The insertion of oral health technicians: issues in dispute in the National Oral Health Policy

The research analyzed the insertion of Oral Health Technicians (OHT) in the oral health team from 2003 and issues in dispute in the National Oral Health Policy. The study used a social-historical approach based on Pierre Bourdieu’s sociology. Documentary and literature analysis and interviews were carried out with formulators and managers of oral health policy. The municipalities presented low adhesion to teams with OHT, as well as there was evidence of maintenance of the traditional relationships of division of dental work, underutilization and greater performance in prevention. The symbolic domination of the market axis prevails in the public service and in the wider dental space, even with achievements in professional regulation. This insertion has not yet been consolidated. The limitations of policy bets, in particular this issue of OHT, should subsidize new actions, considering this symbolic domination and possible ways to tackle it.


Introduction
Since the insertion of oral health teams (eSB) in Primary Care in 2000, they can be composed of a Dental Surgeon (DS) and Oral Health Assistant (OHA) or Oral Health Technician (OHT), in the so-called modality I, or by DS, OHA, and OHT, in modality II. The acronyms OHA and OHT refer to the basic and medium level technical oral health workers, a group predominantly composed by women in Brazil 1 . The trajectory of this group began in Brazil in the 1950s, when the Ministry of Health (MoH), through the Public Health Services Foundation (FSESP), incorporated actions inspired by the North American model, the sanitary dentistry and incremental system, with emphasis on preventive and educational programs, later incorporated by school of dentistry 2 . The diffusion of these models occurs in parallel to the emergence of these workers in the country, and continues to influence their practices 2,3 .
The first regulations for these professions were in 1975, by the Ministry and the Federal Council of Education, and in 1984, by the Federal Council of Dentistry (CFO) [4][5][6] . The first Regulatory Bill (PL) was created in 1989, but vetoed by President Itamar Franco 4,6,7 . In 2000, another attempt was rejected, and in 2003, the PL 1.140, of Representative Rubens Otoni (Workers' Party, Goias), resulted in Law 11.889, sanctioned in 2008 5,6 . The expansion of these professionals since the 1980s, in the context of the Health Reform, and the history of training and incorporation of new practices are well documented in the literature, as well as advances and difficulties, especially related to the incorporation of OHT [1][2][3][4][5][6][7] .
The global literature advocates this incorporation by expanding coverage, access and quality of services, reducing costs and inequalities in oral health 6,[8][9][10][11] . The division of dental labor is historically marked by regulatory disputes in many countries [9][10][11][12][13] . Therapists and hygienists, for example, exercise functions that in Brazil are exclusive to the SD 14 .
Even in universal health care systems, such as Canada and the United Kingdom, dental care is greatly influenced by the free market, which since the expansion of capitalism at the end of the 19th century and the beginning of the professionalization of dentistry has produced and maintained a liberal-privatist ideology 2,15 . Market dentistry", where the assistance occurs through direct or indirect payment by the user, globally influences the organization of oral health practices in the private and public spheres 2 . In Brazil, since 1980, a space has emerged for the defense of oral health as a universal right, and of a model of care that aims to go beyond traditional public health and health and schools of dentistry, the Collective Oral Health (SBC) 16 .This space will represent the "universalist pole", of the struggle for "oral health equal for all", and some of its agents occupied the bureaucratic managerial field of the National Oral Health Policy (PNSB) as of 2003. The demarcation of these two poles, universal and market dentistry, was based on Pierre Bourdieu's definition of social space 17 . It is a sociological resource to analyze the structure and dynamics of the relationships maintained by agents involved in disputes around a common interest, in this case, oral health 17,18 . These poles are not separate, and disputes are observed around this interest, whose correlation of forces also depends on the position of the agents in the specific social fields or spaces and in the wider social space.
In the PNSB analysis (c) , from 2003 to 2018, the incentive to the insertion of OHT in the eSB of the Brazilian National Health System (SUS) was one of the bets put forward by the federal administration. Thus, the transformations around this insertion and the main issues in dispute on the subject were analyzed, considering the position (d) of the policy makers.

Method
Study of social-historical approach, with documentary and bibliographical analysis, secondary data and in-depth interviews with agents involved in the formulation of the PNSB, from 2003 to 2010. It was based on Bourdieu's sociology, on the notions of social space, field, doxa, habitus, agents and symbolic domination. The PNSB was understood as a governmental response that interfered in the broader dental space, in which agents with different insertions interact, such as the scientific and bureaucratic fields, and specific spaces, such as Collective Oral Health and dental entities. The field is a relatively autonomous social microcosm, with its own laws, and it is also a field of games and disputes 17,19,20 .
