Use of dental services by psychoactive substances users at the Psychosocial Alcohol and Drug Care Centers in the Greater Vitoria area, ES Utilização de serviços odontológicos por usuários dos Centros de Atenção Psicossocial Álcool e Drogas da Região Metropolitana de Vitória, ES

Objective: The use of and access to dental services in Brazil are unevenly distributed, despite governmental efforts to make the national health system universal and egalitarian. This study aims to evaluate the access to and use of dental services by psychoactive substances users at the Centros de Atenção Psicossocial Álcool e Drogas (Psychosocial Alcohol and Drug Care Centers) in the Greater Vitoria area, ES. Methods: A transversal study was conducted with 280 participants. Five scripts were used for data collection, one for socio-demographic data and health perception, another for oral health, along with the Oral Health Impact Profile, the Alcohol Smoking and Substance Involvement Screening Test, and the World Health Organization Quality of Lifeinstrument. Data were displayed infrequency tables. The association between demographic factors with drug use, frequency of use and quality of life was tested using Fisher’s test. The Odds Ratio was used to determine the strength of the association. Results: Dental services were used 32.14% of the study population and individuals at high risk for crack dependence were 2.3 times more likely not to use dental services in previous 6 months. Conclusion: The study population showed a satisfactory utilization of the dental services offered while individuals at higher risk of crack addiction used them much less frequently. Indexing terms: Dental care. Drug users. Oral health.

Although the importance of dental care has been widely acknowleged, a considerable portion of the Brazilian population has never been to a dental surgeon. The use ofand access to dental services in Brazil disproportionally favors higher income individuals, despite the efforts to make the health system universal and equal [1,2].
A reduction in this inequality was observed in the data collectedby the Pesquisa Nacional por Amostra de Domicílio (PNAD) (Brazilian National Household Survey), conducted in 1998, 2003 and 2008, which showed a 20% decrease in the inequality of access to and use of dental services between higher and lower income groups in the country. This comparison also shows that even with this reduction, the demand for dental services still ranks third amongst the reasons for seeking health care [3].
The use of dental services reflects the health status of the population, as care and prevention reduce the occurrence of oral diseases through the control and treatment of diseases. While this mitigates unfavorable health conditions, access to health services is largely impacted by social status, income and schooling. Educational level has direct bearings on health inequalities and may be regarded as the main barrier to access dental services. Oral health status, in turn, is directly related to the use and frequency of use of dental services [4].
Both low family income and low educational level affect psychoactive substance users more intensely when it comes to access to dental services, since this population seek much less frequently medical and dental care either for treatment or prevention. They often display lack of interest in personal care such as oral and body hygiene, which may feed further drug abuse [5].
The Estratégia de Saúde da Família (ESF) (Family Health Strategy) initiative has been the focus of the Brazilian government in recent years, aiming to improve primary health care. The Ministry of Health has encouraged the substitution of the traditional unequal model for the provision of public dental services, so that all had equal access, regardless of social class. This new approach has emphasized a preventive rather than curative approach and was translated into the implementation of Equipes de Saúde Bucal -ESB (Oral Health Teams) in the ESF [6].
The CAPS ad are designed as recreation, resignification, care and reception facilities, mediating the subjective and sociocultural values of patients and society. To meet such goals, CAPS ad must be articulated with other services, such as health units and hospitals [7]. However, the CAPS ad have not yet incorporated dental professionals in their health teams [8], which makes referring to dental services rather challenging.
In view of the above, the aim of this study was to determine the prevalence of use of dental services in the previous t 6 months by psychoactive substances users at the Centros de AtençãoPsicossocialÁlcool e Drogas (CAPS) ad of the Greater Vitória area, state of Espírito Santo. We also aimed at assessing the association between the use of these services and socio-demographic variables, quality of life, impact of oral health on quality of life and consumption of psychoactive substances. The target population of this study was substance users patients 18 years of age or older; we excluded those presenting psychiatric comorbidities or disruptive behavioral problems.

