INTRODUCTION

The professional work of dental assistants was legalized by the CFO Resolution No. 185/1993 and changed by Resolution No. 209/1997¹. Its profile of competences was published in 2004² and extended by the National Oral Health Policy³. But it was only in 2008 that Federal Law No.11889 was sanctioned, which regulated to exercise of assistant professions: Oral Health Technician (TSB) and Oral Health Assistant (ASB)⁴.

One of the factors that triggered the legalization of professional assistants was the role played by SUS, which assumed the priority of human resources development for professionalization of workers in the primary care network, in the sense of reorienting and qualifying professional practice. Furthermore, the Ministry of Health Administrative Ruling No.267 of March 5, 2001, which instituted the rules and guidelines for the inclusion of oral health in the family health strategy, structured dental care as a product of the oral health team’s work.

From the time this measure was introduced, a significant increase in the work market was noted for components of the oral health, and a perceptible intensification of the education and hiring of auxiliary personnel for the public sector⁵. But a deeper look into the distribution of these opportunities showed, that in April 2015, with 35673 Oral Heal Teams (ESBs) implemented in the country, the jobs for CDs, TSBs and ASBs were distributed as follows: 45.4%, 9.1% and 45.4%, respectively⁶. In Campinas, this proportion has improved significantly with the passage of time, so that from 2014 through to April, 2016 there was a better distribution of vacancies among the components of the ESB, as there was an increase from 7% to 21% in jobs for TSBs⁶.

The use of auxiliary labor in the dental clinical has been shown to be a necessity for optimizing productivity; increasing the technical quality; as well as adding comfort and safety in caring for patients; reducing physical wear, stress and fatigue of Dental Surgeons - CD; minimizing the operating costs and opening the population’s access to oral health care^7-9.

Nevertheless, for CDs to achieve this maximum productivity, it is necessary for them to use auxiliary personnel, and know how to delegate functions^9-10. A large portion of dentists have not yet learned how to work as a team, and maintain the monopoly of activities and functions that could and must be delegated^8,11. Esposti et al.⁵ verified that although dentists understood that the relationship of partnership and cooperation with the TSBs was fundamental, negative ideas persisted and were related to the fear of losing the work market, and the legal responsibility related to their activities, foreseen in the regulation of exercising the profession. Along this line, in the law there is nothing attributed to CDs that allows them to reduce/curtail the professional skills of assistants^12-13.

The perception of assistants with regard to the work process and to the adequacy of their functions as a result of the new legislation has been investigated in both the public^9,14 and private sectors^8,15. However, the dentists’ view about this question is till incipient and focused on the role of the dentist-professor in the education of the technicians⁵.

Since the dentists in the public service are included in the context of multiprofessional team work, and in theory, act within the limits and skills applied to the other professions, the present study with participation of the dentists of the public network of Campinas, sought to investigate the adequacy of the process of working in a team with the legal attributions and limits of professional activity of the oral health technicians and assistants, based on the legislation in force.

METHODS

RESULTS

The mean time since graduation was 22.1 (±7.4) years and time of work in the public system was 16.2 (±8.9) years. Of the participants, 73.4% (n=47) reported having done Postgraduate courses, and 35 professionals were specialized in courses in the Collective Health area.

In Table 1, according to the four skills analyzed, it may be observed that for the absolute majority of the respondents, the tasks that were delegated in accordance with the law fitted into the following skills: “Clinical care in oral health” and “Organization of the work environment” while those related to the skill “Health Promotion and Prevention of Diseases” were the skills that presented proportionally greater divergence in relation to the law.

Table 2 presents the results of the present study, considering the actions in the work process in which the majority (≥50%) of the respondents reported delegating, which were in accordance with the provision in Law 11,889 / 2008. Please note that 61.1% (22) of the actions explained in the instrument were adequately delegated; among which, 11 had an adequate response from over 90% of the respondents. A fact that drew attention referred to the classification of these actions: the majority were indirect actions both among the 22 listed (64%) and among those with higher frequency of correct responses (82%). The authors point out that among the 20 actions that are foreseen in the Law, 85% (20) were attributions of the assistants, and consequently of the technicians; only 15% (3) of the correctly delegated actions were attributions exclusively of the TSB.

Table 3 presents the actions of the work process of dental surgeons, for whom the majority of the responses were in disagreement with the attributions described in Law 11.889/2008. Considering the 14 actions described (6 indirect and 8 direct), 4 of them were no listed in the legislation and were marked as being delegated to the assistants, characterizing extrapolation of functions. Among the attributions exclusively of the TSB (64.3%, 9), 44.4% (4) were marked by the majority of dentists as “I do not delegate/would not delegate”, characterizing under-use of the technician, while 55.6% (5) of them were delegated to the assistant, characterizing extrapolation of the function of the ASB.

The authors, however, emphasize that the frequency of responses in agreement with the law was not higher than 50% for the attributions “Prepare plaster models” and “Remove sutures”, as the responses were distributed among the following options of the instrument: (I delegate/would delegate to ASB and TSB; delegate/would delegate only to TSB, I do not delegate/would not delegate), although the option with the highest number of responses was adequate to the legislation. Although the action “Prepare plaster models” was an attribution of both professional assistants, 17.2% of the dentists delegated it only to the TSB, while 29.7% of them did not delegate/would not delegate this action. Relative to the action of removal of sutures, exclusive attribution of TSB, 23.4% of the respondents delegated it to the ASBs and 37.5% did not delegate it to the auxiliary personnel.

