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Structural characteristics of oral health services in Brazilian Primary Health Care

Abstract

This study aimed to describe the structure of oral health services in primary health care in Brazil with centers participating in the second cycle of the ‘National Program for Improving Access and Quality of Primary Care’ (PMAQ-AB), the largest health service evaluation program ever instituted in the country. This cross-sectional study evaluated 16,202 oral health services, regarding 22 pieces of dental equipment and 25 dental supplies. The presence of each piece of equipment/dental supply generated a score for services. The sum of these scores was compared among different regions in Brazil. Quantitative data were described by quartiles and categorical data by frequencies, using the SPSS, version 25. Most of the evaluated centers presented adequate equipment in good using conditions and sufficient dental supplies for primary oral health care. Data also showed a lack of some equipment, such as X-rays, bicarbonate jet, and ultrasound devices, while for dental supplies, a lack of amalgam (capsule and manual preparation), anesthesia without vasoconstrictors, and intracanal medication was found. The services presented a median of 14 pieces of equipment and 22 dental supplies. Of the Brazilian regions, the South presented the highest median, while the North and Northeast regions presented the lowest one. The oral health services presented dental offices with good availability of equipment and dental supplies to perform clinical activities. However, differences in the structure of services among the Brazilian regions was still observed.

Primary Health Care; Health Services Research; Dental Health Services

Introduction

The inclusion of Oral Health Teams (OHT) in the Family Health Strategy was the starting point for the application of the principles of Primary Health Care (PHC) in the Brazilian oral health care. The National Oral Health Policy, implemented in 2004, provided the expansion and qualification of Oral Health Services (OHS), increasing the resolution of dental care actions in the PHC. 11. Pucca GA Jr, Costa JF, Chagas LD, Sivestre RM. Oral health policies in Brazil. Braz Oral Res. 2009;23 Suppl 1:9-16. https://doi.org/10.1590/S1806-83242009000500003
https://doi.org/10.1590/S1806-8324200900...

The evaluation of health services is desirable to analyze the quality of care, detect and correct faults, and provide information in order to enhance the decision-making process in relation to health practices and policies, favoring the expansion and equitable access to health services. 22. Miclos PV, Calvo MC, Colussi CF. Evaluation of the performance of actions and outcomes in primary health care. Rev Saude Publica. 2017;51:86. https://doi.org/10.11606/s1518-8787.2017051006831
https://doi.org/10.11606/s1518-8787.2017...

Based on the strategy “evaluate to improve the quality of health services”, one of the measures implemented by the Brazilian Ministry of Health was the National Program for Improving Access and Quality of Primary Care ( Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica - PMAQ-AB in Portuguese). 33. Ministry of Health (BR). National Program for Improving Access and Quality of Primary Care: Instructional manual. Brasília, DF: Ministry of Health; 2012 [cited 2018 Oct 18]. Available from http://bvsms.saude.gov.br/bvs/publicacoes/manual_instrutivo_pmaq_atencao_basica.pdf
http://bvsms.saude.gov.br/bvs/publicacoe...
PMAQ-AB is the largest health service evaluation program ever instituted in the country.

The PMAQ-AB is organized in four phases (adherence and contractualization, development, external evaluation, and recontratualization), forming continuous cycles of evaluation, which seek to overcome some challenges for PHC qualification, such as the precariousness of the physical structure and the unsatisfactory conditions of Basic Health Units. 33. Ministry of Health (BR). National Program for Improving Access and Quality of Primary Care: Instructional manual. Brasília, DF: Ministry of Health; 2012 [cited 2018 Oct 18]. Available from http://bvsms.saude.gov.br/bvs/publicacoes/manual_instrutivo_pmaq_atencao_basica.pdf
http://bvsms.saude.gov.br/bvs/publicacoe...

