Advances and challenges in oral health after a decade of the “Smiling Brazil” Program

ABSTRACT OBJECTIVE To analyze oral health work changes in primary health care after Brazil’s National Oral Health Policy Guidelines were released. METHODS A literature review was conducted on Medline, LILACS, Embase, SciELO, Biblioteca Virtual em Saúde, and The Cochrane Library databases, from 2000 to 2013, on elements to analyze work changes. The descriptors used included: primary health care, family health care, work, health care policy, oral health care services, dentistry, oral health, and Brazil. Thirty-two studies were selected and analyzed, with a predominance of qualitative studies from the Northeast region with workers, especially dentists, focusing on completeness and quality of care. RESULTS Observed advances focused on educational and permanent education actions; on welcoming, bonding, and accountability. The main challenges were related to completeness; extension and improvement of care; integrated teamwork; working conditions; planning, monitoring, and evaluation of actions; stimulating people’s participation and social control; and intersectorial actions. CONCLUSIONS Despite the new regulatory environment, there are very few changes in oral health work. Professionals tend to reproduce the dominant biomedical model. Continuing efforts will be required in work management, training, and permanent education fields. Among the possibilities are the increased engagement of managers and professionals in a process to understand work dynamics and training in the perspective of building significant changes for local realities.

Brazil has made advancements with its Unified Health System (SUS) by establishing universal and full care as its principles and by increasing the coverage of its Primary Health Care (PHC), through Family Health Care Strategy (FHCS). However, the biomedical health care model prevails, and it guides all professional practices, including dentistry. 4,13,35,48,50,54,55 According to its last epidemiological survey, Brazil shifted its prevalence of caries from medium to low. 59 Although results are nationally satisfactory, some factors call our attention: (a) regional differences in the prevalence and seriousness of caries are distinctive, which indicates a need for policies focused on equal care; (b) small reduction of caries in deciduous dentition (18.0%) and 80.0% of affected teeth remaining untreated; (c) significant deficit for older adults, despite adolescents' and adults' need for prosthetics having been decreased; and (d) prevalence of malocclusion requiring treatment in 10.0% of adolescents, which suggests a need for resizing the supply of dental procedures in secondary care. 32,33 These results are associated with the profile of dental practice, characterized by the conduction of eminently clinical actions emphasizing restoring activities and preventive actions focusing on students, which were shown to be insufficient to meet the needs of the population. 31 The Brazilian path to shift the direction of its oral health care model in PHC has found milestones that have a potential to drive work changes: (a) first Conferência Nacional de Saúde Bucal (CNSB -National Oral Health Conference) in 1986, followed by the creation of Brazil's National Oral Health Policy in 1989, a and by the second CNSB in 1993; 9 (b) inclusion of dental professionals in FHCS in 2000, 17 facing the historical restriction of dealing with mother and their children and established a federal financial incentive; creation of new national syllabus guidelines for undergraduate courses in the health care field; 3  The recent path of oral health care signals that a new model is being built in the country (Figure 1).
The "Smiling Brazil" Program, as a guideline of Brazil's National Oral Health Policy (PNSB), d is the largest public oral health care program in the world and it has turned a decade old in 2014. 28 Changes were made to the work of oral health care teams in PHC over that period, in a way to meet the goals for readjusting the health care model. 20 The PHC is a potential space for innovation in the management and organization of the work process, one of the central axes for rearranging SUS's health care.
This article intended to analyze the oral health work changes in primary health care after Brazil's National Oral Health Policy Guidelines were released.

METHODS
The literature review was guided by analyzing elements of work changes in oral health in PHC, according to regulations in effect, 27,c,d and from the publication of the Guidelines of PNSB. The following elements were used to analyze the changes in oral health in PHC: welcoming, bonding, and accountability; extension and improvement of care; intersectorial actions; educational actions; permanent education; fostering of popular participation and social control; completeness; planning, monitoring, and evaluation of actions; integrated teamwork; and working conditions. The guiding questions were: "Which analyzing elements are mentioned?", "Are reports of work changes, advances, or difficulties present?", "Are recommendations, complaints, or suggestions for oral health work in PHC present?". The descriptors used in the search on PubMed were: ("primary health care" OR "family health" OR "work" OR "health policy") AND ("dental health services" OR "dentistry" OR "oral health") AND ("Brazil"). The descriptors were used in English and Portuguese in the remaining databases. The combination was conducted with the use of boolean operators "AND" and "OR", as well as terms from the Medical Subject Headings (MeSH) or analogous ones available in each surveyed database.
