Dental procedure evaluation in the municipality of Florianópolis, State of Santa Catarina, Brazil

Objective: The aim of the present study is to evaluate oral health procedures carried out by primary care in the municipality of Florianópolis as well as its impairments and potentialities during 2014 and 2015. Methods: An observational epidemiological study was carried out based on secondary data obtained from the patient standardized and digital information Electronic Patient Recordin a health care network of the municipality. The data was obtained through the average of the ratio: each dental procedure performed to the number of patients who had accessed the oral health service in the period studied. The results were presented in their absolute and percentage forms. Results: it was shown that Florianópolis followed the national trend of dental procedure diversification and a decrease in the amount of tooth extractions performed in the municipality was observed. Conclusion: The findings of this study may impact the implementation of Oral Health Teams in the Family Health Program. Nonetheless studies on the functioning and activities of Oral Health Teams are necessary in order to qualify the dental care provided in the municipality. Indexing terms: Community dentistry. Family health. Public health.


INTRODUCTION
The Brazilian health system, instituted since 1988 with the promulgation of the Federal Constitution, is guided by leading principles such as the decentralization of care and the organization of health services, integral care to the patient and community participation [1].
The decentralization of health services has led each municipality to organize health care networks which have been offering users with comprehensive care to patients. Thus, the provision of health care went from the federal level to the municipal level, reaching the health system in 5,570 municipalities of the country [2,3].
The large legal framework which orients the formation of the Brazilian health system is clear as to the duties and responsibilities of the federated entities in the organization of the system, at the same time it is obscure as to the costing operations of an integral health care model [3]. Such complex features triggers each municipality in the direction of developing actions according to their local realities and organizational contradictions [4,5].
The Family Health Strategy (FHS), instituted by the Ministry of Health in 1994, included Dentistry -in the year 2000, under protocol 1. 444, in the scope of its actions, providing resource fundings for the dentist and auxiliary staff within the family health teams [6]. However, it was the implementation of the National Oral Health Policy in 2003, under the name of Brazil Smiling Program which has provided greater insertion of dentistry in the SUS (UHS -Universal Health System). with increased contribution to the cost of oral health teams, Center of Dental Specialties (CDS), Regional Dental Prosthesis Laboratories (RDPL), among others [6].
Oral health within the SUS/UHS presents similar challenges to other public health policies and programs, such as the fragile mechanisms for evaluating the quality of services offered, despite the recent implementation of the Basic Care Quality Improvement Program (BCQIP) [7]. The main objectives of the program are to increase access as well as improve the national, regional and local primary care quality in order to to allow greater transparency and effectiveness of government Primary Care (PC) actions [7]. The objective of the present study is to evaluate the oral health procedures performed by primary care in the municipality of Florianópolis in the years 2014 and 2015 in order to assess the barriers and potentialities of the oral health care process in the municipality.

Study site
The municipality of Florianópolis is the capital of the state of Santa Catarina. According to the 2010 census of the Brazilian Institute of Geography and Statistics (BIGS) Florianópolis has 342,315 inhabitants, with 0.85% of the population living in great poverty and 40.08% have private health plans. According to data from the Department of Primary Care of the Ministry of Health Florianópolis has 137 Family Health Teams, 60 -Oral Health Teams, 420 Community Health Agents (CHC), 11 Family Health Support Centers (FHSC) and 1 itinerant dental office. Coverage by family health teams is 100% and by oral health teams 43.32%. The municipality offers two medium-complexity dental specialitiy services (DSC) to the primary health care teams. The Basic Health Care Network was divided into 5 Health Districts by Health Centers: North, South, Central, Eastern and South. The distribution followed geographic and population criteria. All the basic care teams present electronic medical records and made available in the municipal information system.

Data collection
The data was taken from the Electronic Patient Record (INFOSAÚDE -Electronic Health Record System of the Florianópolis Health Department), which integrates all patient standardized and digital information in a health care network of the municipal), with the prior authorization of the local authority of the Municipal Health Department of Florianópolis, as well as the data of the Family Registry in primary care (CADFam Online System/FRPC).

Data analysis
Production data was obtained through the average ratio of each dental procedure performed by the number of patients who accessed the oral health service in the period studied. The variables related to the procedures performed were as follows: Access to dental pulp and medication; topical application of fluoride; tooth extraction; permanent tooth extraction; scraping, smoothing and supragingival polishing (by sextant); subgingival scaling, smoothing and polishing (by sextant); tooth restoration; restoration of anterior permanent tooth; total of procedures. The data were tabulated in spreadsheet of the Statistical Package for the Social Sciences (SPSS) version 20.0 and presented in their absolute and relative frequencies.

Ethical aspects
Since only secondary data were used, this study has not required the approval of the Research Ethics Committee (REC).

