The legislative and the regulation of dental assistants professions in Brazil

O poder legislativo e a regulamentação das profissões auxiliares em saúde bucal

ABSTRACT

Objective:

To analyze the conditions of possibilities and contributions of the legislative power to the regulation of oral health assistants (in Portuguese “Auxiliar de Saúde Bucal” – ASB) and oral health technicians (in Portuguese “Técnico de Saúde Bucal” – TSB) in Brazil.

Methods:

This socio-historical study used Bourdieu´s theoretical framework. Twelve legislative processes were included. Information about their objects, similarities and differences, main stakeholders, their social and professional trajectories and their relationship with oral health were sought. An interview with two key informants was conducted. The multiple correspondence analysis investigated the association between the variables and their intensity of contribution.

Results:

This issue remained in dispute between 1977-2008 and was regulated by Law 11.889/2008, after the incorporation of Oral Health Teams in the Family Health Strategy. The restrictive practice was related to parliamentarians from the southeast region, linked to the pole of the private market, without training in the health area. The defense of clinical practice under dentist´ supervision was related to health and human sciences agents.

Conclusion:

The ASB profession has always been a consensus in regulation. The issue in dispute was the activities of Oral Health Technicians. It prevailed in the Law text a more progressive and broader view.

Indexing terms
Government regulation; Legislative; Oral health; Patient care team

RESUMO

Objetivo:

Analisar as condições de possibilidade e contribuições do poder legislativo para regulamentação das profissões de auxiliar em saúde bucal (ASB) e técnico em saúde bucal (TSB) no Brasil.

Métodos:

Estudo sócio-histórico que utilizou o referencial teórico bourdieusiano. Foram incluídos 12 processos legislativos sobre o tema. Buscou-se informações sobre seus objetos, similaridades e diferenças, principais envolvidos, suas trajetórias social e profissional e relação com a saúde bucal. Realizou-se entrevista com dois informantes-chave. A análise de correspondência múltipla investigou a associação entre variáveis e intensidade de contribuição.

Resultados:

Essa questão permaneceu em disputa entre 1977-2008, sendo regulamentada pela Lei 11.889/2008, após a incorporação da Saúde Bucal na Estratégia Saúde da Família. A prática restritiva esteve relacionada a parlamentares do Sudeste, vinculados ao pólo privado, sem formação na área de saúde. A defesa da atuação clínica sob supervisão do dentista relacionou-se a agentes das áreas de saúde e ciências humanas.

Conclusão:

A regulamentação da profissão de ASB sempre foi um consenso, sendo a questão em disputa as atividades pertinentes ao TSB, prevalecendo no texto da Lei a visão mais progressista e de atuação mais ampliada.

Termos de indexação
Equipe de saúde; Saúde bucal; Regulação governamental; Poder legislativo

INTRODUCTION

The actuation of auxiliary personnel is part of the functioning of the majority of dental services. The first regulation for the profession happened in 1907 in the United States of America (USA), formalizing the occupation of the dental hygienist as a dental assistant [¹], followed by New Zealand, which created the profession of dental nurse in 1920 [²]. The performance’s difference consisted of the latter having clinical assistance as a focus, while the former focused on preventive care [³].

In Brazil, this debate started half-way through the 20th century, yet, only in 2008, the professions of Orthe professions of Oral Health Assistant (in Portuguese “Auxiliar de Saúde Bucal” – ASB) and Oral Health Technician (in Portuguese “Técnico de Saúde Bucal” – TSB) were regulated in the country.

The establishment of a profession depends on its state regulation and its acceptance and incorporation by civil society. In Brazil, the insertion of auxiliary oral health professions happened first in the public sphere, through the Special Public Health Service (in Portuguese “Serviço Especial de Saúde Pública” – SESP), from 1950 [⁴]. Under the influence of technical education development in the USA, and aiming to amplify oral health promotion services [⁵], the Federal Council of Education (in Portuguese “Conselho federal de Educacão” – CFE) established guidelines for the education of Dental Hygienist Technicians (in Portuguese “Técnico de Higiene Dental” – THD) and Dental Office Assistants (in Portuguese “Auxiliar de Consultório Dentário” – ACD) [⁶].

In the 80s, the social construction of auxiliary professions involved movements, national encounters, class entities, and associations, having been debated since the first National Encounter of Administrators and Technicians of Public Dental Services (In Portuguese “Encontro Nacional dos Administradores e Técnicos do Serviço Público Odontológico” – Enatespo), with the recommendation to institute courses for “Dental Assistants” and “Dental Hygienists” [⁷]. The Brazilian Movement of Dental Renovation (In Portuguese “Movimento Brasileiro de Renovação Odontológica” – MBRO) adopted a similar position to that of assistant personnel in Dentistry, appointing the THD as an instrument for dental practice transformation and demonopolization of dental knowledge. The THD would be fundamental to the rendering of dental services in the country, not being a threat in the dentist labor market, nor a “practitioner”, contributing to the greater quality of services [⁸].

The debate on auxiliary professions was also present in the three National Conferences of Oral Health (in Portuguese “Conferências Nacional de Saúde Bucal” – CNSB. The 1st CNSB (1986) pointed to the need for immediate education and incorporation of ACD and THD aiming at coverage extension and an enhancement in productivity, delegating to the public power the financing, encouragement, education and reformulation of the time’s legislation [⁹]. The 2^nd CNSB (1993) recommended the approval of the law project on the regulation of THD and ASB professions (PL 53/1993) and the resolution by the Federal Dentistry Council (in Portuguese “Conselho Federal de Odontologia” – CFO), with the aim of assuring the exercise of functions, representativity in class organs and insertion in the the Brazilian Health System (in Portuguese “Sistema Único de Saúde” – SUS) [¹⁰]. In the 3^rd, the education of assistants was a recurring theme. It was ruled the need of creation and recognition of courses for ACD and THD by the Ministry of Education (in Portuguese “Ministério da Educação” – MEC), its interiorization, warranty of spots for all workers of the oral health team in the public service, the association of these professionals in the class council and integration of dentistry courses with the education of assistant personnel, foreseeing comprehensive healthcare [¹¹].

In the clinical area, the actuation of auxiliary personnel reduces clinical time, allowing greater productivity, continuity of operation movements, and less physical and emotional wear of the dentist. It optimizes dental service, influencing professionals’ quality of life, contributing to promotion and education in health and disease prevention [¹²].

Resolution CFO 63/2005 defined private activities of the TSB, a result of the discussions on auxiliary professions within the organ [⁴], despite not being the organ’s first resolution on auxiliary personnel.

The process of social construction which culminated in the promulgation of Law 11.889/2008 was permeated by contradictory interests between associations and movements of the area’s assistants and technicians, unions, federations, entities and class councils and organs of the country’s education and health system. Through the propositions of different law projects (In Portuguese “Projetos de Lei”– PLs), their approvals, discontinuance and veto, the Legislative Power reflected the national political context [⁴]. Law 11.889/2008 represented an advancement in the definition of a regulatory mark in the administration of labor in health, a relevant achievement in these professions’ work and the amplification of access to dental services [⁴].

Revised literature identified studies that brought contributions to the theme, treating this professional category in different perspectives [⁴,¹³-¹⁷]. These works approached the epidemiological perspective when connecting the role of those professionals in the promotion of oral health [¹⁴], their participation in specialized fields, such as orthodontics [¹⁶], their degree of occupational exposure [¹³], their education [¹⁷], the relation between CD and high school level and technical level professionals [¹⁵]. However, the identified studies did not analyze the content of legislative processes referring to this regulation and the main agents involved. This Analysis contributes to the comprehension of the long process of legislation construction referring to auxiliary professions in Oral Health in Brazil, and the main points in dispute.

