Specialized Dental Care in the Brazilian Unified National Health System (SUS)

ABSTRACT

Objective:

To analyze specialized dental care through access, demand and the work processes provided by the CEO's, using secondary data from the cycles of the PMAQ-CEO.

Material and Methods:

Cross-sectional study using public domain data. Variables of interest were selected from the external evaluation instrument data matrices and were grouped in categories. The categories were geographic distribution, structural, human resources, work processes and access and coordination.

Results:

The total of 932 CEO’s were evaluated in 2014 and 1,042 in 2016, most of them type II, present in the Northeast region. In both cycles, the highest average of dentists worked in the endodontic specialty (2.4 professionals per CEO) and the lowest in oral medicine (0.8 professionals per CEO). Of the two cycles, 91.5% of the CEO’s had a manager, 79.5% performed action planning activities and 74.5% realized internal self-assessment processes. There was an increase in the mean number of days to be seen at the CEO in all analyzed specialties (p<0.001) and 85.2% of the CEO's managers reported that there is a reference for oral cancer confirmed cases.

Conclusion:

Between the PMAQCEO cycles the number of CEO has increased, but there are still a big pent-up demand and the presence of care gaps. However, an expansion and improvement of the CEO’s actions was evidenced, mainly related to the work processes.

Keywords:
Dental Health Services; Health Care Quality; Access; and Evaluation; Specialties; Dental.

Introduction

The oral health services in the Unified Health System (SUS) were historically linked to the difficulty of access to socioeconomically disadvantaged populations. The difficulty of access results in the precariousness of oral health conditions and in inequity in health [¹-³]. As a strategy for the population's oral health care, the Oral Health Teams (ESB) were inserted into the Family Health Strategy Teams (ESF), resulting from several discussions between entities, managers, and professionals based on integrality and continuity of care. However, oral health services were only concentrated in Primary Health Care (PHC) [⁴].

Dental Specialty Clinics (CEO) were implemented as part of the National Oral Health Policy (PNSB) to expand secondary oral health care in the country. The CEO offers medium-complexity care for the specialties of endodontics, stomatology, minor oral surgery of soft and hard tissues, dentistry for special needs users and periodontics. They can also offer other specialties, serving as a primary strategy in maintaining integrality in oral health care. The Regional Dental Prosthesis Laboratories (LRPD) also came with the implementation of the PNSB, helping the ESB of the PHC, in order to carry out the manufacture of dental prostheses [¹,⁵-⁷].

Since 2004, the year in which the PNSB was implemented, noted the need to evaluate CEO efficiency, work processes, user's satisfaction and establishments performances [⁸]. The scientific production about the performance of the CEO was restricted to the global achievement of goals or the performance of outpatient procedures [³,⁶,⁷,⁹]. There was no evaluation of substantial and standardized indicators and the self-assessment process [¹⁰].

In 2013, the Ministry of Health instituted the Program to Improve Access and Quality of Dental Specialty Clinics (PMAQ-CEO) with the objective of increasing and improving access and quality of care for CEO [¹¹]. The PMAQ presented voluntary adherence. The evaluation methods induced the health establishments to promote a national standardization of the quality of care, establishing continuous processes of self-assessment and planning [¹²]. In addition, the PMAQ-CEO aimed to create a database, available for public access, which information on a considerable number of Brazilian CEO [¹⁰,¹²].

There is a lack of studies evaluating specialized oral health care in Brazil [⁴,¹⁰,¹²]. Previously published studies reported the results of the first cycle of the PMAQ-CEO [²,⁸,¹⁰,¹¹,¹³-¹⁷]; however, data from the second cycle are still poorly known. Thus, the aim of the present study was to analyze specialized dental care through access, demand and the work process provided by the CEO's, using secondary data from the cycles of the PMAQ-CEO.