Evaluations using data from the 1st and 2nd cycle of PMAQ-AB have already addressed the work process of the teams, 44. Fagundes DM, Thomaz EB, Queiroz RC, Rocha TA, Silva NC, Vissoci JR, et al. [Dialogues on the work process in oral health in Brazil: an analysis based on the PMAQ-AB survey]. Cad Saude Publica. 2018 Sep;34(9):e00049817. Portuguese. https://doi.org/10.1590/0102-311x00049817
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user satisfaction with services rendered, 55. Protasio AP, Gomes LB, Machado LD, Valença AM. User satisfaction with primary health care by region in Brazil: 1st cycle of external evaluation from PMAQ-AB. Cien Saude Colet. 2017 Jun;22(6):1829-44. https://doi.org/10.1590/1413-81232017226.26472015
https://doi.org/10.1590/1413-81232017226...
service provisions and basic care procedures, 66. Reis CM, Matta-Machado AT, Amaral JH, Werneck MA, Abreu MH. Describing the primary care actions of oral health teams in Brazil. Int J Environ Res Public Health. 2015 Jan;12(1):667-78. https://doi.org/10.3390/ijerph120100667
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, 77. Mendes SR, Martins RC, Matta-Machado AT, Mattos GC, Gallagher JE, Abreu MH. Dental procedures in primary health care of the Brazilian National Health System. Int J Environ Res Public Health. 2017 Dec;14(12):1480. https://doi.org/10.3390/ijerph14121480
https://doi.org/10.3390/ijerph14121480...
and availability of instruments in OHS. 88. Lopes J, Palmier AC, Werneck MA, Matta-Machado AT, Abreu MH. A Survey about dental instruments at the primary health care in Brazil. Braz Dent J. 2018 Sep-Oct;29(5):500-6. https://doi.org/10.1590/0103-6440201801969
https://doi.org/10.1590/0103-64402018019...

The provision of effective healthcare services is directly influenced by infrastructure conditions, and availability and adequacy of equipment, as well as materials and supplies that meet the needs of the service. Problems in this area compromise care, the quality of the services rendered, and the achievement of goals, making it impossible to perform clinical procedures effectively. 99. Baumgarten A, Hugo FN, Bulgarelli AF, Hilgert JB. Curative procedures of oral health and structural characteristics of primary dental care. Rev Saude Publica. 2018 Apr;52:35. https://doi.org/10.11606/S1518-8787.2018052016291
https://doi.org/10.11606/S1518-8787.2018...

Data from the 1st and 2nd cycle of the PMAQ-AB showed failure of OHTs to perform more complex procedures in PHC, such as the manufacture of dental prosthesis, as recommended by the Brazilian oral health policy. 66. Reis CM, Matta-Machado AT, Amaral JH, Werneck MA, Abreu MH. Describing the primary care actions of oral health teams in Brazil. Int J Environ Res Public Health. 2015 Jan;12(1):667-78. https://doi.org/10.3390/ijerph120100667
https://doi.org/10.3390/ijerph120100667...
, 77. Mendes SR, Martins RC, Matta-Machado AT, Mattos GC, Gallagher JE, Abreu MH. Dental procedures in primary health care of the Brazilian National Health System. Int J Environ Res Public Health. 2017 Dec;14(12):1480. https://doi.org/10.3390/ijerph14121480
https://doi.org/10.3390/ijerph14121480...
This may have occurred due to a lack of structural support. 77. Mendes SR, Martins RC, Matta-Machado AT, Mattos GC, Gallagher JE, Abreu MH. Dental procedures in primary health care of the Brazilian National Health System. Int J Environ Res Public Health. 2017 Dec;14(12):1480. https://doi.org/10.3390/ijerph14121480
https://doi.org/10.3390/ijerph14121480...

The structure of the health service is considered an important component for the analysis of a health system. Although a good structure does not necessarily lead to good processes and results, its importance for healthcare outcomes cannot be ignored. 88. Lopes J, Palmier AC, Werneck MA, Matta-Machado AT, Abreu MH. A Survey about dental instruments at the primary health care in Brazil. Braz Dent J. 2018 Sep-Oct;29(5):500-6. https://doi.org/10.1590/0103-6440201801969
https://doi.org/10.1590/0103-64402018019...

Although Lopes et al. 88. Lopes J, Palmier AC, Werneck MA, Matta-Machado AT, Abreu MH. A Survey about dental instruments at the primary health care in Brazil. Braz Dent J. 2018 Sep-Oct;29(5):500-6. https://doi.org/10.1590/0103-6440201801969
https://doi.org/10.1590/0103-64402018019...
evaluated the availability of dental instruments in OHS, that nation-based study fails to describe the structural characteristics regarding the availability of dental equipment and essential supplies for dental practice in Brazilian PHC. Thus, the aim of this study was to describe the structure of Brazilian OHS that participated in the second cycle of the PMAQ-AB, in relation to the presence of essential dental equipment and supplies for dental practices, comparing this structure among Brazilian macro-regions.

