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ORIGINAL ARTICLE • Pesqui. Bras. Odontopediatria Clín. Integr. 26 • 2026 • https://doi.org/10.1590/pboci.2026.016 linkcopy

Open-access Availability of Periodontal Instruments, Procedures, and Specialized Referral in Primary Health Care in Brazil

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    ABSTRACT

    Objective:  To analyze the availability of periodontal instruments, services, and specialized referrals in Primary Health Care and compare Brazilian geographical regions.

    Material and Methods:  The historical time series analysis was carried out based on secondary data extracted from the 1st (2012), 2nd (2014), and 3rd (2018) cycles of the external evaluation of the Basic Care Access and Quality National Program. A comparison was carried out between the proportion (%) of Oral Health Teams (OHT) and dependent variables (Periodontal instruments, service offered, and specialized referral) and the independent variables of Brazilian geographical regions and years.

    Results:  The number of OHT evaluated was 12,562 (2012), 18,333 (2014), and 21,817 (2018). Increase was observed in the availability of periodontal probe, periodontal curette, sharpening stones, and sodium bicarbonate jet for the Brazilian OHT, and in all regions of the country between 2014 and 2018 (p<0.001), and reduction in the availability of dental ultrasound in Brazil, mainly in the Southern (p<0.001), Southeastern (p<0.001), and Midwestern (p=0.008) regions. Supragingival Scaling and Root Planing were the most commonly performed periodontal procedures. At the same time, frenotomy/frenectomy was the least performed procedure by the OHT in Brazil and in all Brazilian regions, with a gradual increase according to the cycle (p<0.001). The offer of periodontal specialist referral increased from 54.6% (2012), 68.3% (2014), to 81.8% (2018) in Brazil and all Brazilian regions (p<0.001).

    Conclusion:  Despite the increase in periodontal instruments, procedures, and specialist referrals in Brazil, regional differences were still observed.

    Keywords:
    Primary Health Care; Outcome and Process Assessment, Health Care; Dental Health Services

    Introduction

    Contemporary dentistry places a greater emphasis on the prevention of oral illnesses and health promotion, with a more conservative clinical practice, resulting in reduced tooth loss. However, tooth maintenance leads to a higher probability of increased dental needs throughout life, and in adulthood, a transition from the carious lesion to the periodontal disease is observed. For this reason, between 1990 and 2010, the growth of the periodontal disease global load was estimated to be 57.3% [1].

    Moreover, periodontal alterations are among the oral conditions that most impact the global population [1,2]. The severe periodontal disease (PD) prevalence affected 10.8% of the world population in 2010 [2] and 9.8% in 2017 [1], reaching around 750 million people [1,2]. According to the Global Burden of Disease Study (GBD), periodontitis is the sixth most prevalent illness worldwide [1,2].

    The PD distribution has shown greater impact in developing countries when compared to developed nations [2]. In the last National Oral Health Surveys carried out in Brazil, a considerable increase in the prevalence of shallow periodontal pockets [from 4mm to 5mm] was verified between 2003 and 2010 among adolescents (between 15 and 19 years old) (from 1.2% to 8.8%) and among adults (35 and 44 years old) (from 8.8% to 15.2%) [3,4]. When the data was adjusted, in 2010 in Brazil, the PD prevalence considered moderate to severe (periodontal pocket depth ≥ 4 mm and at least one sextant with insertion loss ≥ 4 mm) in adults was 15.3%, while severe PD reached 5.8% [periodontal pocket depth ≥ 4 mm and at least one sextant with insertion loss ≥ 6 mm] [5].

    The older the age group investigated, the higher the PD prevalence observed, with peaks between the third and fourth decades of life [2]. Adolescents tend to show milder PD indicators, with greater prevalence of calculus and bleeding during the examination, while adults and older individuals show greater prevalence of periodontal pockets [3,4]. Therefore, PD incidence shows an ascending curve, which declines in older individuals [2] due to the occurrence of tooth loss throughout life [1].