In that sense, the present study has the goal of analyzing historical conditions of possibilities and contributions of the Brazilian legislative power to the formalization of TSB e ASB professions and knowing the main agents involved in the process, their positions and stances.

METHODS

A qualitative study was carried out, from a socio-historical perspective, through document analysis of legislative processes regarding the formalization of auxiliary professions in oral health in Brazil, between 1970 and 2016. It is a subproject of the research “The genesis of oral health policy at the national and municipal levels”, financed by the Fundação de Amparo à Pesquisa do Estado da Bahia - Fapesb notice n. 017/2013.

Bourdieu’s [¹⁸] theoretical-methodological framework was used, especially the concepts of agent, social space, field and illusio.

The document analysis was based on the legislative processes, and on the main agents’ social and professional trajectory, complemented by two key informants’ interview.

A search for documents was carried out at the Brazilian Senate’s electronic address (http://www25.senado.leg.br) considering the terms: “dentistry”, “oral health”, “dentist” and “oral health assistant”. All identified documents were organized in a matrix in the Microsoft Excel 2010 program, containing the following information: date, document, author, content summary, committees in which it was discussed and their respective rapporteurs, president, political regime, political party and source. Documents referring to operating authorization, recognition of institutions, and those that did not address auxiliary professions were excluded. From these procedures, nine parliamentary files submitted between 1977 and 2011 were added, also 4 more files were attached to previously identified projects during the documentary analysis. Among them, there was a PL on the profession of technician in dental prosthesis (in Portuguese, “Técnico de Prótese Dentária” – TPD). The 12 processes referring to the TSB and ASB professions between 1977 and 2015 were included (table 1).

Table 1
Parliamentary processes referring to the formalization of assistant professions (ACD/ ASB, THD/ TSB e TPD) in Dentistry and its proposition period.

n	Profession	Parliamentary processes	Year	Period
1	ACD/ ASB e THD / TSB	PL 4.465	1977	Pre-SUS
2		PL 4.749	1978
3		PL 2.244	1989	Post-SUS
4		PL 284/ PLC 53	1991/ 1993
5		PL 2.487	2000
6		PL 4.381	2001
7		PL 1.140/ PLC 3	2003/ 2007
8		PL 1.537	2003
9		PL 2489	2003
10		Lei 11.889	2008
11		PL 1.187	2011
12		PL 3.644/2015	2015
13	TPD	PLS 620/PL 6.610	2007/2009

• Note: PL: Law Project; PLC: Chamber Law Project; PLS: Senate Law Project.

About each PL, information was sought on: object, similarities and differences between them, main stakeholders (authors and collaborators), their social and professional trajectories, and relationship with oral health. We also sought to identify the positioning of class entities, such as the Brazilian Dentistry Association (in Portuguese “Associação Brasileira de Odontologia” – ABO), CFO, Interstate Dentistry Federation (In Portuguese “Federação Interestadual dos Odontologistas” – FIO) and MBRO, through the analysis of bulletins and/or newspapers of these entities, reports from 2005 published in the electronic mailing list Cedros, in addition to articles published in the Jornal do Site Odonto (www.jornaldosite.com.br) on the topic.

The trajectories were analyzed through information published on the legislative assembly and political parties’ websites, interviews, and articles published on free electronic access bases. This information was organized into matrices and transformed into text. The sources used, except the legislative processes already presented, are listed in table 2.

Table 2
Consulted sources.

Official Documents Brazil. Presidential Veto, Message n0 1.103, December, 30th, 1993.

Chamber of deputies portal (http://www2.camara.leg.br/deputados/pesquisa) Searched names: Agnelo Queiroz (Oct 9, 2016); Augusto Silveira de Carvalho (11 Apr. 2016); Cabo Sabino (14 June 2019); Geraldo Freire (26 Mar. 2016); Gorete Pereira (14 June 2019); José Zavaglia (March 26, 2016); Raphael Baldacci Filho (6 Mar. 2016); Robson Marinho (18 Jan. 2016); Rubens Otoni Gomide (May 6, 2016).

Lattes Curriculum (http://buscatextual.cnpq.br/buscatextual) Searched names: Moacyr da Silva – ID 7204008270876502 (access: 6 apr. 2016; update: 14 apr. 2013); Swedenberger do Nascimento Barbosa – ID 8225365888904509 (accessed: 18 Jun. 2020, update: 15 Apr. 2020); Vitor Gomes Pinto – ID 1647873147509352 (access: 5 apr. 2016, update: 17 jul. 2009); Volnei Garrafa – ID 2059138334891787 (accessed: 18 Jun. 2020, update: 11 Feb. 2020);

Journal of the Interstate Federation of Dentists (In Portuguese “Federacão Interestadual dos Odontologistas”– FIO) 2005 Apr (12p), Aug / Sep. (8p), ten (8p) 2008 Special Edition (8p), Dec. (6p.)

Brazilian Dental Renewal Movement Bulletin (MBRO) 1988 n. 13

Portal of the Federal Council of Dentistry (http://cfo.org.br) CFO. Federal Council of Dentistry. Vote on the bill of the THD and ACD on the agenda this Tuesday of the CCJC. News published on the CFO 2006 website. Available at: http://cfo.org.br/website/votacao-do-projeto-lei-do-thd-e-acd-na-pauta-desta-terca-da-ccjc /. Accessed on: 21 May. 2019. Jul. 11 2006.

Portal of the Regional Council of Dentistry of São Paulo (http://www.crosp.org.br) CROSP. Regional Council of Dentistry of São Paulo. Rozângela Fernandes Camapum. Available at: http://www.crosp.org.br/noticia/ver/2190rozngelacamapumanovacoordenadorageraldesadebucaldominist. Accessed on: 06 May. 2016. Aug 26 2015

Portal of the São Paulo Association of Dental Surgeons (In Portuguese “Associação Paulista de Cirurgiões-dentistas” – APCD) (http://www.apcdrp.com.br) SãO PAULO ASSOCIATION OF DENTAL SURGEONS (APCD). Regional Ribeirão Preto. Emil Adib Razuk. Available at: http://www.apcdrp.com.br/noticia/dremiladibrazukrecebetitulodecidadaoribeiraopretano. Accessed on: 04 Apr 2016.

Internet pages NARVAI, Paulo Capel. Adeus, Flávio Luce. Jornal do Site Odonto 2007. Available at: https://www.jornaldosite.com.br/materias/artigos&cronicas/aniores/paulo%20capel/artcapel123a.htm. Accessed on: 21 May. 2019. Oct 2007.ÁLVARO SIQUEIRA ... Álvaro Siqueira Vantine. Available at: http://www.sagradafamiliaonline.org.br/nossospadres.php?id=136&key=nossos_padres&. Accessed on: 11 abr. 2016. s.d. ENNEC FORTALEZA. IV North-Northeast Meeting of Buco-maxillofacial Surgery and Traumatology. Who was João Hildo Carvalho Furtado. Available at: http://www.itarget.com.br/clients/ennecfortaleza.com.br/?op=9. Accessed on: 11 abr. 2016.