RESULTS
The data was presented according to the health areas / regions of the city of Florianópolis in relation to their absolute and relative frequency by dental procedure performed.

South district
According to table 1 the Southern District, the "pulp access" procedure shows the highest percentage of achievements in the South ECU (Emergency Care Unit) corresponding to 66.7% (3,462) of total pulp accesses in the district, followed by the Health Centers (HC) of Tapera, with 10.2% of the total (532), and Coast of Piranjubaé (390), with 7.52%. It is noteworthy that in the period evaluated, in the years 2014 and 2015, this procedure was not registered in the HC of Carianos. On the other hand, the procedure 'topical application of fluoride' showed a higher prevalence in the Southern District in Pântano do Sul Health Center.
The highest prevalence in deciduous teeth procedure is the Coast of Piranjubaé Health Center corresponding to 25.66% (173) of the total performed in the District in the years 2014 and 2015, followed by the Health Center of Armação with 94 tooth extractions (13.94%) and Tapera (93.7%). The low record of this procedure was observed in the HC of Barra do Sul, with only 1.79% of the total 'primary tooth exodonts' when compared to the other Health Centers of the Southern District in the years of 2014 and 2015. The highest prevalence in the Southern District is found in the HC of the Piranjubaé Coast with 32.08% (625) of the total, followed by HC Fazenda do Rio Tavares and HC Tapera with 10.18% (194) and 9.97% (190) respectively. On the other hand, the HC of Caieira da Barra do Sul recorded only 16 permanent tooth extractions in the period of data collection, corresponding to 0.83% of the total number of permanent tooth extractions performed in the Southern District.
Regarding the supra-gingival scraping procedure, the highest prevalence was found in the Piranjubaé Coast Health Center, followed by the Health Center of Pântano do Sul, Rio Tavares, Tapera, Campeche and Carianos Health Centers with absolute and proportional numbers respectively, thus distributed: 2839 (20.08%), 2232 (15.78%), 2163 (15.3%), 1676 (10.97%) and 1551 (10.9%). It is was noted that the South Health Center, characterized as a care unit for clinical urgency patients, was also included in the supra-gingival scraping procedure.
As to the subgingival scaling procedure, the prevalence in descending order was observed, distributed as follows: HC of Costeira Piranjubaé (57.95%), Tapera HC (22.23%), Caieira da Barra do Sul HC (14.54%), Ribeirão da Ilha HC (1.8%) and finally Campeche HC (1.5%). No record for this procedure was found in the Pântano do Sul C during the period studied.
With reference to restorative procedures in deciduous teeth and permanent and anterior teeth, the Piranjubaé Coastal HC was the one to perform the most of these procedures representing, respectively, 30.7%, 20.93% and 21.83% of the total, followed by the HC of Tapera as the second Health Center, with proportional numbers presented, respectively: 18.8%, 13.18% and 14.17%.

North district
The 'access to pulp' procedure carried out in the North District in the years 2014 and 2015 showed that North Health Center recorded 84.55% (5961) of all accesses performed in the Sanitary District. At the same time, the HC of Vargem Grande recorded only 2 (0.02%) accesses of dental pulp in the period. The 'topical application of fluoride was reported more frequently in the HC of Rio Vermelho, 1092 (33.44%), HC of Ingleses, 1027 (31,45%) and Santo Antonio Lisboa and CS Health Centers 365 (11,17 %). There is no record of this procedure in the HC of Vargem Grande.

Continent district
The highest prevalence of access to dental pulp in the Continent District is found in HC Monte Cristo with a total of 1560 (38.19%), followed by the HC Novo Continente with 496 (12.14%) accesses performed. The Health Centers of Coqueiros and Estreito showed 379 (9.28%) and 344 (8.42%) accesses to the dental pulp, respectively. On the other hand, HC of Continente did not register this procedure and in the years 2014 and 2015 the Health Centers of Vila Aparecida and Abraão performed only 47 (1.15%) and 27 (0.66%) accesses to the dental pulp. Concerning the topical application of fluoride, three Health Centers, Coqueiros, Abraão and Estreito, performed more than half of this procedure (53.46%) in the Continent District.
With regard to data on the 'deciduous tooth extraction' procedure, the Monte Cristo Health Center performed almost one third (31.61%) of all extractions in deciduous teeth throughout the Continente, followed by HC of Novo Continent, with 17.54% of extractions in deciduous teeth. Concerning the extractions in permanent teeth it was observed that the records were maintained, where Monte Cristo HC performing 34.36% of the total in Regarding the supra-gingival scraping procedure in the Continente District, it was observed that this procedure was performed 9269 times at Monte Cristo HC corresponding to 22.63% of the total and the Coqueiros HC performed the same procedure 8038 times, corresponding to 19, 63% of the total. In contrast, the HC of Vila Aparecida and HC Continente registered this procedure 517 (1.26%) and 246 (0.6%).
In relation to deciduous and permanent anterior and posterior teeth restorations, the Monte Cristo HC recorded 34.85%, 24.07% and 28.31% of the total of these procedures in the Southern District (table 3).