    PD is a chronic, multifactorial, and avoidable disease that goes beyond dental problems. It can be related to several systemic conditions such as diabetes and cardiovascular diseases [6]. Although the biofilm accumulated on the tooth surface is the leading cause of the disease onset, individual susceptibility, smoking habits, and systemic factors are the leading causes of the disease progression [6].

    The PD high prevalence results in negative impacts, such as multiple tooth losses, edentulism, and masticatory malfunction, while psychosocial and economic factors can also be influenced. Therefore, continuous oral health care is fundamental so that the disease is prevented, does not progress, and does not reappear. Moreover, periodical visits to the dental surgeon are required [7].

    Social inequalities and access to oral health services are factors that impact PD [5]. Lack of information, resources, and procedures that could prevent the illness from starting and progressing affects socially and economically deprived areas; consequently, their inhabitants are the ones presenting higher prevalence of this disease [5].

    One way of reducing the impact of social inequalities in oral health is to create public policies that guarantee improvement in people’s living conditions and health care. In Brazil, the National Oral Health Policy (NOHP) (in Portuguese – PNSB – Política Nacional de Saúde Bucal), implemented in 2004 as a way to guarantee complete health care in the country via the Unified Health System (UHS) (in Portuguese – SUS – Sistema Único de Saúde), stands out for being the most outstanding public oral health program in the world [8].

    The Brazilian UHS organizes its health care system into three levels, namely, the Primary Health Care (PHC), provided by Oral Health Teams, which include dental surgeons, oral health technicians, and/or oral health assistants working at the Basic Health Units; the Secondary Health Care, provided by dental specialist centers; and the Tertiary Health care that is provided at hospitals due to their complexity [9]. The NOHP considers PHC as the entrance door assisted by a multi-professional team, mainly through the Family Health Strategy, which aims at providing solutions and establishing complete treatment by referring treatments and creating care networks that articulate between the secondary and tertiary care levels [9].

    In Brazil, the fact that PHC is considered the care coordinator and the most decentralized care level requires a better evaluation of its work. The Basic Care Access and Quality National Program (BCAQNP) (in Portuguese – PMAQ-AB – Programa de Melhoria da Atenção e da Qualidade da Atenção Básica) was an evaluation policy created in 2011 to measure, finance, and improve the PHC. This program presented three cycles, each lasting two years. The first cycle was developed in 2011-2012, the 2nd cycle was in 2013-2014, and the 3rd was in 2016-2018 [10,11]. For this reason, the objective of this study was to analyze the availability of periodontal instruments, service offer, and specialist referral in the Primary Health Care and compare Brazilian geographical regions.

    Material and Methods

    Study Design

    The historical time series study was carried out using secondary data from the External Evaluation (EE) of the 1st, 2nd, or 3rd cycle of the PMAQ-AB. The data analyzed is made available to the public by the Health Ministry.

    Data Collection Source

    The PMAQ-AB was created by the Health Ministry (HM) in 2011 to motivate teams and managers to improve the quality of SUS services offered to the population and propose a set of strategies for better qualification, evaluation, and monitoring of the work developed by health teams in the country [10,11]. Adhesion to the PMAQ-AB is voluntary and not mandatory. It is carried out by the municipal management individually, through health teams in the PHC service that want to take part in it.

    All the PMAQ-AB cycles were coordinated in a tripartite arrangement that included the Basic Care Department (BCD) (in Portuguese – DAB – Departamento de Atenção Básica) of the HM, National Council of Health Secretaries (in Portuguese – CONASS – Conselho Nacional dos Secretários de Saúde), and National Council of Municipal Health Secretaries (in Portuguese – CONASEMS – Conselho Nacional dos Secretários Municipais de Saúde). The external evaluation phase also included higher education institutions.