Cedros mailing list ([e-mail]) CAMAPUM, Rosângela; BROM, José Carrijo. PL 1140/03 (THD’s and ACD’s): Vote of 11/23/05. Mailing list. List maintained by the Federal University of Rio de Janeiro. Available at: [e-mail]. Accessed on: 24 nov. 2005. Nov 24 2005.

An interview was conducted with two key informants, selected considering their involvement in the direction of union movements and/or in management, directly or indirectly related to oral health, over the period studied, as pointed out by Rossi [¹⁹]. The interview was carried out simultaneously with both informants, considering the following questions: Who were the main agents and how did they contribute to the construction of bills related to the regulation of auxiliary professions in oral health? What are the reasons for the authorship of the legislative processes to be of the parliamentarians identified?

For the purposes of analysis, the implementation of the SUS was adopted as a landmark, subdividing the period studied into two stages: pre (1977-1987) and post-SUS (1988-2015). This division is related to the implications and challenges that the offer of public oral health actions and services, in particular their necessary expansion, brought to the debate on the formalization of auxiliary professions.

Multiple correspondence analysis (MCA) was performed to investigate the association between different variables and the intensity of their contribution [²⁰]. MCA makes it possible to analyze the relationship between a set of variables, in general, homogeneous to the same theme. Education, year and party variables were included as supplementary due to their influence on inertia [²¹].

The project was approved by the Research Ethics Committee of the Collective Health Institut of Federal University of Bahia, under number 18153513.0.0000.5030. All respondents signed an informed consent form.

RESULTS AND DISCUSSION

The analysis of the 12 parliamentary processes related to the TSB and ASB professions shows that since the end of the 1970s their formalization has been on the agenda among entities and class associations, seeking to identify parliamentarians to defend their proposal. This issue remained in dispute for 31 years, resulting in the presentation of bills on which several filings and a veto were imputed.

[...] the majority of conservative dental entities, the most conservative leaders in the Dentistry academia, were very resistant [...] – These people are going to do what? Replace the dentist’s workforce ?! [...] you cannot do any kind of activity that could reduce this field of work. More with THD and less with ACD [...] (E1, 59 years old, male, dentist and manager)

The Oral Health Technician: the main dispute

Over the entire period studied, one interviewee explains:

[...] the strong divergence was in the technician’s duties. Everyone was in favor, but we defended that they had to have assignments that really expanded access, it was no use being an ACD [...], that would not solve the access problem, there would be two regulations with exactly the same assignment [...] ”

(E2, 53 years old, female, dentist, ex-manager, emphasis added)P

In the pre-SUS situation, during the military dictatorship, initiatives emerged both from the opposition party to the regime (Brazilian Democratic Movement/ In Portuguese “Movimento Democrático Brasileiro”– MDB) and from the one supporting it (Arena). Contrary to what might be expected, the proposal by the deputy of the current party, by allowing the technician to take clinical actions, contradicted the logic of the sectors characterized as reactionary concerning the issue [²²].

PL 4,465/1977, by deputy Geraldo Freire (Arena), lawyer, suggested changes in the curriculum of technical training courses to allow the performance of extractions and technicians’ autonomous exercise in places without CD (tables 3 and 4). These proposals were justified by the low quantity of CD and generated significant controversy among the sectors of market dentistry, fearful of the performance of THDs as “practical”, in a clear positioning of the market reserve [²²]. Thus, this first professional regulation initiative was stillborn (table 3).

Table 3
Parliamentary processes referring to the formalization of assistant professions in oral health, year and author, main proposals, similarities and differences in regards to previous processes, Brazil, 1977-2015.