Bourdieu 17,19 points out that there is a space of points of view on a given issue resulting from the structure of the agents' positions and trajectories, guided by habitus, an acquired system of preferences, classifications, and perceptions, linked to the field. The agents fight to transform or preserve the structure of the space and dispute the legitimate discourse, the doxa, with forces and capitals that depend on their position in the field and in the social space 20 . An individual can act in several fields at the same time, and his practical sense is permeated by relations of symbolic domination 17,19 .
The main disputes and positions taken in the dental space can be related to the tension between the market pole and the universalist pole. The latter is composed of interested agents, not dominant, and active in the space of struggle for the defense of health as a universal right. In Brazil, they are in the SBC space or are influenced by it 16 . The market pole is closer to the economic field, defends the liberal practice and aims at the resulting profit 2,16 . There is the subspace of the equipment and supplies industry, the distributors, the health insurance carriers, the clinics, the technical workers and dental surgeons, as well as dentists who own offices or clinics. Besides the PNSB itself and the regulation of training, the State appears in several other instances, including the   19,20 . reinforces that innovations progress and adaptations are inventions under structural pressure, and at every moment the "universe of possibles" really possible is closed, and there is always interest in certain 'possibles' at the expense of others 19 .
Thus, we sought to identify the main actions of the national management for the implementation of the eSB modality II, from 2003 to 2010, and the historical series of these teams, from 2003 to 2018, through official publications of the Ministry of Health (MOH) (Frame 1). These data were analyzed along with the construction of the viewpoint space on OHT insertion, from 16 social agents, selected for being most directly involved with the management of the PNSB in the period. Data collection and interviews took place between 2019 and 2021. The trajectories were analyzed from the interviews and official resumes. Frame 2 presents this group by region, gender, race/color/ethnicity, predominant fields and spaces of action, experience and ownership of a private dental office, experience in public service, and referred participation in movements, associations, and/or entities.
The time frame corresponds to the government of Luís Inácio Lula da Silva (Lula), for presenting two relevant milestones, the publication of the PNSB (2004) and Law 11.889 (2008). The literature was consulted in SciELO, PubMed, Scopus, Lilacs, and Medline, by the indexed descriptors: oral health, oral health technician, health personnel, dental assistants. Articles in Portuguese and English, theses, dissertations, and chapters on the theme from 2003-2020 were included. N-Vivo 11 software was used for document and interview analysis, and Excel for secondary data. The study was approved by the Research Ethics Committee from the Institute of Collective Health at the Federal University of Bahia (ordinance n o 1.466.724). The presentation and discussion of the results was divided into two sections. The first focused on the implementation of the eSB modality II, and the second on the main issues in dispute that emerged from the space of the formulators' points of view, considering their legal, financial, administrative, political and ideological nature.

The implementation of eSB mode II
In the period analyzed, we identified actions of the MH for training, regulation and insertion of OHA and OHT in the eSB (Frame 1). There were adjustments in the financial incentive, donation of equipment, and initiatives in training through the Secretariat of Work and Health Education Management (SGTES). Gradually, this workforce has been incorporated, however, especially in the private network, part is still trained by the dentist himself 8,21 .
It is worth noting that the institutionalized training of these professionals has been taking place in Brazil since the 1980s, through training centers and technical schools, as components of the RET-SUS 3  The analysis reveals the shortcomings of the implementation of the teams with OHT. Adherence to modality II was low throughout the country. In 2003 there were 5,631 eSB modality I and 539 eSB modality II, rising to 18,731 and 1,693, respectively, in 2010. In 2014, modality II rose to 2,257, and in 2018 there were 2,145, representing only 8.03% of teams. There was greater deployment of mode II in the Southeast and South (Table 1). In 2018, if at least half of the eSB were modality II, the SUS would have absorbed 40% of this workforce (n=13,356). In July 2021, the CFO registered 335,929 dentists, 33,084 OHT and 146,567 OHA. The Southeast region has 33.4% of the total number of TSB, and most of the training centers and eSB modality II 24 . In 2010, Minas Gerais (MG) had the highest number of mode II teams (n=520), followed by Paraná (n=386), Goiás (n=115), São Paulo (n=113) and Ceará (n=123). MG continues to have more active OHT registrations (n=4,814) and more mode II eSB (n=769). The better implementation in the Southeast and South, in addition to the better HDI, reflect differences in investments, reinforcing the importance of federal induction in reducing regional disparities 25 .
In Belo Horizonte, in 2007, the teams were improved and a protocol was created, including the practice of atraumatic restoration 26 . In that year, the city had 189 eSB, with 27.17% of population coverage and 53 modality II eSB (28%). Noteworthy is the study of Sanglard-Oliveira et al. 12 because of the comprehensiveness of the sample of OHT (n=231), and for revealing that more than half performed direct intraoral actions. More recent studies on MG have reinforced the positive association between modality II and improvement in indicators and work process 25,27 . However, considering the whole country, there was little absorption of OHT in the services, and they often exercise OHA functions 21,24,28,29 . In the SUS, there is greater participation in promotion and prevention activities, an aspect that reveals, to some extent, the persistence of the SESP Foundation model 3,24,28,[30][31][32] .
