Dental appointments in the primary health care setting for users with toothache: a longitudinal analysisAbstract
This study aimed to estimate the morbidity associated with toothache treated in the primary health care (PHC) setting, stratified by the population size of Brazilian municipalities, from 2018 to 2022. This longitudinal ecological study was based on public national data from routine public dental service utilization records within the Health Information System for Primary Care. These data were employed to compute the rate of dental appointments for users with toothache (per 1,000 users) within each municipality throughout 15 four-month periods (P1-2018 to P3-2022), classified by population size. We integrated the databases for population size, denominator, and numerators. A longitudinal data regression model was used to estimate the four-monthly variation before and after P2-2020. Records from 5,332 municipalities (95.72%) were analyzed. The average rate of dental appointments for users with toothache (per 1,000 users) ranged from 9.65 (P2-2020) to 27.24 (P1-2018). Throughout the period, larger municipalities showed the lowest rates. Before P2-2020, the average rate in municipalities with >100,000 inhabitants fell by an average of 20.56% every four months, higher than the 7.25% variation in municipalities with < 5,000 inhabitants. After P2-2020, the rate in municipalities with < 5,000 inhabitants rose by 2.27%, a value lower than the variation in larger municipalities. The rates of dental appointments for users with toothache in the PHC setting indicate the persistent severity of dental conditions among public health service users, with variations across different regions of the country. The COVID-19 pandemic has affected the rate of dental appointments for users with toothache, underscoring the need for dental services to enhance their adaptability and responsiveness to such crises.
Primary Health Care; Public Health Surveillance; Oral Health; Health Services; Health Status Indicators
Introduction
Toothache is a public health issue resulting from untreated oral diseases,1 with a global prevalence of 32.7% among children and adolescents.2 In Brazil, the latest national survey showed a 24.6% prevalence of toothache at age 12, 24.7% among 15 to-19-year-olds, 27.5% among 35 to-44-year-olds, and 10.8% among 65 to-74-year-olds.3 Toothache has physical and psychosocial impacts, affecting individuals and society,1,4 and has been one of the major reasons for seeking dental treatment.5,6
Surveillance of dental appointments for patients with toothache in primary health care (PHC) can provide insights into the oral health of the local population, support service organizations, and guide the development of strategies to prevent and control common oral diseases, thus contributing to oral health promotion. In Brazil, oral health teams (OHTs) routinely document toothache during dental visits, and these data are made available by the Health Information System for Primary Care (SISAB).7 However, leveraging these data to obtain morbidity indicators for toothache monitoring remains underexplored.
Toothache morbidity rate can vary according to the population’s health profile and the characteristics of healthcare services. Therefore, when monitoring this indicator, it is essential to consider contextual differences, following the principle of equity in evaluation, planning, and public policy formulation.8 It is also important to consider evidence on contextual factors that contribute to inequalities in oral health outcomes and service utilization.9 Population size has been used in service evaluation studies in Brazil to point out differences in PHC team characteristics,10 performance against PHC8,11 and secondary care12 indicators, and the number of OHTs in the Family Health Strategy (Estratégia de Saúde da Família, ESF).13
Therefore, the objective of this study was to estimate the rate of dental appointments for users with toothache in the PHC setting across Brazilian municipalities and to assess the four-month interval variation of this indicator from 2018 to 2022, according to population size.
Methods
This national longitudinal ecological study utilized public data from SISAB available from https://sisab.saude.gov.br/ and from the Brazilian Institute of Geography and Statistics (IBGE), encompassing 5,570 municipalities across Brazil. The analyzed indicator was rates of dental appointments for users with toothache, which was previously validated by a panel of experts.14 This indicator estimates the morbidity rate associated with toothache among users of oral health services in PHC. The rate was calculated by dividing the number of dental appointments for users with toothache in a specific location and period by the registered population in the same location and period, then multiplying by 1,000 for each municipality and each four-month period (P1-2018 to P3-2022), resulting in 15 measurements. The four-month period was chosen because monthly data resulted in a very small number of cases or no cases at all, especially in very small municipalities. The municipality was the geographical unit for analysis, as it represents the smallest level with available data, and 2018 was the first year in which data were available from SISAB for the numerator of this indicator.