Parliamentary Processes / Year / Author / Rapporteurs / Situation	Proposal	Similarities and Differences
PL 4.465 / 1977 Author: Dep. Geraldo Freire Rapporteurs: Dep. Gomes da Silva (CCJC) Dep. Wilson Braga (CTLS) Situation: Filed on 02/03/1979.	It conferred attribution to THD; He proposed performing dental extractions by the technician, including the discipline of surgery in the courses, under the justification of the small number of DCs. In locations without a DC, the technician’s autonomous exercise would be allowed.	N/A
PL 4,749 / 1978 Author: Dep. José Zavaglia Rapporteurs: Forwarded to the three commissions, but was not analyzed in any of them. There was no rapporteur. Situation: Filed on 02/03/1979	Regulated the exercise of the THD and ACD professions.	Differences: It also provided for the regulation of the ACD; Mandatory to be supervised by the CD; Professional workload for THD 2200 hours and ACD 300 hours; Concession of the exercise of the profession to those who until the decree of the Law had been exercising the profession for 5 years even without a professional course; It did not include in the THD’s competencies “inserting, condensing, sculpting and polishing restorative substances”; It determined the minimum remuneration of 6 minimum wages with an 8-hour working day for THD and 3 minimum wages with an 8-hour working day for ACD.
PL 2,244 / 1989 Author: Dep. Robson Riedel Marinho Rapporteurs: Dep. Marcos Formiga (CJ) Dep. Augusto Carvalho (CT) Situation: Filed on 02/02/1991	Regulated the exercise of the THD and ACD professions.	Similarities: Mandatory CD supervision; Professional workload for THD 2200 hours and ACD 300 hours; Differences: It differs from PL 4.749 / 1978 and rescued from PL 4.465 / 1977 the permission to insert, condense and polish restorative substances; Mandatory Registration with the Federal and Regional Dentistry Councils; Annuities for THD cannot exceed 1/3 of the CD / and for ACD 1/10 of the CD; I veto advertisements for THD or ACD services even in dentistry magazines; Obligation of the CD to inform the Council of the presence of para-dental professionals in its establishments; Concession of the exercise of the profession to those who until the decree of the Law had been exercising the profession for 3 years even without a professional course.
PL 284/1991 in the Chamber PLC 53/1993 in the Senate Author: Dep. Augusto Silveira de Carvalho Rapporteurs: Dep. Sigmaringa Seixas (CCJC) Dep. Zaire Rezende (CTLS) Dep. Nilson Gibson (CCJC) - final writing Situation: Vetoed on 12/30/1993, veto approved by the Chamber of Deputies on 9/9/1999, filed on 9/28/1999	Regulated the exercise of the THD and ACD professions.	Similarities: Mandatory supervision of the CD; Reproduced PL 2,244 / 1989; I veto advertisements for THD or ACD services even in dentistry magazines; Mandatory Registration with the CFO and CRO; Obligation of the CD to inform the Council of the presence of para-dental professionals in its establishments; It allowed THD to “insert, condense and polish restorative substances”; Differences: THD dues cannot exceed 1/4 of the CD; It does not allow concession to act for years of work, different from the provisions of: PL 2,244 / 1989 and PL 4,749 / 1978; It does not refer to the course load.
PL 2,487 / 2000 Author: Dep. Agnelo Queiroz Rapporteurs: Dep. Freire Junior (CTLS) - rejected Situation: Rejected on 8/28/2001	Regulated the exercise of the THD and ACD professions.	Similarities: There is no reference to the concession of professional practice for years of experience; It does not refer to the course load; Differences: Does not refer to annuity costs, differing from: PL 284/1991 and PL 2,244 / 1989.
PL 4,381 / 2001 Author: Dep. Marcos Cintra Cavalcanti de Albuquerque Situation: Joined PL 2487/2000, rejected on 08/28/2001	It regulated the exercise of the TSB and ASB professions.	Similarities: There is no reference to the concession of professional practice for years of experience; It does not refer to the course load; It does not refer to annuity costs. Differences: For the first time it proposes the use of the term Oral Health Technician (TSB) and Oral Health Assistant (ASB), but it presents a more restrictive view of its performance.
PL 1.140 / 2003 in the Chamber PLC 3/2007 in the Senate Author: Rubens Otoni Rapporteurs: Dep. Fernando Coruja (CCJC) Jovair Arantes (CTLS) Dep. Marcelo Barbieri (CTLS) Dep. Benjamim Maranhão (CSSF) Dep. Darci Coelho (CCJC) - final draft Situation: approved on 06/08/2004	It regulated the exercise of the THD and ACD professions (Reproduces the proposal of PL 244/1989).	Similarities: Reproduced PL 2,244 / 1989; Differences: Returns to the nomenclature of THD AND ACD. Annuities for THD cannot exceed 1/4 of the CD / and for ACD 1/10 of the CD, redeeming the annuity, as proposed by PL 284/1991; It gave rise to Law 11,889 / 2008.
PL 1.537 / 2003 Author: Dep. Feu Rosa Situation: Joined to PL 1140/2003 Rejected on 06/08/2004	It regulated the exercise of the TSB and ASB professions.	Similarities: Resumption of Bill 4,381 / 2000, by Deputy Marcos Cintra. it had no similarities with PL 1.140 / 2003. It does not refer to the concession of professional practice for years of activity; it does not refer to the course load; It does not refer to annuity costs. Differences: Proposes the use of the term Oral Health Technician (TSB) and Oral Health Assistant (ASB), with a more restrictive view of their performance.
PL 2,489 / 2003 Author: Dep. Fátima Bezerra Situation: Joined to PL 1140/2003 Rejected on 06/08/2004	It regulated the exercise of the TSB and ASB professions.	Similarities: Proposes the use of the term Oral Health Technician (TSB) and Oral Health Assistant (ASB). Differences: Annuities for TSB cannot exceed 1/4 of the CD / and for ACD 1/10 of the CD; presents a broader perspective of professional activity than that of PL 4,381 / 2001 and PL 1,537 / 2003 .
Law 11,889 / 2008 Author: Dep. Rubens Otoni	It regulated the exercise of the TSB and ASB professions.	Similarities: Annuities for TSB cannot exceed 1/4 of the CD / and for ACD 1/10 of the CD; Direct supervision will be mandatory in all clinical activities, and extra-clinical activities may have indirect supervision; Insert and distribute dental materials for direct dental restoration in the cavity preparation, being prohibited the use of materials and instruments not indicated by the CD.
PL 1,187 / 2011 Author: Dep. Gorete Pereira Rapporteur: Dep. Rogério Carvalho (CSSF) Situation: requires a public hearing by the Social Security and Family Commission to debate the PL Filed on 01/31/2015, unarchived on 02/06, filed on 01/31/2019	Amends Law No. 11,889, of December 24, 2008, which regulates the exercise of the professions of Oral Health Technician – TSB and Assistant in Oral Health – ASB, to establish a national professional salary floor.	Differences: For an eight-hour daily and forty-weekly workweek, the salary floor of R $ 1,020.00 (One thousand and twenty reais) per month will be due to the Technician in Oral Health – TSB; For an eight-hour day and forty-week day, the Oral Health Assistant – ASB will be paid a monthly salary of R $ 770.00 (seven hundred and seventy reais).
PL 3644/2015 Author: Dep. Cabo Sabino Situation: Joined to PL 1187/2011 filed on 31/01/2015	Amends Law 11,889, of December 24, 2008, to define the National Salary Floor for the Oral Health Technician and the Oral Health Assistant	Differences: National Salary Floor for TSB of R $ 1. 312.00 (one thousand, three hundred and twelve reais) and ASB of R $ 1,082.00 (one thousand and eighty-two reais), for an eight-hour workday daily and forty hours a week, with annual adjustment, in the month corresponding to the approval of the Law, by the variation of the IPCA, released by IBGE, in the last 12 months.

• Note: Dep .: Deputy, CCJC: Constitution, Justice and Citizenship Commission, CTLS: Labor and Social Legislation Commission, CJ: Justice Commission, CT: Labor Commission, CSSF: Social and Family Security Commission, THD: Hygiene Technician dental, CD: dental surgeon, ACD: dental assistant, CFO: Federal Dental Council, CRO: Regional Dental Council, TSB: oral health technician, ASB: oral health assistant, IPCA: Consumer Price Index Broad, IBGE: Brazilian Institute of Geography and Statistics.

The following year, deputy José Zavaglia (Brazilian Democratic Movement / In Portuguese “Movimento Democrático Brasileiro”– MDB), an economist (table 4), brought the question back to the debate, seeking a consensus between the interests of dental assistants and entities. It included the ACD, suppressed the exercise of clinical procedures, imposed direct supervision of the dentist, minimum professional workload, criteria for granting the exercise of the profession to those who were exercising the functions until the publication of the law and determined minimum remuneration for THD and ACD (table 3). This proposal was filed even before it was analyzed by the House of Representatives commissions.

From 1984 onwards, counter-hegemonic social movements such as MBRO and Enatespo, spaces of criticism of the State’s responses to the oral problems of the population and related to the development of oral health policies [¹⁹,²³], guided the defense of auxiliary personnel [¹⁹]. This was also a defense of professors and dentists from the Social and Sanitary Dentistry current, which started to be discussed in the 1950s and 1980s, respectively [²³].

The 1^st CNSB defended the expansion, dynamization and lowering the cost of clinical care by incorporating auxiliary personnel with an expanded function, under the supervision of the dentist, approaching a conception of technology compatible with the socio-economic reality and knowledge transfer [¹⁹,²⁴]. A more comprehensive and progressive perception on the subject, linked in particular to public health, in contrast to that more linked to clinical and market dentistry, present in the bills proposed in the pre-SUS period. This caused the CFO to consider its recommendations and appoint a special commission to analyze the exercise of auxiliary professions without legal qualification: requirements necessary for their training and qualification, absence of regulations in the Ministry of Labor and the need to reformulate the attributions of these professions in view of the requirements of activities in the public and private spheres [⁵].

[...] it was the public health personnel versus the people who dominated the dental entities: national ABO, CFO was basically composed at that time by professionals from private practices, there was almost no one in the public health area. The FIO that came with a new staff, [...] more connected to the area of public health, and that was where this struggle of regulation took on more strongly.

(E2, 53 years old, female, dentist, ex-manager, emphasis added)

[...] FIO started to act within the scope of collective spaces, including the National Health Council, [...] everyone who offered to help us wanted, regardless of party affiliation, the parliamentarian knew, supported, and understood it important, we wanted it. ”

(E1, 59 years old, male, dentist and manager)

The main issue in dispute, since its beginnings, has therefore always been the definition of the THD’s duties. In contrast to a broader, progressive performance, related to dental practice in the public sphere and the expansion of the service offer; and a more restrictive performance, defended by the market dentistry pole, which saw in the broader practice of technicians, the expansion of competition in the job market. This issue permeates all the legislative processes analyzed, from 1977 to 2008 (table 3).