Data were collected by one of the authors, whereas the other two, who were familiar with the topic and the method, undertook the selection and evaluation of studies. A total of 77 articles were found on Medline, 538 on LILACS, four on Embase, 67 on SciELO, 338 on BVS, and 13 on The Cochrane Library, which totaled 1,037 articles.
We included the articles that concerned the work, practices, or change of model in oral health in PHC, selected by title. The selected articles were those that discussed the organization and management of work processes in oral health, especially about teamwork in PHC, a central element of the rearrangement of SUS' health care. Studies of theoretical reflection, essays, and theses were excluded.
We selected 211 articles. Sixty of them were excluded for being repeated in the bases, which resulted in 151 studies whose abstracts should be read and 52 to be fully read. At the end, 32 articles were included in the final analysis ( Figure 2).
General publication aspects, methodological characteristics, and main results were identified and analyzed based on their elements (Table 1). Information screening was independently conducted by the researchers and compared in a meeting for consensus. Agreed items were considered proper and included in the description of results. These were grouped according to their previous topic categories (elements for analysis) and analyzed in a descriptive manner.

RESULTS
Most studies were from the Northeast (n = 21; 65.6%), Southeast (n = 6; 18.7%) and South regions (n = 3; 9.3%) ( Table 1). We identified qualitative (n = 24; 75.0%) and quantitative studies (n = 3; 9.3%). A combination of quantitative and qualitative methods was used in 15.6% of the articles ( Table 2). In general, the main subjects were FHCT workers, dental surgeons (DS) being highlighted. Around a third of them included managers and users ( Table 1). All studies (n = 32) mentioned one or more work-analyzing elements, but none included all of them ( Table 2).
The few advances in oral health work focused on educational actions; permanent education actions; welcoming, bonding, and accountability. The main challenges related to completeness; extension and improvement of care; teamwork; planning, monitoring, and evaluation of actions; and working conditions. Few studies 14,36,38,39,57 included fostering of popular participation and social control and intersectorial actions.   PHC, overcome the practices in the traditional school dentistry model and create new possibilities, such as the family approach and diagnosis of the health care situation. 1,10,14,34,39 Actions focusing on clinical care and excess emphasis on technique and specialty persisted, and traditional preventive and educational practices prevailed. 7,14,41 The oral health care teams found difficulties in practices related to FHCT, such as house calls by dentists, actions to prevent illnesses and promote health, as well as meetings and actions for articulation with the community. 5,39 Insufficient changes related to completeness were presented in five studies 18,32,36,43,45 (26.3%), which reported the introduction of care focused on the user, with a space for dialog and for the bringing together knowledge encompassing oral health. Unlike individual actions, the group actions and the advances in the preventive view and the practice of health education of professionals were expressive in FHCT. 1,14,38 Another change regards to the oral health technicians, who spent more of their time in preventive and collective activities than in care activities. 45 Two studies mentioned teamwork and showed that most DS reported integration with their teams, but only a few took part in meetings or used single records. 5,19 The work of a DS was rarely inserted in shared practices with professionals of other fields, as their actions were autonomously, independently, and individually developed. 39 We observed obstacles for teamwork also among dental professionals. 13 The DS recognized their relationship with oral health technicians was damaged by the lack of information on the work process, due to being uncertain of how liable they were regarding the activities of technicians, and also due to being afraid of technicians becoming practical dentists and taking their space in the job market. On the other hand, the DS appreciated the participation of technicians in the reorganization of dental work and in the construction of a relationship of partnership and cooperation.