Material and Methods

Study Design and Data Collect

Cross-sectional study with data of the public domain. The variables were collected in field, in the 2014 and 2016 years by PMAQ-CEO's evaluators and the authors obtained the data from the Ministry of Health website (http://aps.saude.gov.br/ape/pmaq) [¹⁸]. Evaluators were selected and calibrated by higher education and research institutions throughout Brazil. The interviewers were dentists who used the same questionnaire. The questionnaire was available in electronic format, standardized and answered using portable computers (tablets) [¹³]. Exclusion criteria adopted by the PMAQ-CEO were: CEO under renovation, closed, those disabled by the Ministry of Health and those who refused to participate in the external evaluation of the PMAQCEO [¹³,¹⁹].

PMAQ-CEO External Evaluation Instrument (AVE PMAQ-CEO)

During the external evaluation of both PMAQ-CEO cycles, the instrument used was structured in three modules. Module I - observation in the CEO. Module II - interview with the establishment's manager and a dental surgeon who worked at the location. Module III - Interview with CEO users. The objectives of the three modules were: evaluate the establishment's structure conditions, equipment, instruments and supplies; work process and the organization of the service and to verify the users’ satisfaction of the CEO with the service provided [¹⁷,²⁰].

Interest's Variables

Comparisons were made between the first and second cycles of the PMAQ-CEO and according to the data scoring matrices, some variables were selected and grouped into the following categories:

1. Geographic distribution: CEO's geographic region and federative unit where CEO was localized;

2. Structural: CEO’s type;

3. Human resources: number of dentists who worked in minimal specialties and the sum of the working hours of professionals working in the specialties;

4. Work processes: CEO’s management; action planning activities; monitoring and analysis of established goals; self-assessment processes; support from other professionals in helping and supporting the resolution of complex cases; matrix support or support actions for the ESB by PHC in solving cases considered complex; actions carried out by the professionals of the CEO together with the ESB by PHC; use of clinical and electronic medical records; offer of other specialties;

5. Access and coordination: Access to the CEO; organization of referral vacancies for care in a hospital environment; referral for oral cancer's confirmed cases; counter-referral to PHC's teams.

Statistical Analyses

Data were tabulated in the IBM Statistical Package for the Social Sciences^® (SPSS) version 24.0. For the performance of appropriate statistical analyses and tests was accepted at 5% by significance level. The verification of normality sample was using the Kolmogorov-Smirnov test. To compare the means of numerical variables, Student's t and Mann-Whitney U tests were used. To identify associations between dichotomous nominal categorical variables between the first and second cycles of the PMAQ-CEO, the Pearson's chi-square test (χ²) was used.

Results

PMAQ-CEO's assessment was carried out with 932 CEO in the first cycle and 1,042 in the second cycle. Even though CEO adherence was higher in the second cycle, the distribution remained similar across Brazilian states. In both cycles, there was a higher concentration of CEO in Northeast region. However, São Paulo's state had the highest number of CEOs compared to other federative units (mean of 18.7% between the two cycles). Most were type II CEO (mean of 48.8%), followed by type I (mean of 38.8%) and III (mean of 12.3%). North's region shows significant inequality in terms of the availability of CEO. Even with a higher number of states than the South and Southeast regions, the North's region shows a mean of 62 establishments adhering to the program (mean of 6.3%) (Table 1).

Table 1
Distribution of Dental Specialty Clinics (CEO) by geographic region and federative unit according to the first and second cycles of the National Program for the Improvement of Access and Quality (PMAQ), 2014 and 2016.