In regulation, the main highlight was the creation of Law 11.889 (2008). As an act of the State and a regulatory framework, it represented an achievement, including greater support for disputes in the legal field and in the labor market. Frazão e Narvai 7 compared the Law with previous regulations and concluded that despite the quantitative reduction, there were gains in the scope of direct actions and viability of other actions. As for Zanetti et al. 13 they consider that there have been revisions and updates of previous competencies, with ambiguities. Oliveira 5 points out losses in the wording during the course of the PL, and the substitutes maintained technical and corporate limits. In this debate, the entities were divided. A public hearing was held in 2005 in the House of Representatives, and new changes were made after an agreement among FIO, CFO, ABO, and the Brazilian Association of Dental Surgeons. In the perception of OHT and OHA leaders, despite some losses in the text, the Law was a historical achievement 5 .
The legal and symbolic domination of the DS around the competences of the OHT is maintained in Brazil 9 . The ambiguities and limitations of the Law contribute to maintaining the dominated status quo of this professional [5][6][7]13,24,28 . This issue was pointed out in Uberlândia, MG, as one of the main reasons for not exercising the profession, together with low salaries and lack of appreciation by the DS 29 . In Vitória in the state de Espirito Santo, besides these aspects, the absence of a second piece of dental equipment and of protocols, the lack of time and work conditions for planning construction were underlined 33 . And finally, a competitive labor market, with DS and OHT receiving similar salaries 33 .

The space of the formulating agents' points of view: main issues in dispute
The group of formulators of the PNSB showed a predominance of trajectory linked to the bureaucratic field (n=12), followed by the scientific field (n=8) and the space of the dental entities (n=4). There was regional diversity, but with less representation from the North region (n=1). Majority of men (n=14) and self-declared white race/color/ethnicity (n=13) ( Table 2). White homology and male domination was verified in this section, as the dominant fraction in the field of power of the state bureaucracy 34 .
For this group, the performance of direct intraoral actions by the OHT is the main issue in dispute.
They still understand that those people are taking the place of dentists, they are doing things that were supposed to be exclusively dentists [...] (E10) The initial proposal was a greater expansion of attributions, to be able to do restorations, to do periodontal procedures that were larger than those that are in the legislation, to exercise the role that the hygienists, in a certain way, develop in other countries. (E8) Zanetti et al. 13 argue that, in Brazil, disputes over jurisdictional boundaries of competence are marked by three main ideological currents, professionalism, scientific administration, and administrative-politics. This proposal converges with the classification of Vieira-da-Silva 18 of the market, traditional and universal public health. Bourdieu 18,20 states that despite being independent, there is a homology between the agents' position space and the space of position-taking. We verified this homology in the interviewees. Even with 75% (n=12) having some experience in private practice, the participation in movements and organizations defending the Health Reform, and experience in public service, were differentials for entry and adjustments to the universalist pole.
In the case of leaders of dental entities closer to the market pole, such as the CFO, the rejection has been justified by market reserve, judicial risk for the DS, and the perception of lower quality in the work of an OHT 6 . In the universalist pole, the OHT was progressively incorporated, although more in the prevention 14 . Agents from this pole defend teamwork, expansion of the work capacity, and access to the SUS 6,7 .
We failed in the expansion of oral health teams, when I speak of team, I mean the team itself, dentist surgeon, oral health technicians and assistants [...], we should only speak of oral health team when we actually have the team, university-level professional, mid-level and auxiliary professional [...]. (E1) The ENATESPO of 2010 ruled that modality I be transitory, and that managers assume a deadline for implementation of modality II as the standard 5,6 . The fact of OHT being optional was a matter 13 . This analysis becomes more complex in view of the need for greater federal transfers and counterpart contributions from the other entities to guarantee the minimum number of OHTs, the different epidemiological, social, and economic realities of the municipalities, as well as the autonomy of the management levels, elements that are often disregarded or little addressed in the studies.
The confrontations in the political field are highlighted: [...] the interests linked to market dentistry prevailed [...] there was a lot of pressure, many representatives put pressure not to approve the project, it was much modified in relation to what it was initially [...] the current law was ambiguous in some articles, this ambiguity stems from defects in legislative techniques, these defects are not because people didn't know how to write the article, they stem from the need to reconcile interests and compositions that are incompatible and that ultimately expressed concessions to market dentistry [...]