METHODS
Sample calculation was performed using the Bioestat (version 3.1) statistical software, consideringapopulation of 1,000 individuals, with an estimated 50%, prevalence, a 95% confidence level and a 5% sampling error, resulting in a minimum sample of 278 individuals distributed among the three CAPS ad.
Convinience sampling was used and individuals were invited to participate in the study during their activities at the CAPS ad, pending consultations or an individualized approach. Users who agreed to participate in the study were directed to a room and the five questionnaires were administered (30-40 minutes). Only the participant and the researcher remained in the room.
In order to obtain a more accurate representation of the three CAPSs, a visitation schedule was developed, with hours of visitation equally alloted, thus ensuring equal opportunity for participation.
Data collection was structured through a pilot study conducted by the researchers in 2014, involving inmates of a Therapeutic Community in the city of Vitória, ES. This study aimed to evaluate the sociodemographic profile and to describe the psychoactive substances most used by inmates of this Therapeutic Community in the three months prior to the research. The pilot study was approved by the Research Ethics Committee involving human beings (CEP) of UFES, on August 27 of the same year.
Data were collected from interviews carried out by three researchers, and were properly registrered. Five scripts were used to collect: socio-demographic data on oral health status, self-reported need for and access to dental treatment (using an instrument designed by the researchers) as well as the OHIP-14, WHOQOL and ASSIST scripts, previously validated for epidemiological research in Brazil [9][10][11].
To collect data on the impact of oral health on quality of life, the OHIP-14 questionnaire was used, and responses were coded (Lickert scale) with five options for each problem experienced in the previous 6 months: always, often, sometimes, rarely and never. The evaluation of the answers were dichotomous, and the answers "sometimes" "rarely" and "never" indicated that there was no impact and "always" and "often " answers indicated otherwise.
For general quality of life, the 26 item WHOQOLbref questionnaire was adapted, with only the first two questions used in our study. The first one refers to the general quality of life and respondents could choose among "very poor", "poor", "neither poor nor good", "good" and "very good". The second refers to satisfaction with their own health and respondents could choose among "dissatisfied", "neither satisfied nor dissatisfied", "satisfied", "very satisfied", used in a dichotomous way.
To determine the consumption of substances, the structured ASSIST questionnaire, with eight questions regarding use of any of the following: tobacco, alcohol, marijuana, cocaine, stimulants, inhalants, sedatives, hallucinogens and opioids, along with the frequency of use in the previous three months, the desire or craving for drugs, difficulty in controlling, reducing or interrupting use, problems related to use, noncompliance with duties and commitments due to use, concern with the use by people close to them, and drug injecting.For each, a score was given, and if the total score was between 0 and 10 for alcohol and 0 to 3 for other substances, this would indicate low risk of addiction, while a total score between 11 to 26 for alcohol and 4 to 26 for the other substances would indicate a moderate risk. A total score above 26 would indicate a high risk of addiction.
The dependent variable of this study was the use of dental services, obtained from the oral health questionnaire.
The independent variables were extracted from four instruments: sociodemographic profile of the participants (gender, age, color, marital status, schooling, head of household, family income, source of income, government stipend, housing, all obtained from the sociodemographic questionnaire), data on health status and quality of life (health status in the previous 30 days, whealth satisfaction and self-rated quality of life were obtained from questions 1 and 2 of the WHOQOL questionnaire), data on the consumption of substances (marijuana, cocaine, crack, crack / cocaine, alcohol and tobacco, through the ASSIST questionnaire), while data on the impact of oral health on quality of life was obtained from the OHIP-14 questionnaire.
A descriptive analysis of the data was carried out using frequency tables with a number and percentage for each item of the research instruments. The associations between use and frequency of drug use and quality of life and demographic factors were tested using Fisher's test. The strength of association between the variables was tested using the OddsRatio (OR). Significance level was setat 5%. Data were analyzed using the IBM SPSS 20 statistical package.
As for family income, only 6.7% (n = 19) of the families of the participants earned more than three minimum wages. 34.7% (n = 97) earned the minimum wage or less. Only 10.4% (n = 29) of the sample worked on a regular basis or as self-employed, 35.4% (n = 99) received some kind of state benefit and only 3.9% (n = 11) had no income at all. 88.6% (n = 248) did not receive any family stipend. Regarding housing conditions, 38.6% (n = 108) lived in their own homes, 7.1% (n = 20) lived in shelters and 13.6% (n = 38) were homeless and only 7.2% (n = 16) reported more than 6 residents at home (table 1). When questioned about substance addiction, 78.9% (n = 221) of the sample reported being addicted and 61.8% (n = 173) underwent previous treatment for addiction at a range of health facilities, e.g, CAPS 17.3% (n = 30), private clinics 10.4% (n = 18) (table 2).
Regarding the use of dental services, 96.8% (n = 271) of the individuals had already visited the dentist at some time in their lives and 32.1% (n = 90) saw a dentist in the previous 6 months, while 59.3% (n = 166) reported having toothache. Dental pain was reported by 61.3% of the participants as the main reason for dental appointments. Regarding the need for treatment, 96.4% (n = 270) reported needing some type of dental treatment, 57.9% (n = 162) reported needing a prosthesis and only 24.3% (n = 69) used some sorte of dental prosthesis. A large part of the studied population 39.3% (n = 110) considered their oral hygiene satisfactory (table 3).
We found no statistically significant associations between the use of the dental service variable in the previous six months and the socio-demographic variables of the sample (table 4).
Also, no statistically significant associations were found between the use of the dental service with general quality of life and the impact of oral health on quality of life. A potential association between the use of specific substances such as marijuana, cocaine and the consumption of cocaine and crack was not oberved, either. However, a significant association was found when the drug delivery system used suggested crack addiction and individuals at high risk for crack addiction were 2.3 times more likely to not having used dental services in the previous t 6 months (table 5).