Geographic Region	Federative Unit	Type I N (%)	CEO’s Type Type II N (%)	- 1º Cycle Type III N (%)	Total N (%)	Total N (%)	Type I N (%)	CEO’s Type Type II N (%)	- 2º Cycle Type III N (%)	Total N (%)	Total N (%)
North	Acre Amazonas	1 (0.1) 2 (0.2)	1 (0.1) 8 (0.9)	0 (0.0) 1 (0.1)	2 (0.2) 11 (1.2)	60 (6.3)	1 (0.1) 2 (0.2)	1 (0.1) 8 (0.8)	0 (0.0) 3 (0.3)	2 (0.2) 13 (1.2)	66 (6.4)
	Amapá Pará	1 (0.1) 16 (1.7)	0 (0.0) 8 (0.9)	2 (0.2) 5 (0.5)	3 (0.3) 29 (3.1)		0 (0.0) 18 (1.7)	0 (0.0) 10 (1.0)	2 (0.2) 4 (0.4)	2 (0.2) 32 (3.1)
	Rondônia Roraima	0 (0.0) 0 (0.0)	6 (0.6) 1 (0.1)	1 (0.1) 0 (0.0)	7 (0.7) 1 (0.1)		0 (0.0) 0 (0.0)	7 (0.8) 2 (0.2)	1 (0.1) 0 (0.0)	8 (0.8) 2 (0.2)
Northeast	Tocantins Alagoas	4 (0.4) 11 (1.2)	2 (0.2) 10 (1.1)	1 (0.1) 1 (0.1)	7(0.7) 22 (2.4)	357 (38.4)	4 (0.4) 16 (1.5)	1 (0.1) 9 (0.9)	2 (0.2) 0 (0.0)	7 (0.7) 25 (2.4)	410 (39.3)
	Bahia Ceará	29 (3.1) 37 (4.0)	38 (4.1) 16 (1.7)	8 (0.9) 27 (2.9)	75 (8.0) 80 (8.6)		31 (3.0) 31 (3.0)	40 (3.8) 13 (1.2)	7 (0.7) 30 (2.9)	78 (7.5) 74 (7.1)
	Maranhão Paraíba	3 (0.3) 33 (3.5)	22 (2.4) 16 (1.7)	1 (0.1) 4 (0.4)	26 (2.8) 53 (5.7)		6 (0.6) 60 (5.8)	20 (1.9) 18 (1.7)	2 (0.2) 4 (0.4)	28 (2.7) 82 (7.9)
	Pernambuco Piauí	17 (1.8) 14 (1.5)	21 (2.3) 13 (1.4)	2 (0.2) 1 (0.1)	40 (4.3) 28 (3.0)		26 (2.5) 16 (1.5)	26 (2.5) 13 (1.2)	6 (0.6) 1 (0.1)	58 (5.6) 30 (2.9)
	Rio Grande do Norte Sergipe	0 (0.0) 0 (0.0)	21 (2.3) 7 (0.8)	2 (0.2) 3 (0.3)	23 (2.5) 10 (1.1)		1 (0.1) 0 (0.0)	22 (2.1) 8 (0.8)	2 (0.2) 2 (0.2)	25 (2.4) 10 (1.0)
Centre-west	Federal District Goiás	2 (0.2) 7 (0.8)	7 (0.8) 15 (1.6)	0 (0.0) 6 (0.6)	9 (1.0) 28 (3.0)	6z (6.7)	2 (0.2) 12 (1.2)	7 (0.7) 17 (1.6)	0 (.0) 5 (0.5)	9 (0.9) 34 (3.3)	71 (6.8)
	Mato Grosso do Sul Mato Grosso	4 (.4) 1 (0.1)	10 (1.1) 8 (0.9)	1 (0.1) 1 (0.1)	15 (1.6) 10 (1.1)		3 (0.3) 1 (0.1)	11 (1.1) 4 (0.4)	1 (0.1) 8 (0.8)	15 (1.4) 13 (1.2)
South	Paraná Rio Grande do Sul	14 (1.5) 16 (1.7)	22 (2.3) 8 (0.9)	12 (1.3) 1 (0.1)	48 (5.1) 25 (2.7)	116 (12.4)	12 (1.2) 22 (2.1)	21 (2.0) 11 (1.1)	15 (1.4) 1 (0.1)	48 (4.6) 34 (3.3)	131 (12.6)
Southeast	Santa Catarina Espírito Santo	25 (2.7) 6 (0.6)	15 (1.6) 02 (0.2)	3 (0.3) 1 (0.1)	43 (4.6) 9 (1.0)	337 (36.2)	28 (2.7) 7 (0.7)	17 (1.6) 1 (0.1)	4 (0.4) 1 (0.1)	49 (4.7) 9 (0.9)	364 (34.9)
	Minas Gerais Rio de Janeiro	27 (2.9) 16 (1.7)	54 (5.8) 44 (4.7)	2 (0.2) 6 (0.6)	83 (8.9) 66 (7.1)		31 (3.0) 19 (1.8)	54 (5.2) 47 (4.5)	6 (0.6) 8 (0.8)	91 (8.7) 74 (7.1)
	São Paulo TOTAL	63 (6.8) 349 (37.4)	99 (10.6) 474 (50.9)	17 (1.8) 109 (11.7)	179 (19.2) 932 (100.0)	932 (100.0)	69 (6.6) 418 (40.1)	100 (9.6) 488 (46.8)	21 (2.0) 136 (13.1)	190 (18.2) 1042 (100.0)	1042 (100.0)