. (E1)
In the financial and administrative dimension, the agents of the bureaucratic field highlight the budget limitations and the Fiscal Responsibility Law as restrictions to the expansion of the payroll. In the last adjustment of Lula's government, in 2008, the MH transferred a monthly value of 2.6 thousand Reais to eSB modality II, only 600 Reais difference to modality I. The minimum wage that year was R$415.00. The municipal counterpart, therefore, remained high, especially for municipalities that did not receive the dental equipment. The precarious conditions of the services for insertion of extra equipment, besides the need for adjustments in the work process were highlighted. In the political and ideological aspects, the strength of corporate thinking, the opposing lobby of dentists and entities, and the lack of understanding and/or opposition of managers, also influenced by these categories of thought, were evidenced. Historically, the dental corporation shows distance from the experience of these professionals 33 .
These dominant views are present in many countries with different social realities and availability of DSs 8,11 . [...] inclusive, it was an entity with banners that were against and held banners in the Federal Chamber against the approval of the technicians' bill, because they said they were going to take space from dentists, it was a very serious issue [...]. (E2) Zanetti et al. 35 understand the OHT as a bureaucratic body subjugated to two others and, therefore, vulnerable to the interaction of two rationalities, one more administrative, of the managers, and the other more corporate, of the clinical dentists. In management, the authors highlight the rational motivations for the presence of an OHT on the team 35 . However, this rationality is also influenced by the dominant habits in the medical field and in the dental space, tied to the interests of the market pole, and maintains the correlation of forces unfavorable to the integration and more autonomy of OHTs 16,17 .
The reduction in the capacity for mobilization and political confrontation of the entities representing these professionals appears as an issue, and deserves further study.
[...] the debate was held with the national entities, there was also the participation of entities representing oral health technicians and assistants, which today is very disorganized, but at that time there was a national organization, with an important role in defining the Law [. Among the entities that position themselves in defense of these professions, the FIO, a union entity, stands out, and its relationship with the National Association of Assistants and Technicians in Dentistry (ANATO) 4,7 . Leaders of the FIO worked with the National Coordination of Oral Health and in the National Health Council in the period. We identified the relation between the founding agents of the FIO with ANATO, an entity that had its first organizational initiatives in the 1980s, after the formation of the National Commission of Dental Assistants and Technicians (CONATO) 36 . One of the reasons for its emergence was the interest of the category in participating in the CFO Commissions, which required professional organization. CONATO has been working for regulation since the first Bill (1989), and was the forerunner of ANATO, which continued working for the approval of the Law in 2008 4,36 .
There was also recognition of the insufficiencies of the policy for training of OHTs and the lack of regulation of the opening of new dental schools, which contributes to an excessive number of DSs. The literature also points out the uncontrolled expansion of DSs as a factor in the worsening of legal disputes over competencies 13 .
[...] colleges generate a mass of people with quality that ranges from very debatable to excellence, you will have an oral health assistant or oral health technician to do what? If these underemployed professionals do exactly what these professionals should do [...]. (E7) The analysis of this space of viewpoints of agents who occupied the field of power in the bureaucratic field of the PNSB evidenced the continuity of disputes around the division of dental work in Brazil. The hypotheses about its mechanisms of reproduction and different local realities require further study. This formulating group continues to dispute the PNSB in the power spaces in the bureaucratic, scientific and political fields, and in the dental entities, and the present analysis can contribute to updating the responses and inducing federal policies in future scenarios, especially in those in which the correlation of forces in the field of state power is again favorable to the universalist pole.
The insertion of OHT as advocated by the universalist pole may become a voided "possible", i.e., historically unrealized, according to the analysis supported by the referential of Pierre Bourdieu. Despite the efforts in the legal, bureaucratic, political fields, and the space of the entities, modality II had low implementation, with a downward trend since 2014. Law 11.889 was an achievement; however, the final text maintained the monopoly of dentists in professional practice, with no gain in autonomy for OHT. The participation of these primary and secondary level workers in the formulation of the PNSB was not evidenced. The national monthly costing incentive remained unattractive to managers. In the places where insertion occurred, traditional relations of division of dental work and underutilization of OHT predominate. Legal, practical, and symbolic domination of the market pole prevail in the SUS and in the broader dental space. The opening of possibilities provided by the PNSB has not yet been enough to bring about changes in the dominant doxa and habitus around this issue. Transformations in the work processes are still under dispute in the micropolitics of management and services. OHTs, dentists, entities, and researchers from the universalist pole remain as interested agents. Studies that update information and analyze the actions and positions of technicians as protagonists, as well as those of the market pole on the subject are necessary.
The sociological perspective of political analysis undertaken emphasizes the role of symbolic domination to legitimize the status quo and give an appearance of "natural" to the relations of domination. It is necessary to know and recognize the immanent rules and laws of the field and objects in dispute in order to continue to "play the game" and transform it. The analysis of the Brazilian case revealed potentialities and limitations of the bets that have not yet been consolidated in the space of the possible, still open, and, subsidize future actions, considering the persistence of this domination and possible ways to confront it.