Regulatory paths

After the promulgation of the 1988 Constitution and the creation of SUS, the discussion was resumed with the presentation of Bill n. 2,244 / 1989 by Deputy Robson Riedel Marinho (Brazilian Social Democracy Party - PSDB). The PL provided for the regulation of the professions of THD and ACD, had the technical assistance of 10 CDs (5 university professors and heads of class entities, two leaders of dental entities, two federal deputies and a clinician) and a THD (table 4). Dentists Emil Adib Razuk, Raphael Baldacci Filho, who belonged to the political field, and Moacyr da Silva, with a predominant trajectory in the scientific field, were classified as collaborators, while Álvaro Siqueira Vantine, Volnei Garrafa, Vitor Gomes Pinto, João Hildo de Carvalho Furtado and Swedenberger do Nascimento Barbosa as a technical adviser (table 4).

Table 4
Participants in legislative processes on auxiliary professions in oral health from 1977 to 2015, according to place and date of birth, training and activity related to documents.

Participants, place and date of birth	Education	Activity related to the regulation of auxiliary professions
Agnelo Santos Queiroz Filho Itapetinga-BA, 9/11/1958	Medicine, Federal University of Bahia, 1978-1984; Post-Graduation in General and Thoracic Surgery, Base Hospital – Brasília / DF, 1984-1987; Post-Graduation in Public Policy, Federal University of Rio de Janeiro.	Author of PL 2,487 / 2000 in the Chamber.
Álvaro Siqueira Vantine, Pitangueiras- P, 24/12/1944	Dentistry São Paulo State University “Júlio de Mesquita Filho” (UNESP), no year information.	“Technical advice” to PL 2244/89 (p. 34).
Augusto Silveira de Carvalho, Patos de Minas- MG, 27/7/1953	Sociology, University of Brasília (UnB), 1977.	It presented a substitute for PL 2244/89. Author of PL 284/91.
Cabo Sabino, Quixadá, CE, 16/02/1971	Real estate agent. Incomplete higher education	Author of PL 3.644/2015.
Emil Adib Razuk, Pederneiras-SP	Dentistry, Faculty of Pharmacy and Dentistry of Araraquara, 1957.	Former president of CRO-SP and Federal Deputy. “Invaluable collaboration” in PL 2244/89 (p. 25).
Fátima Bezerra, Nova Palmeira-PB, 19/05/1955	Pedagogy, Federal University of Rio Grande do Norte.	Author of PL 1,187 / 2011 proposing the amendment of Law 11,889, of December 24, 2008, which regulates the profession of Oral Health Technician - TSB and Oral Health Assistant - ASB, to establish a national professional salary floor .
João Miguel Feu Rosa, Vitória-ES, 19/01/1947	Engineering, Federal University of Espírito Santo (UFES), 1970; master in Industrial Engineering, PUC, Rio de Janeiro, RJ, 1973; PhD in Operations Research, Lancaster Univ., England, 1992.	Author of PL 1,537 / 2003.
Francisco Carlos Paludetti, S/I	CD	“Invaluable collaboration” to PL 2244/89 (p. 25).
Geraldo Freire da Silva, Boa Esperança-MG, 29/06/1912	Bachelor of Legal and Social Sciences from the Minas Gerais Law School, 1933; Law from Universidade Federal Fluminense, 1938.	Author of PL 4.465 / 1977, which gives attribution to the Dental Hygiene Technician and makes other arrangements; suggests the inclusion of the surgery discipline in technical courses so that the technician can perform dental extractions under justification for the reduced number of CDs.
Gorete Pereira, Juazeiro do Norte – CE, 10/04/1952	Physiotherapy, University of Fortaleza (UNIFOR), Fortaleza, CE, 1972-1976; Post-Graduation in Educational Technology, UNIFOR, Fortaleza, CE, 1980-1981; Law (Incomplete), UNIFOR, Fortaleza, CE, 1999-2000 ..	Author of PL 1,187 / 2011.
João Hildo de Carvalho Furtado, Fortaleza-CE, 11/04/1933	Dentistry, Faculty of Dentistry and Pharmacy of Ceará, 1953; PhD in Dentistry; Free Teaching in surgery and maxillofacial prosthesis.	“Technical advice” to PL 2244/89 (p. 34).
José Zavaglia, Ribeirão Bonito-SP, 09/01/1918	Economics	Author of PL 4.749 / 1978 that regulates the exercise of the professions of Dental Hygiene Technician and Dental Office Attendant.
Marcos Cintra Cavalcanti de Albuquerque, São Paulo-SP, 23/08/1945	Economics, Harvard College, Cambridge, MA, USA, 1968; Master in Regional Planning, Harvard University Graduate School of Design, Cambridge, MA, USA, 1974; Masters in Economics, Harvard University, Cambridge, MA, USA, 1976; PhD in Economics, Harvard University, Cambridge, MA, USA, 1985. Specialization in Economic Planning, UNICAMP, Campinas, SP, 1970-1971	Author of PL 4,381 / 2001.
Maria Lenice da Silva Avelar, S/I	THD	“Technical advice” to PL 2.244 / 89 (p. 34).
Moacyr da Silva, S/I	Dentistry, University of São Paulo, 1963; PhD in Dentistry, University of São Paulo, 1971.	“Invaluable collaboration” to PL 2244/89 (p. 25).
Raphael Baldacci Filho, Caçapava-SP, 14/10/1928	Dentistry, Federal University of São Paulo, 1950.	President of the São Paulo Association of CD and Federal Deputy. He demanded a total veto of PL 39/64, which deals with the prosthetic profession. However, it is mentioned as having “Invaluable collaboration” in PL 2244/89 (p. 25).
Robson Riedel Marinho, Belo Horizonte-MG, 07/01/1950	Law, University of Vale do Paraíba, 1973.	Author of the Bill of Law (PL) 2.244 / 89, primary and precursor to Law 11.889 / 2008.
Rozângela Fernandes Camapum, Uruaçu-GO, 08/06/1963	Dentistry, Federal University of Goiás, 1984; Specialization in Pediatric Dentistry by ABO-GO, 1989.	Collaborator in PL 2244/89.
Rubens Otoni Gomide, Goianésia-GO, 06/02/1956	Law, Faculty of Law of Anápolis, 1980; Mechanics, Federal University of Uberlândia; Social Sciences, Faculty of Philosophy Bernardo (Anápolis).	Author of PL 1.140 / 2003, which originated Law 11.889 / 2008, a regulation that finally regulates auxiliary professions of technical level in Dentistry.
Swedenberger do Nascimento Barbosa, Natal-RN, 09/11/57	Dentistry, Federal University of Rio Grande do Norte, 1980; Master in Health Sciences, University of Brasília (UnB), 2009; PhD in Health Sciences, UnB, 2015.	“Technical advice” to PL 2244/89 (p. 34).
Volnei Garrafa, Três de Maio, RS 16/09/1946	Dentistry, Pontifical Catholic University of Rio Grande do Sul, 1968; PhD in Sciences, UNESP, 1974	“Technical advice” to PL 2244/89 (p. 34).
Vitor Gomes Pinto, Porto Alegre-RS, 11/11/1941	Dentistry, Federal University of Rio Grande do Sul, 1965; Master in Public Health, University of São Paulo, 1977; PhD in Public Health, University of São Paulo, 1992.	“Technical advice” to PL 2244/89 (p. 34).