Endodontics was the specialty with the highest number of working dentists (mean of 2.4 dentists per establishment in both cycles). Stomatology was the specialty with the lowest number of professionals working (mean of <1 dentist per CEO). Only periodontics showed a reduction in the number of professionals (p<0.05) (Table 2).

Table 2
Mean and standard deviation values of numerical variables measured by the External Assessment (AVE) of the National Program for Improving Access and Quality of Dental Specialty Clinics (PMAQ-CEO) 2014 e 2016.

		1º Cycle				2º Cycle			p-value
Variables	N	Meana	SDb	CI95%	N	Mean	SDb	CI95%
Dentists by Specialty
Oral Surgery	1.511	1.6	1.6	1.5-1.7	1.576	1.5	0.8	1.4-1.5	0.065
Endodontics	2.403	2.5	3.4	2.3-2.8	2.443	2.3	1.4	2.2-2.4	0.054
Oral Medicine	828	0.8	1.9	0.7-1.0	876	0.8	0.7	0.8-0.8	0.483
Dentistry for Special Needs Users	1.347	1.4	2.2	1.3-1.5	1.379	1.3	1.0	1.2-1.3	0.133
Periodontics	1.484	1.5	2.3	1.4-1.7	1.423	1.3	0.8	1.3-1.4	0.005c
Dental Prosthesis	1.264	2.2	3.6	1.9-2.5	1.046	1.2	1.2	1.2-1.3	<0.001c
Weekly workloade
Oral surgery	932	30.6	20.3	29.3-32.0	1.024	32.6	20.5	32.0-35.5	0.034c
Endodontics	932	49.2	33.8	47.0-51.4	1027	51.5	33.5	51.1-56.3	0.122
Oral Medicine	932	15.0	35.6	12.7-17.3	739	21.5	15.9	20.6-23.2	<0.001c
Dentistry for Special Needs Users	932	26.4	18.2	25.2-27.5	958	31.1	24.5	30.5-34.7	<0.001c
Periodontics	932	29.6	23.6	28.1-31.1	997	31.4	26.1	30.1-34.6	0.042d
Dental prosthesis	541	31.7	19.7	30.0-33.3	609	36.5	28.3	34.2-38.8	0.001c
Estimated Number of
Days to be Attendede
Oral surgery	441	35.9	65.8	35.7-49.4	961	58.1	107.9	51.3-65.0	<0.001c
Endodontics	441	67.0	90.7	64.2-82.5	949	83.4	119.5	75.8-91.0	<0.001c
Oral Medicine	441	7.1	11.9	6.1-8.0	829	7.9	16.4	6.8-9.0	<0.001c
Dentistry for Special Needs Users	441	14.6	30.3	12.0-17.7	933	17.2	35.2	14.9-19.5	<0.001c
Periodontics	441	28.0	57.3	24.5-35.6	936	34.6	79.1	29.5-36.6	<0.001c
Dental prosthesis	441	111.2	127.0	97.9-121.1	690	118.4	180.4	104.9-131.8	<0.001c

• ^a
  Mean by Establishments;
• ^b
  Standart Deviation;
• ^c
  Student's t test;
• ^d
  Mann-Whitney U test;
• ^e
  Number of Dental Specialty Centers that Answered the Question.