    The external evaluation in the 1st cycle was divided into three modules: Module I – Health Unit Observation; Module II – Interview with the Basic Health Care Team and verification of the health unit documents; and Module III – Interviews with users at the Health Units. The 2nd and 3rd cycles of the External Evaluation were divided into six modules (Module I – Health Unit observation; Module II – Interview with the Professional of the Basic Care Team and verification of the health unit documents; Module III – Interview with users at the Health Unit; Module IV – Interview with the Professional of the Family Health Extended Centers and verification of the Health Unit documents; Module V – Observation of dental offices at the Health Unit; and, Module VI – Interview with the Professional of the Oral Health Team and verification of the Health Unit documents).

    Study Universe and Sample

    In this study, the sample universe included Oral Health Teams (OHT) in the PHC who adhered to and received external evaluation of the BCAQNP 1st, 2nd, and 3rd cycles. Each cycle was treated independently; that is, the OHT evaluated did not have to take part in more than one cycle.

    Variables from Module II of the 1st cycle (2012 and Module V [input] and VI [work process) of the 2nd cycle (2014, and 3rd cycle (2018) were selected from the data collection instrument of the PMAQ-AB external evaluation, which comprised the interview with the Professional of the OHT (dental surgeon or oral health technician/assistant) and verification of documents and/or instruments of the Basic Health Unit. All OHTs were eligible, regardless of the professional category of the respondent.

    Data Collection

    The external evaluation was carried out by independent professionals, who had been previously selected and calibrated to apply the forms validated, record the data on tablets, and analyze the proof documents, whenever required. The participant professionals signed the Free and Informed Consent Term and were informed that they could refuse to participate.

    In the 1st cycle, 17,482 Basic Care Teams (BCT) and OHT adhered (53.0% of the BCT registered within the year), in the 2nd cycle, 19,946 OHT adhered (89.6% of the OHT registered within the year), while in the 3rd cycle, 25,090 OHT adhered (93.0% of the OHT registered within the year).

    External evaluation of 16,552 BCT was carried out in the first cycle [94.7% of the BCT that adhered to this cycle], in the 2º cycle, 18,333 Oral Health Teams were evaluated (91.9% of the OHT that adhered to this cycle), and in the third cycle, 22,993 OHT (91.6% of the OHT registered within the year). However, some data loss might have occurred due to the inaccurate input of data regarding some of the variables.

    Variables

    The outcomes (dependent variables) of the study were divided into three blocks (Chart 1) (Supplementary 1):

    • Periodontal instruments: millimetric probes, periodontal curettes, curette sharpening, dental ultrasound, and bicarbonate jet;

    • Offer of periodontal procedures by the OHT: Supra and subgingival scratching, smoothing, and polishing, ulotomy/ulectomy, and frenectomy;

    • Availability of periodontal specialist referral.

    The independent variables were:

    • Brazilian geographic regions: South, Southeast, Midwest, Northeast, and North;

    • Year of the evaluation cycles: 2012, 2014, or 2018.

    Data Analysis

    The data were adjusted and analyzed using the Statistical Package for the Social Sciences (SPSS) 20.0, and presented in absolute (n) and relative (%) frequencies. The associations of the variables investigated (outcomes) and the independent variables [regions or cycles] were carried out using the Chi-square test [p<0.05]. For comparison of prevalence between the Brazilian regions, the Bonferroni adjusted Z test was employed, and for the comparison between cycles, the Cochran Q Pairwise Test was used, p<0.05. After previous adjustment for compatibility, all variables were dichotomized into ‘Yes’ or ‘No’. We decided to present only the results in the tables of the category ‘Yes’. However, the category ‘No’ was considered for analysis. Equiplots (https://www.equidade.org/equiplot_creator) were used to provide a graphic exhibition of the inequalities between the Brazilian geographical regions, only for variables where the comparison between cycles was possible.

    Results

    In Brazil, the specific periodontal instruments most available to the OHT in 2014 and 2018 were the periodontal curettes (84.1% and 95.7%, respectively), while the ultrasound was the least available (26.0% and 21.6%, respectively). Regional discrepancies were noticed regarding instruments since the Southern and Southeastern regions showed a higher proportion of instruments available. In comparison, the Northern and Northeastern regions presented a lower proportion (p<0.001) (Table 1).