• Note: THD: dental hygiene technician, CD: dental surgeon, ACD: dental assistant, CFO: Federal Dentistry Council, CRO: Regional Dentistry Council, TSB: oral health technician, ASB: oral health assistant; S / I: No Information

It was also observed the participation of dentists with political dispositions and founders of Collective Oral Health in Brazil and responsible for the insertion of oral health in the Brazilian Health Reform (in Portuguese “Reforma Sanitária Brasileira” – RSB) process [²⁵], such as Volnei Garrafa and Swedenberger do Nascimento Barbosa. It is worth mentioning that these two agents have a trajectory within the scientific field, with one pursuing a career in the university bureaucratic field and the other within the political field. Rozângela Fernandes Camapum, cited as a “surpassable” collaborator, also had political dispositions (table 4).

This proposal maintained the direct supervision of the dentist for the procedures of the auxiliary team and the minimum course load. It rescued the performance of clinical activities, but it banned advertisements from assistants, including in magazines in the area, and granted the profession’s exercise to those who were at least three years working. It established the control of the professional practice of the category by the CFO and parameters for the assistants’ annuity with this entity (table 3).

This parliamentary process was approved in all instances in which it was processed, but it was shelved at the end of the deputy’s mandate. Almost all the PLs presented later, as well as Law 11,889 / 2008, bring aspects very similar to the text and justification of PL 2,244 / 1989, with minimal changes, and made reference to the importance of Deputy Robson Marinho for the cause (table 3).

In 1991, deputy Augusto Carvalho (Brazilian Communist Party - PCB), presented PL 284/1991, approved in the Senate (PLC 53/1993) and taken to presidential sanction, but vetoed by President Itamar Franco. The veto was based on questions of an economic nature and which could also represent threats to market dentistry itself, presented contradictory arguments to the proposal, suggesting that it discouraged professional improvement when the training course was a prerogative. In addition, he cited the creation of another council for the category, when the body responsible for its regulation already existed.

The regulation of such professions restricts the labor market, delimits freedom of work, discourages professional development and prevents full contractual freedom [...] and will create, as in other regulated professions, the creation of another council category and in its midst the inconvenience of forming another reserve of the labor market [...] (Veto message No. 1,103, of December 30, 1993)

Oral Health Team

After this veto, social mobilization for the professional formalization of auxiliary staff in Dentistry in Brazil cooled. Only 7 years later, a new PL was presented by deputy Agnelo Queiroz (Communist Party of Brazil/ In Portuguese “Partido Comunista do Brasil” – PCdoB), with the same content as the previous proposal, removing only the definition of maximum annuity to be paid by assistants (Table 3). This PL was joined by another one from 2001 by Deputy Marcos Cintra (Liberal Front Party/ In Portuguese “Partido da Frente Liberal” – PFL), economist and professor at the School of Business Administration of São Paulo, Fundação Getúlio Vargas. For the first time in legislative acts, the terms TSB and ASB appeared, albeit in a restrictive perspective, limiting the TSB’s attributions to those of the ACD in the other proposals. A position opposed to the PL series presented up to that moment. PL n. 2,487 / 2000 was archived at the end of the legislature (tables 3 and 4).

The terms ASB and TSB appear as Professor Paulo Capel Narvai’s propositions in an article related to the VIII Enatespo, carried out in São Paulo, in 1991, prepared for discussion and propositions on the theme of auxiliary professions by invitation of the National Division of Oral Health / Ministry of Health [²⁶]. The author questioned the use of the term ACD, considering that its actions were not restricted to the dental office, just as the term attendant would also not be the most appropriate. With regard to THD, he pointed out that the term should be more debated, discussing the importance of the oral health team.

There is a paradox between the actions of the legislative and executive branches. From the 2000s onwards, as a result of the Enatespos and the participation of agents primarily from the scientific and bureaucratic fields, militants of the health movement, who were consultants at the Ministry of Health at the time of the formulation of the oral health policy [¹⁹], the insertion of the oral health team in the Family Health Strategy (ESB / ESF) generated approximately 10,000 new public jobs and courses for technical training and training of the auxiliary team [⁵]. The executive branch opened vacancies for ASB and TSB, even without these professions being regulated.

In 2003, three more PLs were presented, two of equal content, reproducing the text of PL No. 4,487 / 2000, disagreeing only about the terminology for the auxiliary categories and the determination of maximum annuities for the TSB and ASB. The third was the re-presentation of PL n. 4,381 / 2001, by deputy Marcos Cintra (table 3).

Bill 1.140 / 2003 (PLC 3/2007, in the Senate), presented by Deputy Rubens Otoni (Workers Party/ In Portuguese “Partido dos Trabalhadores” – PT), obtained approval in all instances and gave rise to Law 11,889, of 12/24/2008, regulating the exercise of TSB and ASB in Brazil. The other two PLs proposed in 2003 were attached to it.

Strategies and disputes

The presence of a dentist in the president’s office was important for the approval of the PL. This CD was able to access technical standards by which the text should pass so that it was not vetoed, having made the necessary adjustments.

[...] how will it be vetoed?! It will be vetoed because there it said what was the contribution [related to the value in the class council], the registration of TSB and ASB in the Federal and Regional Councils of Dentistry. What we wanted was the question of assignments, the question of salary, we made another bill [...]

(E1, dentist and manager)

During the processing of PL 1.140 / 2003, there were moments when the dispute between the ideologies of professionalism [³], on one hand, and the scientific administration articulated to the political administration, on the other, became even more explicit. In an account of the mobilization activities in the Chamber of Deputies on 11/22/2005, in the Cedros list, two union activists narrate: “We were FIO, ANATO, CRO-GO, SODF, SOEGO and THDs from Goiânia and Brasília. We arrived early, filled the auditorium, passed in all offices [...]”. There is reference to entities representing auxiliary personnel (National Association of Auxiliary and Dental Technicians), dentist union entities (FIO, Union of Dentists of the Federal District and Union of Dentists in the State of Goiás) and a professional entity (Regional Council of Dentistry) Goiás).

The main element of disagreement was evident: “[...] we reached an agreement, leaving a single impasse: the Brazilian Association of Dental Surgeons (ABCD) and the São Paulo Regional Dentistry Council (CRO-SP) did not accept for THDs to do restorations”, verbalizing the ideology of professionalism more forcefully.

FIO 2005 bulletins / newspapers portrayed articulation between national dental entities and the national oral health coordinator with the objective of approving the PL and the process inside the Chamber of Deputies. In April / 2005, he cited a manifesto signed by the Ministry of Health, FIO, ABO, CFO and ANATO in support of the substitute for PL 1.140 / 2003 with the deletion of the item “prophylaxis of oral diseases” and the CD / THD ratio in the proportion of 1 to 5, as proposed in Resolution 185/1993 of the CFO. However, the opinion of the rapporteur, Deputy Marcelo Barbieri, in the Labor Committee, in September, disregarding the agreement with FIO and national associations of THD and ACD, prevented the presence of THD in SUS and in Smiling Brazil program, which provided for the supervision of a dentist for each THD and assignments in preventing oral diseases. The opinion was pointed out as a historical setback, but it was supported by the APCD, which criticized the position of the other entities. In December of that year, the support of Deputy Jovair Arantes stood out in the defense of the proposal prepared by class entities and his work in substituting for a more comprehensive wording regarding the performance of THD and ACD.

The vehement defense of the interdiction of restorations by auxiliary personnel exemplifies what Freidson [²⁷] lists as a ubiquitous characteristic of the professions: the claim that there are such complex problems that it would be in the public interest that their execution is denied to those who do not have a specific type of training.