Dental prosthesis specialty was offered in 61.8% CEO's. However, there was a reduction in the number of dentists working in the dental prosthesis specialty. On the other hand, there was an increase in the sum of the weekly workload. There was a significant increase in the number of people on waiting lists for dental care in CEO's. Stomatology was the specialty that presented the shortest waiting time for attendance at the CEO. Dental prosthesis presented the longest time. There was an increase in the mean number of days to be seen at the CEO in all analyzed specialties (p<0.001) (Table 2).

Beyond of the five minimum specialties for the CEO implementation, 77.9% of the establishments offer other specialties: dental prosthesis, implantology, orthodontics/orthopedics, and pediatric dentistry, among others (Table 3). Of the two evaluation cycles, 91.5% CEO's have a manager (p<0.001), performed action planning activities (79.5%), analyzing analyzed the established goals (88.6%, p<0.001), and realized internal selfassessment processes (74.5%). Accession to the electronic clinical records is still low (mean of 13.3%), however has a increase to the first to the second cycle (p<0.001). Referenced offer to the service is predominant (59.2%) followed by the mixed offer (39.7%). There is no limited number for the hospital care reference (67.7%) and 85.2% of the CEO managers reported that there is a reference for oral cancer confirmed cases (p<0.001) (Table 3).

Table 3
Dental Specialty Clinic’s (CEO) work process, access, referral and counter-referral that participated in the first and second cycles of the National Program for the Improvement of Access and Quality (PMAQ), 2014 and 2016.