    Thumbnail
    Table 1
    Comparison between the availability of periodontal instruments in the Primary Health Care according to the Brazilian geographical regions and cycles.

    An expansion was observed in the availability of specific instruments such as periodontal probe, periodontal curettes, sharpening stones, and bicarbonate jet to the PHC in Brazil and in all Brazilian regions between 2014 and 2018 (p<0.001). The only reduction occurred in the availability of dental ultrasound in Brazil, mainly related to decrease in the Southern (p<0.001), Southeastern (p<0.001), and Midwestern (p=0.008) regions, keeping numbers in the Northern (p=0.201) region, and expansion only in the Northeastern region (p<0.001) (Table 1) (Figure 1a).

    thumbnail of Figure 1
    Figure 1
    Equiplot of the availability of periodontal (a) instruments, (b) procedures, and (c) specialist referral by Oral Health Teams, according to Brazilian region and year.

    Regarding the offer of periodontal procedures by the OHT, supragingival scaling and root planing were the most performed procedures in Brazil, while frenectomy was the least performed. A gradual increase was observed in the offer of supragingival scaling and root planing and ulotomy/ulectomy (p<0.001). The same expansion was observed in all Brazilian regions (p<0.001). Despite the reduction in regional inequalities regarding the procedures carried out, the Northern region remained with the lowest proportion of procedures performed by the OHT (p<0.001) (Table 2) (Figure 1b).

    Thumbnail
    Table 2
    Comparison between the offer of periodontal procedures at the Primary Health Care according to Brazilian Geographical regions and cycles.

    The offer of periodontal specialist referral was higher at each cycle, and grew from 54.6% to 81.8% in Brazil (p<0.001). Such expansion occurred in all Brazilian regions (p<0.001). The Northeastern region presented the highest proportion of specialist referral availability in 2018, while the Northern region showed the lowest (p<0.001) (Table 3) (Figure 1c).

    Thumbnail
    Table 3
    Comparison between the availability of periodontal specialist referral in the Primary Health Care according to Brazilian geographical regions and cycles.

    Discussion

    This study showed an expansion in the availability of periodontal instruments, procedures, and specialized referrals for the OHT in PHC in Brazil and the Brazilian regions. This result shows a greater installed capacity in the access and resolution of periodontal disease, which has a high prevalence in the Brazilian population [3,4,5] and worldwide [1,2]. Brazil has become a reference in the provision of public oral services, especially in recent decades, after the implementation of the NOHP, especially in the PHC [8]. In addition, the BCAQNP has been shown to have a positive impact not only as an assessment tool, but with performance-based financing incentives [11], and therefore, a significant increase in the OHT evaluated in each cycle and the collection instrument improvement, thus obtaining more information.

    In general, better results for equipment availability were obtained, and greater availability of periodontal procedures was observed in the Southern and Southeastern regions, unlike the Northern region, which presented worse results. Previous studies demonstrated that areas with worse sociodemographic conditions are more affected by the reduced offer of oral health care, lacking instruments and supplies for basic dental treatment [12]. This shows that public health policies, despite reducing inequalities in recent decades [13], are still far from achieving equal distribution and need to be more effective. The slow improvement process and significant regional disparities may derive from the PHC financing model, where municipalities have a greater participation than the federal government [14,15].

    When considering social and political differences at the municipal level, which is responsible for the PHC management, the difficulties in implementing more significant changes in health outcomes become clearer [16]. The Health Ministry’s financial incentive has been more expressive in the PHC implementation than in supporting its operational costs [15]. In addition, operational costs with human resources are above 80% [14,15], which results in a shortage of resources for equipment maintenance, building costs, and materials [14]. Another reason for the higher expenditure on personnel is the fact that the more distant municipalities have a lower capacity for retaining professionals; therefore, financial incentives have been used to make the work more attractive for those professionals [17].

    The periodontal instruments evaluated showed improvement between cycles, except for the ultrasound.