Intersectorial actions were mentioned in two of the 32 studies, 14,57 related to oral health prevention and education actions developed in the community or at schools. 57 We observed intersectorial actions to be volunteer practices in some of the teams, not reaching the expected impacts. Such circumstance may lead professionals to disbelief regarding FHCT, considering the inability of the health sector to deal with social determining factors of the health-disease process in an isolated manner.
Educational actions were present in nine studies, 1   nursing homes, churches, and daycare facilities. The actions that were most reported were the ones of prevention and promotion in groups, 1,14 highlighting oral health technicians as the ones responsible for them. 45 The ones of education in health were more present in the daily lives of FHCT professionals. 38,42  According to Mialhe et al, 26 the educational activities in oral health were conducted sporadically and mainly focused on pregnant women, mothers, and their children, in a vertical model of transmission of information, targeting changes in individual behaviors and incorporation of healthy habits. That vision was shared by the population, which considered oral hygiene instructions as one of the most important improvements. 11 Eight studies 1,19,21,[37][38][39][40][41][42][43][44]57 reported that planning, monitoring, and evaluation of actions were insufficient practices, and indicated difficulties in the conduction of surveys to recognize population needs, considering social and epidemiological characteristics. 38,44 Despite the advances, oral health needs much investment, besides the control and evaluation of its actions through information systems, which strengthen planning and decision-making. 37 Fostering of popular participation and social control was mentioned in three studies 36,38,39 as an action to be stimulated by teams. Pezatto et al 36 pointed out that the appropriation of oral health topics by social control spaces is one of the challenges in implementing oral health care services in SUS.
The extension and improvement of oral health care were mentioned in 19 of the 32 studies. Among those, five 11,19,36,37,53 mentioned advances, but difficulties prevailed (73.6%) regarding meeting the needs of the related population. 5 Excessive demand was highlighted as a negative aspect, with predominance of healing actions by the DS. 19 Even with the extended access to oral health care services, organizing the demand was a critical bottleneck, as there are several gateways, large repressed demand, and little supply. 19,32,34 Increasing and improving care requires facing challenges related to insufficient public investments; to the difficulties in referring patients to specialty services; the actions focusing on clinical care with excess emphasis on technique and specialty; and the rising demand for services by the population, focused on healing actions. 34 Despite the difficulties, we observed positive aspects in the studies: limiting of clients, enabling better supervision; changes in the profile of dental procedures conducted; and population-based coverage according to the minimum limit as per the Ministry of Health. 11,37,53 Establishing welcoming, bonding, and accountability allows negotiating with users and professionals of full health care, which helps the therapeutic act to be focused on the professional, however being conducted according to the user's wishes. These elements were mentioned by seven studies. 5,10,32,34,[45][46][47] Among those, six pointed out changes: the influence of new national syllabus guidelines in the more humanized practice of dentists, reinforcing the bond, the extended look at the territory and the community; and the potential work of community health care agent in the establishment of bonding, welcoming, and autonomy of users. 5,47 We identified 11 studies 5,14,19,21,22,30,40,42,46,47,56 out of the 12 that mentioned difficulties regarding the working conditions of SUS. Some critical bottlenecks were poor labor relationships, with small wages and unstable employment, 5,19,22 with probable effects on turnover and professional satisfaction, which jeopardizes the quality of health care; 5,22 DS having double shifts in public and private health care units; and the lack of compliance with the weekly workload of 40 hours in FHCT, as something agreed to by managers and workers. 42,44 The lack of financial, structural, physical, and human resources also influenced the working conditions. 5,30 Among the 15 studies on permanent education in health, eight 18,19,21,22,26,30,39,44 showed that professionals working in FHCT were not trained before starting their position, 44 and that no training processes focusing on professional oral health training was available, to make care more complete. 18,19,26,30,38 However, seven studies 10,13,16,29,34,39,42,45 pointed changes: over 90.0% of the DS from a study 5 reported taking part in training courses -the ones who did not had just been hired; another study 22 showed that 67.8% of the DS had been trained to FHCT and felt the need to specialize in public health care, to be able to work in FHCT.