Variables	1rt Cycle N (%)	2nd Cycle N (%)	p-valuea
CEO’s work process CEO's management
Manager with role accumulation	347 (37.5)	339 (43.0)	<0.001a
Exclusive manager	464 (50.2)	403 (51.0)
There is no manager in the CEO Offer of other specialties (except minimum specialties)	114 (12.3)	48 (6.0)
Yes	728 (78.1)	813 (78.0)	1.000
No	204 (21.9)	229 (22.0)
Action planning activities
Yes	721 (77.7)	831 (82.0)	0.020a
No	207 (22.3)	183 (18.0)
Monitoring and analysis of established goals (By specialty)
Yes	792 (85.3)	930 (91.7)	<0.001a
No	136 (14.7)	84 (8.3)
Team's periodic self-assessment
Yes	678 (73.1)	761 (75.0)	0.325
No	250 (26.9)	253 (25.0)
Support from other professionals to solving complex cases
Yes	603 (65.0)	791 (78.0)	<0.001a
No	325 (35.0)	223 (22.0)
CEO's matrix support to the Primary care oral health teams in the resolution of complex cases
Yes	656 (70.7)	878 (86.6)	<0.001a
No	272 (29.3)	136 (13.4)
Support frequency for Primary care oral health teams
Often	230 (35.1)	361 (41.1)	0.017a
Without frequency	426 (64.9)	517 (58.9)
CEO professionals' actions carried out with Primary care oral health teams Discussion of difficult and challenging clinical cases and sentinel events
Yes	482 (73.5)	776 (86.1)	<0.001a
No	174 (26.5)	122 (13.9)
Clinical actions shared with professionals from the Primary care oral health teams
Yes	489 (74.5)	663 (75.5)	0.676
No	167 (25.5)	215 (24.5)
Training detection of oral cancer with Primary care professionals
Yes	358 (54.6)	627 (71.4)	<0.001a
No	298 (45.4)	251 (28.6)
Joint construction of therapeutic projects with Primary care oral health team professionals
Yes	276 (42.1)	458 (52.2)	<0.001a
No	380 (57.9)	420 (47.8)
Continuing education activities together with Primary care oral health team professionals
Yes	351 (53.5)	601 (68.5)	<0.001a
No	305 (46.5)	277 (31.5)
Clinical protocols construction and discussion Yes	483 (73.6)	706 (80.4)	0.002a
No	173 (26.4)	172 (19.6)
Reference's criteria agreement by specialty
Yes	581 (88.6)	756 (85.1)	0.165
No	75 (11.4)	122 (13.9)
When requested, the CEO's professionals carry out home care visits with primary care oral health teams
Yes	315 (48.0)	461 (52.5)	0.089
No	341 (52.0)	417 (47.5)
Clinical record's use
Clinical record’s use
Yes	908 (97.8)	1003 (98.9)	0.070
No	20 (2.2)	11 (1.1)
Electronic clinical record's use
Yes	73 (8.0)	186 (18.5)	<0.001a
No	835 (92.0)	817 (81.5)
Electronic clinical records integrated with the others point network
Yes	56 (76.7)	156 (83.9)	0.210
No	17 (23.3)	30 (16.1)
CEO' Access, reference and counter-referral
CEO’s access
Spontaneous demand	12 (1.3)	07 (0.7)	0.075
Referenced demand	531 (57.2)	625 (61.6)
Mixed demand	385 (41.5)	382 (37.7)
Referrals vaccancy offer to care in hospital environment
Quota system	121 (21.9)	148 (19.5)	0.375
Without limited number	364 (65.8)	548 (69.5)
Others	68 (12.3)	84 (11.1)
Pent-up demand for hospital-level care
Yes	110 (19.9)	159 (20.9)	0.064
No	409 (74.0)	575 (75.7)
Without knowledge	34 (6.1)	26 (3.4)
Reference for oral cancer confirmed cases
Yes	742 (80.0)	920 (90.7)	<0.001a
No	186 (20.0)	94 (9.3)

Discussion

The results of the present study show us the expansion and the improvement of the specialized dental care provided by the Brazilian’s CEO. The inequality in the distribution of specialized establishments is visible. There is a predominant number of CEO in the Northeast and Southeast regions, concentrated in São Paulo's state (SP). This characteristic points to sociodemographic inequities with the presence of significant care gaps. Between 2015 and 2017, there was a 6.8% growth in the number of CEO [²¹]; however, just installing these establishments is not enough to guarantee specialized dental services for users [⁸].

There are some factors that can be interpreted as hindrances to access to the CEO services. Geographic’s barriers, locomotion difficulties, social vulnerability and unique characteristics of each federative unit are variables that are capable to impact performances and use of services of CEO [⁹,⁴]. Difference performances were observed between the macro-regions. The South and Southeast CEO shows better indicators than the North and Northeast CEO [⁴,²]. Comparative ecologic study [²²] with 2000's e 2010’s data’s showed that HDI lower cities represented access' indicators more satisfy. This results follow-up equality tendency in the oral health assistance services in poorly socioeconomically states. But, in this same study, it is seen that the proportion of specialized procedures were higher in states with higher HDI [²²], as well as in a study [²¹] carried out with data available on institutional websites of the Ministry of Health, in the 2015 to 2017's period.

Hierarchy in health is a fundamental part of the provision of specialized health care. A study that evaluated changes in oral health policy [²¹] reinforced the need to add to the public health services scientific discussions of public health services the strengthening of regionalization to improve access, supply and performance of specialized oral health services.

Even with a high CEO number, there is an uneven distribution among Brazilian regions, reinforcing social inequities in the use of oral health services [²¹,²³]. In a study that evaluated the first cycle of the PMAQCEO [²], it was seen that there is an incompatibility in the workload of oral health between assistants and technicians and dentists that affects the provision availability of service. The availability of the number of these professionals, as well as their workload, are factors that can also affect user access.