DISCUSSION
In our sample, the most frequent characteristics were as such: male, under 52-year-old, brown, single, and had not inished high school. Other studies involving users of psychoactive substances concur with our data [12,13]. Low income also prevails (less than two minimum wages) as well as a large number of individuals without regular work or self-employed. Our findings corroborate a study carried out in two CAPSs in São Paulo, which used a similar sample, and found that use of psychoactive substances affects a large number of individuals in an active phase of working life. Low family income and schooling contribute to a stronger addiction, and to the unwillingness to seek medical or dental care [5].
Most of the sample reported being substance addicted and had already undergone previous treatment for addiction, with most of these treatments being carried out at therapeutic communities (48.6%). This may account for the fact that although there are many Therapeutic Communities in Brazil, they lack an adequate system of supervision and, despite professing the principles and methodologies of the Anti-Asylum Movement and the Psychiatric Reform, many still fail to offer dignified care and satisfactory quality of services [14].
Our findings show that the most of the population studied had visited a dental surgeon in their lifetime, but many did not have the opportunity to see a dentist in the previous six months. The main reason for seeking dental care was dental pain. The prevalence of use of dental services in the previous 6 months was 32.14%. Studies assessing the use of dental services by users of psychoactive substances have shown that in China, 89.89% of the participants had not seen a dentist in the previous year [15], while in the United States, only 32% visit a dentist in the 6 months prior to the study [16]. The population here studied had similar access to and use of dental care to that found in the United States.
Regarding use of dental services in the Brazilian population in general, a study carried out in Florianópolis, SC, found a 66.8% prevalence of use [17]. Data from the southeastern region of Brazil show that the prevalence of use in the previous year was 46.5% in the 35-44 age group, while the national average was 49.1% in the previous 12 months [18].
The different cutoff points adopted to report the use of dental services by addicts restrict comparisons with some previous studies.
Given that the data collected in our study were related to the six months prior to the date of the interview and the fact that the data discussed above refer to the previous year, the 32.14% prevalence of service use detetected would be similar to that of the general population. The fact that the population here studied presented a satisfactory prevalence of use, but a high prevalence of dental pain (59,3%) and a clear need for dental treatment, suggests that the users of psychoactive substances at CAPS ad in Greater Vitoria area were able to access dental services, but their oral needs were not met.
A study carried out with two ESF teams in the countryside of São Paulo, aimed at identifying how drug user care is performed in basic health units, has found that, once the patient is identified as user of psychoactive substances, professional care becomes loaded with prejudices, and fails to provide an integral care [19].
Another study carried out in Fortaleza, Ceará, has shown that the ESF professionals find it difficult to establish links with crack users. This bias contributes to the centralization of assistance in specialized services, such as the CAPS ad, reinforcing the misguided assumption that the institutional model is the most effective approach [20].
The CAPS ad must be tied with both the Basic Health Units and the Family Health Strategy, in order to meet all the needs of the individuals who use these facilities. The lack of dental professionals within the CAPS ad, add to the health workers the burden of referring substance users to the dental health sector of the ESF.
Surveys involving users of psychoactive substances and dental surgeons should be carried out with the objective of evaluating the effectiveness of dental services and the reception offered to this population.
When questioned about the need for dental treatments, 96.4% of the sample reported needing some type of dental treatment and 57.9% reported the need to use some type of dental prosthesis. The data corroborate a study conducted in the United States, which found that 44% of individuals reported having access only to basic dental treatments, and no access to specialized services, while the main reason to visit the dentist was toothache [21]. Another study conducted in the United States has shown that 81% of substance users self-report their dental condition as poor, in need to be improved [22].
Despite the large number of individuals reporting pain in the previous 6 months and need for dental treatment, only 23.9% considered their oral hygiene to be poor.
No statistically significant associations were found betwenthe study variable and the socio-demographic data. A study carried out in the United States found an association between high school graduates and fewer reports of urgent dental care needs [16]. The association of these variables were not found in the relevant literature.
When the study variable was compared to general quality of life and impact of oral health on quality of life, no statistically significant association was found, nor a possible association with the use of specific substances such as alcohol, tobacco, marijuana, cocaine, and the associated consumption of cocaine and crack.
When a possible association between the use of specific substances and the use of dental services was found, a statistically significant association was found for users in high risk for crack addiction. These individuals were 2.3 times more likely to report non-use of dental services in the previous 6 months. Of the studies found in the literature, only one -conducted in the United States and involving 563 users of various substances-assessed the use of the service with substance use, and found no statistically significant association between the use of specific drugs and the time since they last visited a dentist [23].
Conducting studies with a design that would allow a comparison between substance users and non-users, as well as studies with dentists working in primary care, are needed to better understand the relationship between use of dental services and the use of psychoactive substances.

CONCLUSION
The individuals undergoing treatment for the use of psychoactive substances at the CAPS ad in the Greater Vitoria area present a satisfactory prevalence of use of dental services. Our findings demonstrate that individuals at a higher risk for crack addiction rarely make use of oral health services.
The Basic Health Units and the Family Health Strategy need to design effective strategies both for caring and creating permanent links with psychoactive substance users, so that all their health needs, including oral care, are met ain line with the SUS tenets.
Greater attention should be paid to crack addicted individuals, since the study indicates that these CAPS ad patients in the Greater Vitoria area seldom use dental services.
Primary care professionals, especially dental surgeons, need qualification to provide comprehensive and continuous care to users of psychoactive substances that seek dental or are referred to them.