Central district
As shown in table 3, the 'pulp access' procedure in the Central District presents a higher record percentage in the municipal information system at the Agronômica Health Center, with 732 (31.08%) pulp accesses made in the period from 2014 to 2015, followed by Trindade and Prainha HCs, respectively, with 613 (26.02%) and 452 (19.19%) procedures performed. On the other hand, during the evaluated years, in the HC of Saco dos Limões, this procedure was carried out only 47 times, corresponding to 1.99% of total accesses in the Center District. On the other hand, the 'topical application of fluoride' procedure presented a higher prevalence in the Trindade HC and was performed 938 times, corresponding to 42.1% of the total, compared to the other Health Centers of the Central District. It was also observed that the Health Centers which carried out this procedure were the Health Centers of the Center and Agronomics, with respectively 428 (19.21%) and 290 (13.01%) fluoride applications. It Table 3. Distribution of dental procedures performed in the Continent District of Florianópolis in the years 2014 and 2015. should be pointed out that this procedure, unlike the other procedures studied, was recorded by person and not by the dental unit

Dental pulp acess and medication (by tooth) Topical application of fluoride (per session) Exodontics of deciduous tooth Exodontics of permanent tooth Scraping, smoothing and supragingival polishing (by sextant) Subgingival scaling and smoothing (by sextant) Deciduous tooth restoration Permanent anterior tooth restoration
As to the deciduous teeth extraction the record distribution in decreasing order was as follows: Agronômica HC, 203 (27.88%); Prainha HC, 139 (19.09%); and Center of Dental Specialties (CDS), 126 (17.3%). In the evaluated period, Center HC performed only 15 exodonties in deciduous teeth, corresponding to 2.06% of all the extractions carried out in the Central District. Analysis of the same period showed that 'permanent tooth extraction' to have higher prevalence in the HC of Agronômica com 427 (21.39%) extractions performed on permanent teeth in the period, followed by Prainha (18.33%) and Saco dos Lemons HCs (17.63%). Regarding the supra-gingival scaling procedure, the Agronomica, Trindade and Central HCs performed the majority of this procedure with 5965 (31.10%), 4271 (22.26%) and 3214 (16.75%) scraping. It must be emphasized that the record of this procedure is performed by sextant in the individualized odontogram of the municipal information system, thus, in the same appointment, which can show 6 registrations per patient leading to high values when compared with the other procedures. Even though the supra-gingival scraping is a clinical primacry care characteristic, it was performed in the medium complexity (CDS-Center) 985 times, corresponding to 5.13% of the total performed in the Central District. On the other hand, subclinical scaling was more prevalent in the Center District in Trindade (63.88%), Prainha (26.90%) and Monte Serrat HCs (6.36%). Due to its surgical characteristic this procedure is considered of medium complexity ( the open field), therefore, it is worth noting that the Center for Dental Specialties of recorded 6 times of this clinical practice, equivalent to 0.32% of the total subgingival scaling, over the two years analyzed in the Sanitary Center District. In contrast, the CDS center is the health unit in the District which performed most restorations on deciduous teeth, 619 (24.23%), followed by the primary care units of Prainha, 555 (21.73%), Agronômica, 511 (20%) and Trindade, 428 (16.78%). Low recording of this procedure was found in the Central HC, with only 62 restorations in primary teeth, representing 2.42% of the total.

Eastern district
As for the pulp access procedure, the highest prevalence of records in the municipal information system during the analyzed period was found in the HC of Barra da Lagoa, 700 (30.67%), followed by the HC of Saco Grande, 650 (28, 48%), João Paulo HC, 229 (10.03%). Regarding this procedure, the HC Pantanal reported that at least 4 (0.17%) reported this procedure in the Eastern District during the analyzed period.
In relation to 'topical application of fluoride', Saco Grande HC presented a higher prevalence, 605 (28.19%), followed by Barra da Lagoa, 631 (29.40%) and Itacorubi HCs, 361 (16.82%). On the other hand, this procedure characterized as preventive was not registered by the Pantanal HC.
As far as deciduous and permanent exodontia is concerned the records in the Eastern District present similarities: Saco Grande 182 (28.43%), 452 (28.19%); Barra da Lagoa HC 129 (20.15%), 262 (16.34%); Itacorubi HC, 88 (13.75%), 257 (16.03%), respectively Again, the Pantanal HC has not Table 5. Distribution of dental procedures performed in the Eastern District in the years 2014 and 2015. presented a record of the permanent tooth extraction procedure in the period of 2014 and 2015 and only 1 (0.15%) record of the primary tooth extraction procedure in the period. The HC of the Costa da Lagoa did not show extraction in deciduous record in the studied period.