The numerator, which indicates the total number of dental appointments for users with toothache, was derived from individual dental care forms filled out by the OHT. Toothache is defined as the “condition of an individual with toothache, regardless of the number of affected teeth or the characteristics of the pain,” requiring mandatory registration in the oral health surveillance section of the form. Recorded visits are entered into SISAB through citizens’ electronic medical records or simplified data collection. Data were extracted from SISAB using the “Health/Production” report. The denominator consisted of the registered population obtained from the linked registrations report in SISAB. Table 1 shows the data extraction filters. The extraction generated 15*xls files, each corresponding to a four-month period, for both the numerator and denominator.
Population size, stratified by municipal population estimates from IBGE as of July 1, 2019 was grouped into: up to 5,000; from 5,000 to 9,999; from 10,000 to 49,999; from 50,000 to 99,999 thousand; and > 100,000 inhabitants.8,15 Data processing began by linking the numerator, denominator, and population size databases to the key variable “ibge.” The indicator was not calculated for municipalities without dental care records for toothache or without a registered population.
Descriptive data analysis was carried out. Extreme values (rates > 2,000 per 1,000) were replaced with the average from the other four-month periods for the same municipality. Percentages of missing data were estimated for the numerator and denominator, based on four-month period and population size. Average values of the indicator and their 95% confidence intervals were obtained and presented in scatterplots and line graphs. A pattern of variation was identified in the indicator, with a reduction in P2-2020, regardless of population size. The variable “event” was created to compare the four-month interval variation before (P1-2018 to P2-2020) and after this period (P3-2020 to P3-2022) to assess the effect of the COVID-19 pandemic.
The average four-monthly interval variation of the indicator was estimated through a longitudinal data regression model (xtmixed) with unstructured covariance. A natural logarithmic transformation was applied to the indicator to estimate the variation. The LR test demonstrated the adequacy of the random-effects model and intercept (LRchi2 = 7568.25; p < 0.001). Interactions between the four-month period, event, and population size variables were tested to investigate whether the effect of population size on the rate varied at different time points or could be considered a fixed effect over time. Marginal estimates were obtained to compare the four-month interval variations of the indicator before and after P2-2020 and the four-month interval variations across municipalities by population size separately before and after P2-2020. The statistical significance of these comparisons was tested using the Wald test, employing the lincon command. All analyses were conducted using Stata® 18.0. Approval from the Research Ethics Committee was not needed for this study because it used publicly available secondary data. This study followed the comprehensive reporting guidelines established by the RECORD statement.16
Results
Data extraction yielded 83,307 (99.7%) records for the denominator, including all municipalities and four-month periods. For the numerator, the percentage of municipalities with recorded data ranged from 72.4% (P2-2020) to 92.11% (P3-2022). Lower percentages were observed in P1-2020 and P2-2020, coinciding with the interruption/reduction of dental services during the COVID-19 pandemic (Figure 1). The highest percentages of complete data in all 15 four-month periods were observed in municipalities with > 50,000 inhabitants, and the highest percentages of absent records were in those with up to 5,000 inhabitants (Figure 2). Sixteen extreme values were imputed: Belo Horizonte: P1-2018 and P2-2018; Rodeio Bonito: P1-2018; Salto do Jacuí: P1-2018, P2-2018, P3-2018, P1-2019, and P2-2019; Maringá: P3-2019; Vigia: P1-2018; Água Boa: P1-2018; Itamarati: P1-2018, P2-2018, and P3-2018; and Carauari: P1-2018 and P2-2018. A total of 70,842 records obtained from 5,332 (95.7%) municipalities were considered in the data analysis.
Percentage of valid records for calculating the indicator Rate of dental appointments for users with toothache (per 1,000 users) in four-month periods, 2018 to 2022.
Percentage of municipalities according to the number of missing records in the 15 four-month periods by population size. Brazil, 2018-2022.