Methodology

This study was approved by the Research Ethics Committee of the Universidade Federal de Minas Gerais (CAAE - 02396512.8.0000.5149).

This cross-sectional, quantitative study used secondary data from the second cycle of the PMAQ-AB external evaluation from 2013 to 2014. For this study, information on the access conditions and quality of the participating OHT program were collected.

In December 2014, Brazil had a total of 24,279 OHTs, 1010. Ministry of Health (BR). Strategic Management Support Room – SAGE. [homepage] [cited 2018 Dec 4]. Available from: http://sage.saude.gov.br
http://sage.saude.gov.br...
of which 19,946 (82.0%) participated in the second cycle of PMAQ-AB. However, 2,433 were not included in this evaluation, since they did not fit the requirements of the program, such as an appropriate oral health surveillance system, the presence of a dentist in the unit, and appropriate dental equipment. Some PHC units included more than one OHT. Therefore, 16,202 PHC services were evaluated, corresponding to 17,513 OHTs (72.0% of the total).

The external evaluation of PMAQ-AB consisted of data collection through an evaluation tool developed by the Brazilian Ministry of Health, in partnership with 46 Brazilian teaching and research institutions, containing established quality standards according to norms, protocols, principles, and guidelines for the organization of actions and practices, the collection of technical and scientific knowledge, and the competencies of the professionals involved.

Data collection was done with tablets, using a specific program for PMAQ-AB organized in three modules. Data were obtained through Module I - Observation in the Basic Health Units. The program contained photos and descriptions of the dental equipment and supplies, criteria for assessing the presence and minimum quantity of materials for each health unit’s operations according to parameters established by the Ministry of Health. After data collection, the partner institutions performed the data validation and sent the results to the Ministry of Health central database.

The questions evaluated in this study were predominantly dichotomous and evaluated the presence and quantity of 22 pieces of dental equipment and 25 dental supplies routinely used by the OHTs in the healthcare services. The presence of each piece of dental equipment/supply attributed a score to each Basic Health Unit, with the final score being the sum of the quantity of dental equipment and supplies identified at the health service (from 0 to 22 points for equipment and from 0 to 25 for supplies). For example, if a service score was 18 for equipment, it meant that this service presented 18 of the 22 surveyed pieces of dental equipment at the clinic. The same occurred for supplies. After this, health services were divided by Brazilian macro-regions, and the score for equipment and supplies for each macro-region was calculated.

The results were analyzed descriptively, using the Statistical Package for Social Sciences (SPSS), v. 25.0 (IBM SPSS Statistics for Windows, Armonk, USA). Quantitative data were analyzed by the Kolmogorov-Smirnov test. Since they did not present a normal distribution (p < 0.001), they were described by medians and quartiles, and the categorical data were described by frequency.

Results

Table 1 shows the frequency of the dental equipment present in the evaluated OHS. Almost all services had a dental chair (99.0%), cuspidor (98.2%), aspiration (98.1%), operatory light (98.7%), dental stool (98.4%), high-speed air-driven handpiece (98.8%), low-speed air-driven handpiece (92.7%), and air compressor (96.9%). When asked about the equipment’s condition of use, above 90% of the dental services had at least one functioning piece of equipment. A deficiency of essential equipment to perform prophylaxis, such as ultrasonic scalers (30.4%) and bicarbonate air polishers (31.1%), was observed, in addition to the lack of ancillary equipment for diagnosis, represented by a dental X-ray machine, present in 25.6% of the evaluated services, as well as equipment for the sterilization of materials, such as an autoclave (76.2%) and dry heat sterilizers (22.5%).

Table 1
Descriptive analysis of present dental equipment that met proper use conditions in the oral health services evaluated in this study. PMAQ-AB. Brazil, 2013-2014 (n = 16,202).

Table 2 shows the distribution of the health services of the OHTs, evaluated according to the scores of the calculated equipment and the scores calculated by macro-region. The OHT presented a median of 14 (Q25 = 13, Q75 = 16) pieces of equipment per health unit. When analyzing these data by macro-region, it was observed that the South region had the highest median, with 16 pieces of dental equipment per health unit, followed by the Southeast and Midwest regions, with a median of 15.