    In the last cycle, more than half of the OHT had a millimeter periodontal probe. This is a fundamental instrument for probing clinical depth, clinical level of periodontal attachment, bleeding on probing, and position of the gingival margin [18]. However, a considerable proportion did not have this instrument. This result is alarming due to the importance of the device for periodontal evaluation, directly compromising the diagnosis and the establishment of a treatment plan [12].

    Although most OHTs had periodontal curettes, 3/5 of them did not have a sharpening stone, which can result in inadequate material for the surgical periodontal procedure and inefficient removal of dental calculus. The lack of this material directly impairs the work process, the quality of oral health treatment, and consequently affects the patient’s general health [12]. It is worth noting that dental calculus was the most prevalent periodontal alteration in Brazil. In 2003, dental calculus had a prevalence of 33.4% among adolescents and 46.8% among adults [3], and in 2010, a smaller proportion was found, that is, 28.4% among adolescents and 28.6% among adults [4]. This reduction may be a consequence of greater access to dental services by the Brazilian population after the creation of the NOHP in 2004, as part of the expansion and decentralization of oral care in the PHC [8]. Therefore, the continuous availability of this basic input is fundamental for the removal of dental calculus by the Oral Health Teams.

    With the high demand for patients in PHC, the use of dental ultrasound would optimize clinical time, making it possible to serve more patients. Its primary use is to remove supra/subgingival deposits by vibrating the active tip and coolant jet, in addition to providing easy access to deep periodontal pockets and furcation areas [7]. This present study observed the scarcity of dental ultrasound available to the oral health team. Just over 1/5 of the participants had this equipment available, with a reduction in the Southern, Southeastern, and Midwestern regions, an equal proportion in the North, and an increase in the Northeast between cycles. This result may be a consequence of a lack of equipment maintenance and, therefore, no conditions of use at the time of the new evaluation cycle. Another reason might be the increase in the number of OHT evaluated per cycle; this might have resulted from the inclusion of OHT with worse infrastructure conditions. The Northeastern region stood out regarding the expansion of its PHC and the solutions provided by it. It was also the region with the highest adherence of PHC to the BCAQNP in the country. Due to the fundamental principle of equity in the SUS, this data is positive when verifying a region with worse sociodemographic conditions that showed improvement in its public health system. However, the Northern region has been producing these improvements more timidly.

    The availability of sodium bicarbonate jets among the teams showed a significant increase. That instrument is used to aid the removal of biofilm and stains from the tooth surface; thus, it is vital in the control of gingivitis and periodontitis [12]. However, this study showed that it is not available to half of the OHT. Lack of this equipment might hamper the oral health treatment and maintenance [12]. For this reason, the Brazilian PHC needs to pay more attention to low-cost equipment that optimizes the work mainly among generalist professionals.

    As for the procedures available, this study revealed a substantial increase in the supragingival scaling and root planing procedure performed by the OHT in Brazil and in all Brazilian regions, making this the most performed periodontal procedure in clinical practice. The maintenance of healthy teeth and the high prevalence of dental calculus and gingivitis explain the incredible demand and availability of this procedure [19]. Despite being a basic procedure, it might have a relevant effect on the prevention and control of periodontal disease, significantly impacting the lives of the population. Subgingival scaling and root planing presented high availability in 2018, the only cycle in which it was researched. This result demonstrates a change in the conduction of treatments considered basic and/or complex, and due to the high prevalence of periodontal pockets, they might be carried out at the PHC unit [20]. Moreover, high demand for this procedure should be understood as an essential factor in the maintenance of the population’s oral health since the subgingival periodontal treatment presents high success rates in the periodontitis control, and is associated with tooth maintenance and quality of life improvement in the long run [21].

