the study, coordination on final reading and approval of the article for submission.