Table 2
Descriptive analysis of oral health services evaluated per macro-region and relevant scores for dental equipment. PMAQ-AB. Brazil. 2013-2014 (n = 16,202).

Table 3 shows the frequency of dental supplies present in the OHS analyzed in this study. Nearly all of the OHS had acids and adhesives for dental composite resins fillings (96.7%), anesthesia with vasoconstrictors (96.3%), various burs (98.1%), personal protective equipment (97.8%), light-curing resins (97.5%), and temporary restorative material (96.5%). On the other hand, there was a deficiency of some important dental supplies, such as amalgam in capsules (67.0%), amalgam for manual preparation (25.9%), anesthesia without vasoconstrictors (77.2%), intracanal medications for live pulp and necrosis (73.6%), sealants (70.1%), and disposable syringes for irrigation (75.8%). When asked if the quantities were sufficient, more than 94% responded positively.

Table 3
Descriptive analysis of dental supplies present in the oral health services evaluated in this study. PMAQ-AB. Brazil, 2013-2014 (n = 16,202).

Table 4 shows the distribution of OHS according to the Brazilian macro-region and the scores of supplies calculated and verified per macro-region. The total median of OHSs was 22 inputs (Q25 = 20, Q75 = 23). When analyzing these data by macro-region, it was observed that the South region had the highest median with 23 inputs per health unit, followed by the Southeast and Midwest regions with a median of 22.

Table 4
Descriptive analysis of oral health services of the OHT evaluated by macro-region and relevant scores for inputs. PMAQ-AB. Brazil, 2013-2014 (n = 16,202).

Discussion

Descriptive analyzes showed that most of the evaluated OHS had dental equipment that met the proper conditions of use and a sufficient quantity of supplies recommended for primary care in oral health, but regional inequalities were identified based on the scores of dental equipment and supplies among the Brazilian macro-regions.

A deficiency was observed in the availability and operating conditions of some essential dental equipment. In most of the services, only one piece of equipment was in usable condition to perform dental care, such as autoclaves, dental chairs, high-speed pens, and X-ray devices. In addition, a deficiency was found in the availability of some dental supplies, such as amalgam in capsules and for manual preparation, anesthesia without vasoconstrictors, and intracanal medication for live and necrotic pulp.

Most OHS are well-structured, but some must be improved so as to avoid failure in dental care due to lack of infrastructure. Infrastructure, as well as the presence and regular maintenance of dental supplies, are important for the proper operation of health services, 1111. Ministry of Health (BR). Portaria nº 2.488, de 21 de outubro de 2011. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes e normas para a organização da Atenção Básica, para a Estratégia Saúde da Família (ESF) e o Programa de Agentes Comunitários de Saúde (PACS). 2011 [cited 2019 Apr 11]. Available from: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2011/prt2488_21_10_2011.html
http://bvsms.saude.gov.br/bvs/saudelegis...
given that the lack or insufficiency of such conditions has a direct impact on the effectiveness of dental care.