The CFO, with a favorable position for approval, highlighted on its official website the possibility of voting on the project of the Chamber of Deputies in July / 2007. A speech by professors from PUC-RS in favor of the ACD and THD in the Chamber of Deputies was booed. The position of dentistry students at that time was compared to that of doctors when they proposed the “Medical Act”:

[...] any day they will be against the prevention of diseases in the mouth for fear of taking the work from dentists [...]. We were fought a lot when we used [auxiliary personnel] in the pilot program in the city of Bagé, from SESP [...]. And now colleagues come to want to imitate the Medical Act. I believe that a reformulation in dental education is lacking, giving a greater emphasis on what our profession is and how it should be exercised with assistants.

(Flavio Luce apud Narvai, 2007)

Strategy to make oral health policy feasible?

The approval of the regulation of auxiliary professions, especially the TSB, was understood by the interviewees as a stimulus for hiring technicians and a strategy for universal and comprehensive oral health care.

[...] I believe that regulation was a great victory. It was from there that more [vacancies] were opened, either in private entities or in the public service [...] it was when the insertion of TSB was expanded [...]

(E1, dentist and manager)

Although the participation of THD in modality II of the ESB / ESF predicted an increase of 23.1% in the financial incentive in relation to modality I [²⁸], the National Oral Health Policy (In Portuguese “Política Nacional de Saúde Bucal” – PNSB) proved to be insufficient as a strategy to expand access through auxiliary personnel, especially technicians [²³]. PNSB foresees similarity in the performance of technicians and assistants, with an emphasis on health education and supervised oral hygiene actions [²⁸], to the detriment of assistance actions [³]. To expand access, it proposes to overcome the biomedical model, through the transversal insertion of oral health in a more comprehensive perspective, through lines of care and by living condition [²⁸].

The approval of the PL in the Senate was celebrated by the class entities. FIO highlighted the importance of Filomena Barros, president of ANATO in monitoring the process at the National Congress. The role of CD Swenderberger Barbosa, special advisor to the presidency, was also highlighted when the project arrived at the Planalto Palace to be sanctioned.

After Law 11,889 / 2008 was enacted, there are still demands. In that sense, in 2011 and 2015 PL were presented in this regard, respectively, by Gorete Pereira (Party of the Republic - PR) and by Cabo Sabino (PR) to establish a national professional salary floor. The proposals were for a minimum wage for an eight-hour daily and forty-weekly workday for both categories, being higher for the TSB, differing only in the amount proposed in each PL (table 3).

The analysis of the 12 parliamentary processes shows that in Brazil, even with the inclusion of auxiliary professionals in the public sphere since the 1950s and the expansion of the participation of these professionals from the inclusion of ESB / ESF, the Brazilian State was silent regarding formalization of the ASB and TSB professions, even though the CNE has approved the THD and ACD courses since 1975, highlighting their duties (Brazil, 1975), and the series of resolutions by the CFO since 1984 recognizing the auxiliary professions and adapting their assignments to their interests [²³]. The legislative path until the formalization of auxiliary professions lasted 31 years (1977 to 2008), permeated different political-administrative situations, starting in the period of the military dictatorship and extending until the end of the first decade of the 21^st century. The deliberations of the Legislative and Executive branches reflected the national context, whether vetoing or not concluding the processing of these projects during the term of a legislature, leading them to be archived. Five parliamentary cases were closed, one was vetoed (PL 281/1991, PLC 53/1993), 4 rejected and 1 approved.

Only after seven years of the incorporation of ESB / ESF, PL 1.140 / 2003 was approved, which gave rise to Law 11.889 / 2008, regulating the exercise of auxiliary professions. The importance of the performance of dental surgeons within the political field is highlighted in different ways from 1989 until regulation was obtained in 2008. These dentists were important agents for the collective oral health space, with political and militant dispositions from the the RSB [²⁵].

Who was interested in the theme and why?

The diversity of social, professional and political affiliations (including both right and left parties) among proponents is highlighted. The initiatives were made both by deputies from the opposition party to the military dictatorship (MDB) and in support of it (Arena). In the democratic period, the bills were formulated by parties of the left (PT, PCB and PCdoB), right (PR) and center (PSDB), according to the classification proposed by Schimitt [²⁹].

The multiple correspondence analysis related the restrictive practice of TSB to parliamentarians from the southeastern region (São Paulo and Espírito Santo), without training in the health field and with professions related to the private market, graduates in economics and engineering (figure 1). The defense for the clinical performance of the TSB, under the supervision of the dentist, was related to agents in the health area (Medicine) and human science (Law, Sociology and Pedagogy). The projects that dealt with the claims about a salary floor were presented by a health professional and with incomplete higher education, respectively, after the regulation of auxiliary professions (figure 1).

Figure 1
Multiple correspondence analysis.

The identification of these parliamentarians took place, according to empirical evidence, through the network of contacts (social capital) of the dentists that worked in associations and class entities, especially the FIO, in Collective Oral Health and in RSB. In other words, it did not matter which party or political current they were affiliated with, as long as they were sensitive to the cause [³⁰]. The final reports by Enatespos and the CNSB expressed support for auxiliary personnel, the PLs always obtained favorable opinions. The regulation incorporated into the official discourse the point of view of entities such as FIO, ANATO, dentists’ unions, which are more progressive and have a broader role in the TSB, with direct supervision by the dentist for clinical activities.

CONCLUSION

The analysis carried out showed the long historical process of social construction of the regulation of auxiliary professions in oral health in Brazil, especially the TSB profession. It points to the need to mobilize different types of capital, especially social, political, bureaucratic, and the articulation of agents from different social spaces, with emphasis on the political field and the militant space, but also the scientific field and founders of Collective Oral Health in this construction.

The development of this entire process is not separate from internal disputes in the dental field, its product being a result of the struggle between different projects. The interests of the private sector (Dentistry Market) and the public sector permeated the advances and setbacks for each PL presented, filed, vetoed or approved. The interests of the SUS, related to the implementation of oral health teams and the expansion of the offer of services, were not shown to be sufficient for a timely regulation and were even threatened. The articulation between representatives of the executive, legislative and judicial branches, absent throughout almost the entire process, was what made it possible to regulate the professions of TSB and ASB in the country.

How to cite this article

• Barros SG, Jordan JM, Bleicher L, Soares CLM, Rossi TRA. The legislative and the regulation of dental assistants professions in Brazil. RGO, Rev Gaúch Odontol. 2022; 70:e20220015. http://dx.doi.org/10.1590/1981-86372022001520200121