The average of the indicator ranged from 9.65 (P2-2020) to 27.24 (P1-2018) in Brazil, from 9.65 to 27.44, and from 14.68 to 18.57 before and after P2-2020, respectively (Figure 3). Between P1-2019 and P2-2020, the rate decreased, with the lowest averages observed in municipalities with > 100,000 inhabitants. From P2-2020 onwards, the rate increased, regardless of population size. Throughout the period, municipalities with larger populations had the lowest rates (Figure 3).
Average and 95% confidence interval of the Rate of dental appointments for users with toothache (per 1,000 users) in Brazil and according to the population size of the municipalities over the four-month periods. Brazil, 2018 to 2022.
The interactions among population size, four-month period, and event were significant and indicated that the rate decreased over the four-month periods before P2-2020, with a more significant decrease for municipalities with larger populations (Table 2). The coefficients obtained by marginal estimates were negative, indicating an average four-monthly percentage reduction in the indicator before P2-2020. The 7.25% reduction in the rate before P2-2020 in municipalities with up to 5,000 inhabitants was significantly lower than the four-monthly interval variations observed in municipalities with larger populations. The highest four-monthly interval variation was observed in municipalities with >100,000 inhabitants, with an average four-monthly reduction of 20.56% in the rate before P2-2020 (Table 3).
Regression model to evaluate the four-monthly variation in the rate of dental appointments for users with toothache, according to population size before and after P2-2020, from 2018 to 2022 in Brazil (N=70842 records; 5332 municipalities)
Marginal estimates and results of the Wald test to compare the four-monthly variations in the rate of dental appointments for users with toothache (per 1,000) before and after P2-2020 (event) and according to population size.
After P2-2020, municipalities with up to 5,000 inhabitants had an average four-monthly rate increase of 2.27%, which was significantly lower than that observed for municipalities with larger populations. No significant difference was observed in the four-monthly percentage variation in the rate across municipalities with a population size ranging from 10,000 to 49,999 inhabitants, 50,000 to 99,999 inhabitants, and > 100,000 inhabitants. The coefficients of four-monthly interval variation differed before and after the event, with higher rates in the period before P2-2020 (Table 3).
Discussion
This study found that 10 to 30 individuals per 1,000 had toothache-related appointments in PHC units every four months, with variations over time and between population sizes. Before P2-2020, all municipalities, regardless of size, experienced a four-monthly reduction in the rate, which was more pronounced in larger municipalities. After this period, rates increased in all municipalities, but the average variation was lower in municipalities with up to 5,000 inhabitants compared to larger ones. Throughout the period, municipalities with over 100,000 inhabitants had the lowest rates, while those with up to 5,000 inhabitants recorded the highest rates.
The quality of secondary data obtained from SISAB may be affected by issues such as lack of standardization, duplications, and inconsistencies. However, because toothache is a clinically identifiable event that must be registered by the OHT in the individual dental care form, some of these errors are mitigated. Missing data was the main issue in this study, arising from the failure to register toothache-related appointments in some locations and periods. Since SISAB reports do not indicate zero values for the absence of appointments, such cases were assumed to be missing data. This did not compromise estimation, as data had been registered by 72.45% to 92.12% of Brazilian municipalities. Differences in service organization levels and work processes of the OHT may account for the higher percentages of absent records in smaller municipalities. These municipalities may face technical, organizational, and service management challenges, including limited access to technology, a preference for traditional registration and communication methods, reluctance to adopt information systems, and financial constraints that hinder investment in health information systems.11,17 Efforts to improve data quality through systems such as e-SUS PHC should be complemented by preventive measures and strategies to address socioeconomic disparities, aiming to reduce oral health inequities.