Dental X-ray machines were rarely found in the OHS evaluated in this study. This finding can be explained by the Brazilian Ministry of Health parameter of one dental X-ray machine for every 25,000 inhabitants. 1212. Ministry of Health (BR). Portaria nº 1.101, de 12 de junho de 2002. Estabelece os parâmetros de cobertura assistencial no âmbido do Sistema único de Saúde – SUS.. [cited 2019 Nov 7]. Available from: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2002/prt1101_12_06_2002.html
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Dental X-ray exams are complementary and do not substitute the complete clinical examination, but when available, they can serve as a subsidiary resource for patient diagnoses, prognoses, therapeutic planning, and preservation. 1313. American Dental Association Council on Scientific Affairs. The use of dental radiographs: update and recommendations. J Am Dent Assoc. 2006 Sep;137(9):1304-12. https://doi.org/10.14219/jada.archive.2006.0393
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The low availability of autoclaves can be explained by the sterilization process of dental instruments occurring outside the health service in some municipalities, in a centralized sterilization facility. 1414. Abreu MH, Resende VL, Lee KH, Matta-Machado AT, Starr JR. Regional differences in infection control conditions in a sample of primary health care services in Brazil. Cad Saude Publica. 2017 Nov;33(11):e00072416. https://doi.org/10.1590/0102-311x00072416
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However, there are advantages in the availability of this equipment in health services, such as increased efficiency and reduced costs. Steam sterilization, using autoclaves, is the most commonly used method recommended for the disinfection of critical instruments to prevent and control cross-infection in dentistry 1515. Rani L. Sterilization protocols in dentistry: a review. Int J Pharm Sci Res. 2016;8:558-64. . Due to this recommendation, the low amount of dry heat sterilizers available in the evaluated services (22.5%) is justified, since dry heat is recommended only for oils and powders in the medical field and for some types of burs and orthodontic pliers in dentistry. 1616. Agência Nacional de Vigilância Sanitária – Anvisa. Serviços odontológicos: prevenção e controle de riscos. Brasília, DF: Agência Nacional de Vigilância Sanitária; 2006 [cited 2019 Apr 11]. Available from: http://www.anvisa.gov.br/servicosaude/manuais/manual_odonto.pdf
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Although the frequency of personal protective equipment was high, the percentage of centers having sufficient quantities was lower. This raises concern, especially considering the current coronavirus disease pandemic (COVID-19) 1717. Center for Disease Control and Prevention – CDC. Guidance for dental settings. Interim infection prevention and control guidance for dental settings during the COVID-19 response. 2020 [cited 2020 July 27]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html
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, 1818. Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine. J Dent Res. 2020 May;99(5):481-7. https://doi.org/10.1177/0022034520914246
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Dental care involves close contact of the professional with the patient’s oral and nasal cavities. Due to the nature of dental procedures and the large amount of droplets and aerosols which could be produced, personal protective equipment is essential and should be available in sufficient quantity to health professionals. 1717. Center for Disease Control and Prevention – CDC. Guidance for dental settings. Interim infection prevention and control guidance for dental settings during the COVID-19 response. 2020 [cited 2020 July 27]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html
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The low availability of amalgam in capsules and for manual preparation can be explained by the substitution of this material by composite resin due to the increasing demand for esthetic restorations, the use of the mercury in its alloy, and the need for greater tooth wear during preparation. 2020. Moraschini V, Fai CK, Alto RM, Dos Santos GO. Amalgam and resin composite longevity of posterior restorations: a systematic review and meta-analysis. J Dent. 2015 Sep;43(9):1043-50. https://doi.org/10.1016/j.jdent.2015.06.005
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Amalgam is still the worldwide material of choice for restorations in posterior teeth with interproximal caries 2121. Rasines Alcaraz MG, Veitz-Keenan A, Sahrmann P, Schmidlin PR, Davis D, Iheozor-Ejiofor Z. Direct composite resin fillings versus amalgam fillings for permanent or adult posterior teeth. Cochrane Database Syst Rev. 2014 Mar;3(3):CD005620. https://doi.org/10.1002/14651858.CD005620.pub2
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as it has a lower cost 1919. Mattos FF, Pordeus IA. COVID-19: a new turning point for dental practice. Braz Oral Res. 2020;34:e085. https://doi.org/10.1590/1807-3107bor-2020.vol34.0085
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and greater clinical longevity when compared to composite resins, 2020. Moraschini V, Fai CK, Alto RM, Dos Santos GO. Amalgam and resin composite longevity of posterior restorations: a systematic review and meta-analysis. J Dent. 2015 Sep;43(9):1043-50. https://doi.org/10.1016/j.jdent.2015.06.005
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justifying its use when we consider effectiveness, efficiency and cost, especially in public health.