Results regarding the waiting time and number of people waiting for assistance at the CEO point to a significant pent-up demand. In the second cycle of the PMAQ-CEO, an increase in the mean of the number of days for service was observed (mean varies from 34 to 180 days). It is important to assess the presence of pentup demand for specialties, as well as the absenteeism percentage. The presence of pent-up demand and high rates of absenteeism are crucial points in the evaluation of the resoluteness and integrality of secondary dental care [²⁴]. In addition, the CEO's queues may depend of work processes organized and integrated with the care network, so referenced demand and counter-referral are essential.

From the first to the second cycle, there was an increase in referenced demand with a mean of 59.2%. It is necessary for CEO to provide predominantly elective and referenced care according to the organization of the network health care [²²]. Care of the spontaneous demand can have a negative impact on the process of articulating the network and cause obstacles in the integrality of the care of users [⁸,²⁵]. In addition, referred users are more likely to complete their treatments and be counter-referred to maintain care, ensuring the efficiency and effectiveness of the service provided [²⁶,²⁷].

In the second cycle of the PMAQ-CEO, the increase of monitoring and planning of actions and goals by the CEO strengthens need for constant realization of these practices to improve services [²⁸]. A study with data from the first cycle of the PMAQ-CEO [⁸] exposed issues related to the planning of specialized clinics, identifying the importance of the manager, analyzing the multiple work organizations and a lack of implementation of planning tools in all Brazilians' CEO.

Between the cycles was perceived an increase in the number of actions carried out by the CEO’s professionals together with the Primary care oral health team’s professionals; however, no studies were found that address joint actions with the ESF teams. With the exception of a study [²⁹] that described the CEO's work process using results from the first cycle focused on the users with special needs specialty. This study [²⁹] highlighted the importance of matrix support in solving complex cases and continuing education practices as an aggregator in the quality of care provided and the organization of CEO's services.

Oral medicine is the specialty with the greatest deficiency in the Brazilian CEO scenarios. States such as Acre (AC), Amazonas (AM) and Roraima (RR) did not have active professionals [³⁰]. The availability of stomatology is the lowest among other specialties, with a mean of 0.2 professionals and 2.9 hours per week for every 10,000 inhabitants [⁸]. Such results imply considerable results in the precouses diagnosis in cases of mouth cancer [³⁰]. The deficiency and disparity in the distribution of professionals working in CEO in oral medicine are indicators that may favor the late diagnosis of oral cancer, due to the lack of offer this service in establishments without active professionals. On the other hand, endodontics presents the best scenario within the CEO's specialties, with the highest mean of professionals working and with a greater weekly workload [¹⁰]. A limitation of the present study is the use of secondary data, which may be subject to registration errors, which may interfere with real results in the inferences of this study. However, the high adherence of specialized clinics to the PMAQ-CEO consists of a census of all these establishments, reducing potential risks of selection bias [¹⁰].

Conclusion

Through the results of the PMAQ-CEO, it was possible to evaluate the Brazilian’s CEO in two different moments. An unequal geographic distribution of specialized oral health establishments, the presence of care gaps mainly in the North region, a reduction in the number of professionals and an increase in pent-up demand were visualized. However, an expansion and improvement of the CEO’s actions was evidenced. It needs the creation and implementation of strategies aimed at improving oral health indicators related to specialized services in users who need the CEO's services. Among the points that need attention are: access to the CEO, equitable distribution of establishments and a wider availability of professionals with longer and more flexible hours.

• Academic Editor: Wilton Wilney Nascimento Padilha

• Financial Support
  None.

Data Availability

The data used to support the findings of this study can be made available upon request to the corresponding author.

References

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Publication Dates

• Publication in this collection
  20 Oct 2023
• Date of issue
  2023

History

• Received
  15 July 2022
• Reviewed
  29 Sept 2022
• Accepted
  12 Oct 2022