The rates reflect the persistent prevalence of toothache as a frequent issue in dental care in the PHC setting in Brazil, concurring with previous studies that have identified it as a main reason for seeking dental care.5,6 National data indicate a higher prevalence of dental pain in adults and older adults without private health insurance,18 as well as among adults aged 35 to 44 years who use public health services.4 This suggests that the rate of dental appointments for users with toothache may be influenced by the profile of public health service users, who are exposed to factors that heighten their risk of oral diseases and, consequently, toothache. According to the 2019 National Health Survey, a higher percentage of exclusive users of the Brazilian Public Health System (SUS) among low-income and less educated adults.19 An association has been demonstrated between worse socioeconomic background and a higher prevalence of toothache,1,4,20 as well as with oral conditions such as dental caries and periodontal disease, which are the main causes of dental pain.1,4,20-22 This finding highlights the persistent oral health inequities in different social contexts. In this context, managers can design preventive, individual, and collective measures and undertake intersectoral efforts to reduce social and health vulnerabilities.
Disparities in rates were observed among municipalities, with lower values in areas with larger populations, suggesting unequal access to oral health services. A previous study has shown a lower percentage of users of oral health services in SUS in municipalities with > 100,000 inhabitants.23This corroborates the lower coverage of oral health services in the PHC setting in municipalities with larger populations compared to those with 5,000 inhabitants.8 Larger municipalities may face challenges in providing public services, resulting in a lower capacity to meet the population’s needs. The complexity and diversity of the health infrastructure in these municipalities can also lead to difficulties in organizing the work of health teams.
On the other hand, differences in rates by population size can be attributed to local oral healthcare models. Lower rates in municipalities with > 50,000 inhabitants may indicate the adoption of a model focused on health surveillance and promotion, where service organization and supply are not driven by spontaneous demand, thus reducing the need for emergency treatments. This finding is supported by previous research indicating a higher rate of tooth extraction in small municipalities,8,11 which could reflect a tendency toward more invasive procedures.11 Smaller municipalities may struggle with service organization, with consequently fewer restorative and preventive procedures and specialized treatments. Organization may thus be driven by immediate demand, focusing on emergency interventions, which can elevate the rate of dental appointments for users with toothache.
Moreover, fluctuations in the indicator appear to have been influenced by the COVID-19 pandemic, with a significant reduction in the first four months of 2020 across all population sizes. Although guidelines recommended maintaining urgent care in PHC,24 this finding is in line with a previous study that has demonstrated a reduction in urgent care.25 Possible explanations include a lack of government communication regarding available services during the pandemic, the inability of public services to maintain essential care, and the distancing of patients for fear of contamination.25 This study also showed disparities in four-monthly interval variations before and after P2-2020. Larger municipalities possibly reacted more quickly to the guidelines, as they were the first to register confirmed COVID-1926 cases, impacting morbidity rates more strongly. Consistently, after P2-2020, municipalities with up to 5,000 inhabitants showed a smaller positive four-monthly interval variation compared to larger municipalities, indicating a slower recovery from the initial levels of care provision for toothache. This may reflect structural challenges in reorganizing services and offering care to users.17
The observed rates may not accurately reflect the prevalence of toothache, considering that individuals could have multiple appointments during the period. Analyzing health service indicators at the municipal level presents challenges because of population heterogeneity, which can obscure disparities among subgroups. Despite these limitations, regular monitoring of toothache in PHC is crucial, with tailored strategies needed for different-sized municipalities. Strengthening oral health services in larger municipalities, emphasizing health surveillance and promotion, and addressing the impact of service fluctuations, such as those caused by the COVID-19 pandemic, are essential. Continued professional development for health teams and intersectoral collaboration can improve oral health outcomes and reduce the burden of toothache in communities.
Conclusion
The rates of dental care for toothache in the PHC setting indicated the persistence of a severe condition among public health service users. Higher morbidity associated with toothache is concentrated in small municipalities. In general, rates decreased until P2-2020, coinciding with the suspension of oral health services during the COVID-19 pandemic. This reduction was more pronounced in larger municipalities. After this period, rate growth was less pronounced, particularly in small municipalities.
Acknowledgments
This research was supported by CAPES (001), FAPEMIG (PPM-00603-18, APQ-00763-20), and CNPq (310938/2022-8).
References
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*The zero value means that there were no missing data for municipalities based on population size.