The low availability of anesthesia without vasoconstrictors can cause problems for the service, since this is the anesthesia of choice for cardiac patients, given that the use of anesthesia with vasoconstrictors in these patients can lead to hypertension, arrhythmias, and infarction. In addition, interactions may occur between drugs used to control hypertension and vasoconstrictors, causing hypertensive crises or orthostatic hypotension. 2222. Southerland JH, Gill DG, Gangula PR, Halpern LR, Cardona CY, Mouton CP. Dental management in patients with hypertension: challenges and solutions. Clin Cosmet Investig Dent. 2016 Oct;8:111-20. https://doi.org/10.2147/CCIDE.S99446
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Dental pain is considered a public health problem and one of the main reasons that lead patients to seek dental care. 2323. Cavalheiro CH, Abegg C, Fontanive VN, Davoglio RS. Dental pain, use of dental services and oral health-related quality of life in southern Brazil. Braz Oral Res. 2016 Aug;30(1):e39. https://doi.org/10.1590/1807-3107BOR-2016.vol30.0039
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In urgent care, the correct access to pulp and the use of intracanal medication are fundamental steps for the management of endodontic pain. These medications help reduce the bacterial population of the root canal system and its by-products, thus contributing to reduce pain. 2424. Torabinejad M, Handysides R, Khademi AA, Bakland LK. Clinical implications of the smear layer in endodontics: a review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002 Dec;94(6):658-66. https://doi.org/10.1067/moe.2002.128962
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After COVID-19 pandemic, several guidelines for dental practice have been published. 1717. Center for Disease Control and Prevention – CDC. Guidance for dental settings. Interim infection prevention and control guidance for dental settings during the COVID-19 response. 2020 [cited 2020 July 27]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html
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, 2525. American Dental Association – ADA . COVID-19 safety and clinical resources. Chicago: American Dental Association; 2020 [cited 2020 July 30]. Available from: https://success.ada.org/en/practice-management/patients/safety-and-clinical
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, 2626. Agência Nacional de Vigilância Sanitária – Anvisa.. Nota Técnica GVIMS/GGTES/ANVISA Nº 04/2020. Orientações para serviços de saúde: medidas de prevenção e controle que devem ser adotadas durante a assistência aos casos suspeitos ou confirmados de infecção pelo novo coronavírus (SARS-CoV-2). Brasília, DF: Anvisa; 2020 Mar 31 [cited 2020 July 30]. Available from: http://portal.anvisa.gov.br/documents/33852/271858/Nota+T%C3%A9cnica+n+04-2020+GVIMS-GGTES-ANVISA/ab598660-3de4-4f14-8e6f-b9341c196b28
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These guidelines have recommended the suspension of elective dental treatment maintaining only emergency dental appointments. The deficiency of supplies for urgent care may result in a non-resolving treatment, leading patients to recurrent pain and urgent returns to PHCs before beginning specialized treatment. The mean waiting time for specialized endodontic treatment after PHC referral ranges from 1 month 2727. Martins RC, Reis CM, Matta Machado AT, Amaral JH, Werneck MA, Abreu MH. Relationship between primary and secondary dental care in public health services in Brazil. PLoS One. 2016 Oct;11(10):e0164986. https://doi.org/10.1371/journal.pone.0164986
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to 5 months. 2828. Magalhães MB, Oliveira DV, Lima RF, Ferreira EF, Martins RC. Evaluation of secondary care in endodontics at Dental Specialties Centers (DSC). Cien Saude Colet. 2018 May [cited 2019 Mar 20]. Available from http://www.cienciaesaudecoletiva.com.br/en/articles/evaluation-of-secondary-care-in-endodontics-at-dental-specialties-centers-dsc/16782?id=16782
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This time lapse can cause recurrent urgent treatments for pain relief, overloading PHCs. With social distancing measures and dental professionals performing only urgency treatments, 1717. Center for Disease Control and Prevention – CDC. Guidance for dental settings. Interim infection prevention and control guidance for dental settings during the COVID-19 response. 2020 [cited 2020 July 27]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html
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, 2525. American Dental Association – ADA . COVID-19 safety and clinical resources. Chicago: American Dental Association; 2020 [cited 2020 July 30]. Available from: https://success.ada.org/en/practice-management/patients/safety-and-clinical
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, 2626. Agência Nacional de Vigilância Sanitária – Anvisa.. Nota Técnica GVIMS/GGTES/ANVISA Nº 04/2020. Orientações para serviços de saúde: medidas de prevenção e controle que devem ser adotadas durante a assistência aos casos suspeitos ou confirmados de infecção pelo novo coronavírus (SARS-CoV-2). Brasília, DF: Anvisa; 2020 Mar 31 [cited 2020 July 30]. Available from: http://portal.anvisa.gov.br/documents/33852/271858/Nota+T%C3%A9cnica+n+04-2020+GVIMS-GGTES-ANVISA/ab598660-3de4-4f14-8e6f-b9341c196b28
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the adequate supply of materials to solve urgent cases is essential.