DISCUSSION

To enable the oral health team to work in an integrated manner, respectfully, and attain their maximum productivity, not only is incorporation of the auxiliary personnel required, but the dentist needs to know how to delegate functions^9-10, thereby allowing the role played by assistants and technicians to attain its potentialities, and allowing the development of their professional skills and attributions that culminate in extending the profile of dental practice¹⁴. In the public sector, it is extremely important to organize the work and delegate in the correct manner, so that among other gains, a larger number of persons could be contemplated to receive oral health care actions^5,7,18. However, in a recent analysis, Warmling et al.¹⁴ discussed Law 11.889/2008 indicating that it has not been shown to be a legal instrument capable of encouraging promotion of extending the skills and attributions of these workers.

The rate of return of the questionnaires in the present study, 36% of the sample universe, was higher than the return of 25% expected for studies involving this methodology^19-20.These rates ranged from 19.1%²¹ to 25.4%15 and was considered satisfactory, also considering the Brazilian culture of infrequent participation in researches²².

In the present study, the authors noted that the majority of the actions proposed were being delegated in compliance with the legislation. Generally speaking, the functions most correctly delegated were those of indirect action; these are common to assistants and technicians. The actions that were exclusively the functions of the TSB were those that presented the most inconsistency in relation to the legislation. This finding corroborates the data that have been pointed out in the literature: that there are no significant differences between the work process performed by the oral health assistants and technicians, since the skills and attributions marked by the assistants were also reported by the technicians, resulting in a low number of attributions that were exclusively of the latter¹⁴.

Studies conducted before the regulation of the professions^11,23-24 verified that the majority of the auxiliary personnel mainly perform the functions of reception, preparation of the patient, developing radiographs, while the functions of an educational-preventive nature are shown with lower frequency. In the present study, the actions related to organization of the work environment were those most correctly delegated, while those of clinical care in oral health were those most cut off from the technicians. Warmling et al.¹⁴ verified that the auxiliary professionals that were active in SUS worked more intensely with the skills of health promotion and prevention of disease, which has a relationship with the findings of this study, however, the extrapolation of ASB functions was noted. Furthermore, important regional differences should be considered; the TSB have hardly been absorbed into dental services, a reality also found in the municipality of Campinas. When this occurs, it has been noted that this is limited both to performing the role destined to the ASB¹⁴ and to ASB performing actions exclusively those of the technician, as may be noted in the present study.

Some functions were delegated to the ASB that were attributed specifically to the TSB, such as the training and qualification of community agents for oral health promotion actions; cleaning and antisepsis of the operating fields before and after surgical procedures; participation in educational actions for health promotion and prevention of oral diseases; participation in epidemiological surveys, and teaching oral hygiene techniques. In these situations, the authors noted that the extrapolations verified were relative to reversible actions that could be redone without damage to the work or user²⁴.

At this point, it is worth pondering the practical difference between the attributions exclusively of the TSB: “teach oral hygiene techniques and perform prevention of oral diseases by means of topical fluoride application, according to the dental surgeons instructions” and the attribution “organize and perform oral hygiene activities” of the ASB skill. Although the instrument was elaborated based on the text of the legislation, in practice in the municipality, supervised tooth brushing performed at the schools is carried out by the ASB and the similarity in the attributions may be the reason for the response in disagreement with the law. This may be justified by the nature of professionals’ autonomy foreseen by the Ministry of Health², which guarantees that the professional transcends the prescriptions, but this is not synonymous with independence, rather with interdependence, characterizing commitment and interaction between the parties.

Actions that should be delegated to the TSB and that denoted their under-use in the public service of Campinas, such as “Remove sutures”, “During cavity preparation, distribute dental materials in direct dental restorations” ad “Perform isolation of the operating field” suggested situations pointed out in the literature with regard to the role of the TSB in health actions: misinformation about the work process and presence of concerns about the legal responsibility of CDs about activities developed by TSBs⁵, which lead to the need for complementary studies that qualitatively investigate the reasons why professionals reported that they did not delegate these activities. Relative to the actions “Prepare plaster models” and “take photographs and radiographs” the result was predictable, considering that the actions performed in primary care do not involve impression taking, and the absence of x-ray appliances in the Health Centers.

Organization of the work in oral health must contemplate the participation of the TSBs, so that they also perform clinical attendance in individual actions, therefore, there is need of adequate physical space for their work⁵. This is guaranteed to Modality 2 oral health teams, by means of incentives to acquire an additional dental office, in accordance with Administrative Ruling GM/MS No. 2,372, of October 7, 2009²⁵. In the present study there was no visit to the CS, and therefore, the adequacy of the work space was not evaluated.

CONCLUSION

The majority of the oral health teams’ (ESB) actions are being delegated in a manner compatible with the legal provision, however, there are situations of extrapolation of functions, especially to assistants, and under-use of professionals, especially of the oral health technicians.