REFERENCES

• ¹
  Sanglard-Oliveira CA, Werneck MAF, Lucas SD, Abreu MHNG. Exploring professionalization among Brazilian oral health technicians. Human Resources for Health 2012;10(5):1-10. https://doi.org/10.1186/1478-4491-10-5
  » https://doi.org/10.1186/1478-4491-10-5
• ²
  Baltutis LM, Gussy MG, Morgan MV. The role of the dental hygienist in the public health sector; an Australian perspective. Int Dental J. 2000;50(1):29-35. https://doi.org/10.1111/j.1875-595X.2000.tb00543.x
  » https://doi.org/10.1111/j.1875-595X.2000.tb00543.x
• ³
  Zanetti CHG, Oliveira JAA, Mendonça MHM. Divisão do trabalho odontológico em perspectiva: desafio de interpretar as competências dos técnicos. Trabalho, Educ Saúde 2012;10(2):195-222. http://dx.doi.org/10.1590/S1981-77462012000200002
  » https://doi.org/10.1590/S1981-77462012000200002
• ⁴
  Frazão P, Narvai PC. Lei n.11.889/2008: avanço ou retrocesso nas competências do técnico em sáude bucal? Trabalho, Educ Saúde. 2011;9(1):109-123.
• ⁵
  Pezzato LM, Cocco MIM. O técnico em higiene dental e o atendente de consultório dentário no mundo do trabalho. Rev Saúde Debate. 2004;68(1):212-219.
• ⁶
  Brasil. Parecer MEC/CFE n.º 460 de 6 de fevereiro de 1975. Dispõe sobre a habilitação em nível de 2º grau de Técnico em Higiene Dental e Atendente de Consultório Dentário. Diário Oficial da República Federativa do Brasil, seção I, p. 3937.
• ⁷
  Enatespo. I Encontro Nacional de Administradores e Técnicos de Serviços Públicos Odontológicos. Relatório. Porto Alegre: Enatespo; 1984.
• ⁸
  Narvai PC, Manfredini M, Botazzo C, Raineri N, Schneider DA, Frazão P. Contra o técnico em higiene dental. Rev Saúde Debate. 1989;28:59-65.
• ⁹
  Brasil. Ministério da Saúde. Relatório final da 1ª Conferência Nacional de Saúde Bucal. Brasília: Ministério da Saúde; 1986 [citado 2020 Mar 10]. Disponível em: <https://bvsms.saude.gov.br/bvs/publicacoes/1_conferencia_nacional_saude_bucal_relatorio_final.pdf>.
  » https://bvsms.saude.gov.br/bvs/publicacoes/1_conferencia_nacional_saude_bucal_relatorio_final.pdf
• ¹⁰
  Brasil. Ministério da Saúde. Relatório final da 2ª Conferência Nacional de Saúde Bucal. Brasília: Ministério da Saúde; 1993 [citado 2020 Mar 10]. Disponível em: <http://189.28.128.100/dab/docs/portaldab/publicacoes/2_conferencia_nacional_saude_bucal_relatorio_final.pdf>.
  » http://189.28.128.100/dab/docs/portaldab/publicacoes/2_conferencia_nacional_saude_bucal_relatorio_final.pdf
• ¹¹
  Brasil. Ministério da Saúde. Relatório final da 3ª Conferência Nacional de Saúde Bucal. Acesso e qualidade superando a exclusão social. Brasília: Ministério da Saúde; 2005 [citado 2020 Mar 10]. Disponível em: <https://bvsms.saude.gov.br/bvs/publicacoes/3_conferencia_nacional_saude_bucal_relatorio_final.pdf>.
  » https://bvsms.saude.gov.br/bvs/publicacoes/3_conferencia_nacional_saude_bucal_relatorio_final.pdf
• ¹²
  Leite DO, Souza RC, Naressi SCM, Nicodemo D, Koga KS, Orenha ES. Impacto do trabalho auxiliado na qualidade de vida do cirurgião dentista. Braz Dental Sci. 2011;1(2):27-33. https://doi.org/10.14295/bds.2011.v14i1/2.706
  » https://doi.org/10.14295/bds.2011.v14i1/2.706
• ¹³
  Garcia LP, Blank VLG. Prevalência de exposições ocupacionais de cirurgiões-dentistas e auxiliares de consultório dentário a material biológico. Cad Saúde Pública. 2006;22(1):97-108. https://doi.org/10.1590/S0102-311X2006000100011
  » https://doi.org/10.1590/S0102-311X2006000100011
• ¹⁴
  Narvai PC. Recursos humanos para promoção da saúde bucal: um olhar no início do século XXI. In: Kriger L, coord. ABOPREV: promoção de saúde bucal. 3ª ed. São Paulo: Artes Médicas; 2003. p. 475-94.
• ¹⁵
  Paranhos LR, Ricci ID, Tomasso S, Salazar M, Siqueira DF. Análise da relação entre o cirurgião-dentista e o pessoal auxiliar. Rev Odonto Ciênc. 2008;23(4):365-70.
• ¹⁶
  Silva RF, Monini AC, Daruge Junior E, Francesquini Júnior L, Lanza MA. Utilização de auxiliares odontológicos em Ortodontia: implicações éticas e legais. Rev Dental Press Ortod Ortop Fac. 2006;11(5):121-128. http://dx.doi.org/10.1590/S1415-54192006000500013
  » https://doi.org/10.1590/S1415-54192006000500013
• ¹⁷
  Pezzato LM, Monteiro MI, Bagnato MHS. Processos de formação do técnico em higiene dental e do auxiliar de consultório dentário no Brasil: algumas memórias. Odontole Soc. 2007;9(1):39-49.
• ¹⁸
  Boudieu P. Razões práticas: sobre a teoria da ação. Campinas: Papirus; 1996.
• ¹⁹
  Rossi TRA. Produção social das políticas de saúde bucal no Brasil. Salvador: EDUFBA; 2018.
• ²⁰
  Greenacre, M. La prática del análisis de correspondências. Bilbao, Espanha: Fundación BBVA; 2008.
• ²¹
  Infantosi AFC, Costa JCGD, Almeida RMVR. Análise de correspondência: bases teóricas na interpretação de dados categóricos em Ciências da Saúde. Cad Saúde Pública. 2014;30(3):473-486. http://dx.doi.org/10.1590/0102-311X00128513
  » https://doi.org/10.1590/0102-311X00128513
• ²²
  Kovaleski DF, Boing AF, Freitas SFT. Recursos humanos auxiliares em saúde bucal: retomando a temática. Rev Odontol UNESP. 2005;34(4):161-65.
• ²³
  Aguiar DML, Frazão P. A insuficiência da política pública para inclusão do técnico em saúde bucal na atenção primária no Brasil. In: Chaves SCL, org. Política de saúde bucal no Brasil: teoria e prática. Salvador: EDUFBA; 2016. p. 297-317.
• ²⁴
  Barbosa SN. Pessoal auxiliar em Odontologia: regulamentação das profissões de THD e ACD. Rev Divulg Saúde para Debate. 1991;6:37-39.
• ²⁵
  Soares CLM, Paim JS, Chaves SCL, Rossi, TRA, Barros SG, Cruz DN. O movimento da Saúde Bucal Coletiva no Brasil. Ciênc Saúde Coletiva. 2017;22(6):1805-1816. https://doi.org/10.1590/1413-81232017226.22972016
  » https://doi.org/10.1590/1413-81232017226.22972016
• ²⁶
  Narvai PC. Em defesa do técnico em saúde bucal. Divulg Saúde para Debate. 1991;6:27-34.
• ²⁷
  Freidson E. Para uma análise comparada das profissões: a institucionalização do discurso e do conhecimento formais. Rev Bras Ciências Sociais. 1996;11(31):141-154.
• ²⁸
  Brasil. Ministério da Saúde. Política Nacional de Saúde Bucal. Brasília: Ministério da Saúde; 2004.
• ²⁹
  Schimitt RA. Partidos políticos no Brasil (1945-2000). Rio de Janeiro: Zahar; 2000.
• ³⁰
  Barros SG. Política Nacional de Aids: a construção da resposta governamental à epidemia de HIV/aids no Brasil. Salvador: Edufba; 2018.

Edited by

Assistant editor: Luciana Butini Oliveira

Publication Dates

• Publication in this collection
  06 May 2022
• Date of issue
  2022

History

• Received
  23 July 2020
• Reviewed
  24 Oct 2020
• Accepted
  11 Dec 2020