The analysis by Brazilian macro-regions revealed the heterogeneity in the availability of equipment and dental supplies. The South region presented the best equipment and input scores, followed by the Midwest and Southeast regions, which matched the equipment and supplies scores. The differences found can be explained by the type of health services’ organization, which can be influenced by socioeconomic needs and the demographic conditions of each region. Brazil is a developing country with great territorial extension and high levels of socioeconomic inequality, which may explain different types of service management within its macro regions. The Brazilian economy is concentrated in the Southeast and South regions of the country, which consequently have better incentives for public health. 2929. Griesse MA. The geographic, political, and economic context for corporate social responsibility in Brazil. J Bus Ethics. 2007;73(1):21-37. https://doi.org/10.1007/s10551-006-9194-2
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The North and Northeast regions are recognized as the least developed in Brazil, with difficulties mainly in infrastructure and basic sanitation, 3030. Paim J, Travassos C, Almeida C, Bahia L, Macinko J. The Brazilian health system: history, advances, and challenges. Lancet. 2011 May;377(9779):1778-97. https://doi.org/10.1016/S0140-6736 (11)60054-8
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which was reflected in the present study’s findings, with lower equipment and supplies scores. As of 2004, 11. Pucca GA Jr, Costa JF, Chagas LD, Sivestre RM. Oral health policies in Brazil. Braz Oral Res. 2009;23 Suppl 1:9-16. https://doi.org/10.1590/S1806-83242009000500003
https://doi.org/10.1590/S1806-8324200900...
there was an increase in financial incentives for oral health in municipalities with a lower Human Development Index. However, the impact of public policies and organization of OHS may be related to human development in these two regions.

Another study, using data from the 1st cycle of PMAQ-AB, also found regional differences between primary and secondary care, with better results for the South and Southeast regions. 2727. Martins RC, Reis CM, Matta Machado AT, Amaral JH, Werneck MA, Abreu MH. Relationship between primary and secondary dental care in public health services in Brazil. PLoS One. 2016 Oct;11(10):e0164986. https://doi.org/10.1371/journal.pone.0164986
https://doi.org/10.1371/journal.pone.016...
These differences between macro-regions have also been demonstrated in basic care procedures performed using the PMAQ-AB with participating OHTs, 66. Reis CM, Matta-Machado AT, Amaral JH, Werneck MA, Abreu MH. Describing the primary care actions of oral health teams in Brazil. Int J Environ Res Public Health. 2015 Jan;12(1):667-78. https://doi.org/10.3390/ijerph120100667
https://doi.org/10.3390/ijerph120100667...
reinforcing the idea that health inequalities in Brazil have a regional character, partly due to differences in the social determinants of health among regions, which are mirrored in the quality of the health care services.

Regarding the Midwest region, the good score presented in this study may reflect the increase in the number of OHTs. In 2004, this macro-region had 839 teams, jumping to 1,973 in 2014, an increase of 135%. There was also an increase in fund transfers per region in 2012 and 2013. 1010. Ministry of Health (BR). Strategic Management Support Room – SAGE. [homepage] [cited 2018 Dec 4]. Available from: http://sage.saude.gov.br
http://sage.saude.gov.br...

One limitation of the present study is the use of secondary data, which can lead to errors arising from the methodology of data collection and processing before being made available to researchers. In addition, PMAQ-AB transfers a monetary incentive based on performance of the participating teams.

As external evaluation is limited to the presentation of the equipment or input in the service, but their long-term maintenance for effective use in dental care is not assessed. This can lead to the reporting of equipment/inputs that are not available in the day-to-day service to guarantee a good performance rating. Comparisons with other studies are difficult, since the nation-based studies on this subject are still scarce.

Effective oral health care is not dependent only to the service structures, but this aspect is relevant and should be considered. The availability of equipment and supplies in OHS can directly impact the quality of service offered to the population, which may lead to an increased waiting time for dental care and even aggravate the repressed demand for primary oral health care in Brazil.

The OHS evaluated in this study, for the most part, had enough dental equipment and supplies to carry out clinical activities. However, efforts are still needed to scale up and qualify services in terms of infrastructure, especially when considering regional inequalities.

Acknowledgements

This study was supported by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), and Pró-Reitoria de Pesquisa da Universidade Federal de Minas Gerais (PRPq-UFMG).

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Publication Dates

  • Publication in this collection
    12 Feb 2021
  • Date of issue
    2021

History

  • Received
    21 May 2020
  • Accepted
    6 Oct 2020
  • Reviewed
    9 Nov 2020
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