Dental pulp acess and medication (by tooth) Topical application of fluoride (per session) Exodontics of deciduous tooth
Regarding the subgingival smoothing and scaling procedure, by sextant, the highest records were found in Canto da Lagoa HC, 822 (37.84%), followed by the Barra da Lagoa HC, 641 (29.51%). In the Eastern District, this procedure was not registered in the Pantanal HC during the years 2014 and 2015. Regarding to scaling and supragingival root planing, by sextant, Pantanal HC presented only 12 records, corresponding to 0.05% of the total registered in the Eastern District.

DISCUSSION
For comparison purposes, the data collected in the present study in Florianópolis were assembled into four groups: 1. Restorative procedures (includes restorative procedures in deciduous teeth, anterior permanent teeth and posterior permanent teeth); 2. Preventive procedures (topical application of fluoride); 3. Surgical procedures (includes extractions of deciduous teeth and permanent teeth); 4. Periodontal procedures (includes scraping and supragingival smoothing by sextant and scaling and subgingival smoothing by sextant).
In a similar study, Barros [8], Viana and Chaves have analyzed the profile of dental procedures performed in 11 municipalities in the State of Bahia. In four municipalities in Bahia, there was an increase in the percentage of preventive procedures from 1999 (0.2%) to 2006 (14.3%), concomitantly with the implementation of FHS. Other cities presented a small increase in their percentage of preventive procedures performed, such as the city of Salvador, capital of Bahia: 31.6% in 1999 to 32.1% in 2006. In Florianópolis, where FHS implantation dates back to 1996, the percentage of preventive procedures in the present study was 5.32%, suggesting that the implementation of the model of care recommended in the FHP encourages the adoption of preventive measures in oral health, despite the percentage amount of activities is still small. In Florianópolis, 29.63% of all procedures performed were restorative. In Bahia, until 2006, all municipalities started to perform restorative procedures, accounting for 66.7% of dental procudures, showing a wide difference between the percentages in the two States. This fact can be justified by the late expansion of FHS coverage in the municipality of Florianópolis or in the disease burden of the different populations. It is important to highlight the need to implement epidemiological surveys in the region in order to identify whether the needs of the population and the procedures performed are aligned.
Surgical procedures in Florianópolis have accounted for 6.66% of the total number of procedures performed. In the municipalities of Bahia, the exodontia accounted for 21.4% of the total number of procedures. In municipalities in the interior, this index was even higher: in Muquém de São Francisco (BA), 62.5% of the procedures performed in 2006 were exodontia. FHS implementation and the consequent increase of the preventive and restorative procedures, may improve the Dentistry of the municipalities of Bahia, similar to the Dentistry of Florianópolis.
The periodontal procedures represented 58.37% of the dental procedures performed in Florianópolis, analyzed in the present study. Of the 11 municipalities in Bahia, 5 did not offer periodontal procedures in 1999, prior to the implementation of the FHS. At the end of the analysis, in 2006, 10 of the 11 municipalities were performing periodontal procedures.
Barros and Chaves [9] have also observed diversification of dental procedures over time (an increase of restorative and periodontal procedures) and the emergence of preventive and collective procedures in other municipalities, which was related to health municipalization and therefore consequent increase in the primary health care.
When the total number of dental procedures performed per thousand inhabitants is expressed, a significant increase at the national level from 60 procedures per thousand inhabitants in 1994 to approximately 100 procedures per thousand inhabitants in 2007 can be observed. The Brazilian Souther Region itself, where Florianópolis is located, presents an increase in the same proportion: from 70 procedures per thousand inhabitants in 1994 to approximately 110 procedures per thousand inhabitants in 2007.
Other studies have suggested that the presence of oral health technicians and dental assistants (OHT and DA, respectively) in health teams increases the access of the population and the productivity of professional dental surgeons [11]. In this context, Florianópolis presents 46.99% coverage of OHT with the presence of OHT and DA, leading to understand that the expansion of the oral health care network, with complete OHT teams, will positively impact the curative and preventive measures in the municipality.

CONCLUSION
It is observed that Florianópolis has followed the national trend of diversification of dental procedures over time, since in the present study the preventive procedures were responsible for 5.32% of the procedures performed. It is also verified that Florianópolis followed the national drop in the number of exodontics performed, since the present study showed that the exodontics represented only 6.66% of the dental procedures performed in the city. The present study may show the impact of OHT implantation in FHS. However, further studies on the functioning and activities of OHT implanted can help managers to optimize oral health actions in order to improve the dental care provided in the municipality.