DISCUSSION
Most of the analyzed studies were published from 2008, which indicates a recent interest in the field. The increased number of qualitative studies over the last few years adds an important dimension to the evaluation of actions in oral health, by producing knowledge from the experiences of professionals.
There was a predominance of studies from the Northeast region, which indicates that the results characterize a region, and not Brazil as a whole. According to Soares et al, 54 as the Northeast region is the one with the highest number of family health care teams in the country, that might explain the predominance of studies in the region.
The most investigated work-analyzing elements in oral health in PHC were completeness, extension, and improvement of care. The literature suggests these are two of the most commonly analyzed elements, which may positively contribute to improving and orienting public policies (in overcoming inequalities in the access to health care services, in reaching equity in the system, and in achieving completeness regarding practices and teamwork). 5,52 Despite the significant extension of coverage in oral health in PHC over the last decade, there are barriers that keep Brazilians from accessing the services. 24 The advances in the extension and improvement of care to the population are few and the work process in oral health care may be damaged by the permanent excess demand and predominance of healing actions.
Among the principles and guidelines of SUS, completeness may be the least visible one in the path of the health care system and its practices. 24 The study pointed out that completeness is insufficient, with weak points to be dealt with the work of FHCT teams. These analyses may be associated with the polysemy and coverage of the concept of completeness. To be effective, they require extended clinic, integration of individual and collective practices, and ability to solve problems with ensured access and articulation with other levels of care. 24,52 Teamwork directly influences completeness. 58 For oral health care professionals, integration in the work of family health care teams is limited by the historical isolation of these two professional categories, associated with the late introduction of oral health in FHCT and to the individualist and technicist training of professionals. That jeopardizes the full integration of the human being. 5,45 Professionals will be required to learn and re-learn through their individual experiences in collective work situations. Work is the result of a debate over rules and values of a worker with themselves, about how to be able to manage the complexity of issues regarding collective work. e In that sense, permanent education in health arises as a fundamental device. However, the review of the literature showed that training is focused on qualifying, 18 which is generally distant from work routines and restricted to professional centers.
The intersectorial actions and fostering of popular participation and social control were not investigated to a great extent, which corroborates the literature. 54,55 The volunteer nature of some teams or professionals may be partially explained by the fact that acting pursuant to the intersectoriality principle requires availability for periods that are not established in employment contracts. 15 Despite the existence of a consensus regarding the need for intersectoriality in PHC, it is a process being built in FHCT. 48 One of the challenges to implement it is the training of professionals, which is guided according to the perception of complexity of problems, and to the recognition of the need for intersectorial actions to intervene in such problems. 51 The planning, monitoring, and evaluation of actions are far from the everyday routines of oral health care teams. 54 It is a challenge that requires mobilization, engagement, and decision by managers and professionals.
Improving working conditions in SUS is directly related to improving the quality of care, but that is not a linear relationship. In contexts that are considered favorable to work, according to the principles of FHCT, teams focus their practices on treating occasional or scheduled patients. 25 At the same time, in adverse contexts, professionals seek alternatives to be efficient. 6 It is hard to define to which extent working conditions influence the change in professional practices.
The literature shows that, after a decade since the "Smiling Brazil" Program was implemented, the main problems and difficulties in the work of oral health care teams are not exclusive to dentistry. Strictly speaking, they follow the reality of FHCT teams, pursuant to what has been established by recent studies on the work of family health care teams. 2,49,56 The advances are concentrated in educational and permanent education actions, in welcoming, bonding, and accountability. The main challenges are related to completeness; extension and improvement of care; integrated teamwork; working conditions; planning, monitoring, and evaluation of actions; stimulating people's participation and social control; and intersectorial actions.
Despite the new regulatory environment, there are very few changes in oral health work. Professionals tend to reproduce the dominant biomedical model. Continuing efforts will be required in the management of work, training, and permanent education. Increasing the engagement of managers and professionals in the process to understand the dynamics of work and training in the perspective of building significant changes for local realities is one of the possibilities to enable the substitution of traditional practices and a new way to provide health care services.