    Ulotomy/ulectomy also presented a higher and quite expressive proportion. In the Metropolitan Region of Vitoria in Espírito Santo [RMV-ES], a study was developed to evaluate dental procedures before and after the NOHP implementation in 2004. Among those, ulotomy obtained 0.1% between 1994 and 1999. Between 2008 and 2014, this percentage increased to 1.6% [22]. This data might have resulted from the simplicity of the procedure and favorable post-operative recovery when the technique is used in situations of late tooth eruption. It is used as a therapeutic option that prevents future bad occlusions if no tooth exposure surgery is carried out.

    Frenectomy showed low availability in 2014, the only cycle in which it was investigated in this study. The RMV study showed that frenectomy did not present a significant increase before and after the NOHP [22]. This result might be due to several factors, such as a lack of suitable input in the BHC, professionals’ qualifications and safety in the diagnosis, and the appropriate time for the performance and execution of such a procedure. Another factor might be the specialist referral network growth process, which should be understood as the most suitable place for its occurrence. The data from this study reinforce this hypothesis since an expressive increase in the availability of periodontal specialist referral was observed in the three cycles investigated. The high demand for the public health service requires an analysis of the interface between procedures that must be provided by the primary and secondary health care [9]. In practice, we noticed that due to the high prevalence of periodontal diseases, the high demand of users and the availability of human resources with proper professional qualification in the PHC, the OHT develops actions related to the periodontal disease prevention, diagnosis, and treatment [7].

    The greater availability of periodontal specialist referral in the Northeast is a consequence of that region being the one concentrating the greater proportion of the Dental Specialty Center [CEO] implemented in Brazil, followed by the Southeast [19]. This shows the holistic approach of the oral health policy there, one that focuses on offering dental services at different levels. The Northeast example showed that even in a scenario of unfavorable socioeconomic conditions, it was possible to implement public health policies to improve the quality of the service rendered.

    Our results demonstrated that, in addition to the process of greater availability of periodontal input and offering basic periodontics procedures in the PHC, the OHT has been supported in more complex cases by the availability of referral to the CEO. This organization reinforces consistent action regarding solutions provided by health services when dealing with periodontal diseases. This requires qualified professionals to articulate the kind of work that can reduce the prevalence of this disease based on the following: prevention work developed by the PHC, installed capacity for early diagnosis and execution of the low complexity periodontal procedures at the PHC, setting case protocols for the specialist service, motivated users that adhere to the appointments and the treatment plans during the referral and counter-referral process, along with unified record or a suitable system of communication and interaction between the different health care levels [9].

    Despite the scientific knowledge involved in the association between general and oral health, mainly concerning periodontal disease [6], few studies have focused on periodontal disease care primarily in the public health service. The population’s oral and periodontal disease care is vital for being associated with a reduction in tooth loss and consequent improvement of the individuals’ quality of life. Moreover, the presence of periodontal disease is related to several systemic illnesses such as diabetes and cardiovascular diseases [6]. These illnesses also show significant prevalence and impact individuals’ lives with consequences for the public and private health service and high socioeconomic cost for the population [23]. Thus, preventive and therapeutic action focusing on reducing the prevalence and severity of this disease might impact the different levels of health care and also result in lower economic and social costs for the population and the health system.

    This study’s limitation is the difficulty of comparing cycles, either for the inclusion of new OHT evaluated per cycle and/or the difference in the format or number of items assessed in each cycle of the BCAQNP. While in the first cycle, the evaluation process reached around 50.0% of the BHU per municipality, this number grew in the following cycles. In the third cycle, for example, the adhesion was over 90% of the OHT registered in Brazil, which provided data closer to the reality of the oral health care in the country. Therefore, the BCAQNP was an invaluable program for the maintenance of access to and quality of oral health in primary care. Currently, this program is being replaced with another evaluation system proposed by the federal government, namely, the Brazil Prevent (in Portuguese Previne Brasil) [24]. Considering the simplification of the evaluation in the new program, the data presented in this work can be used soon as a basis for the assessment of the impact of such changes.

    Conclusion

    An increase in the availability of periodontal instruments, procedures, and specialist referral for oral health teams in Brazil was observed. Despite the trend of reducing regional differences throughout the cycles, they remained evident, with better results in the Southern and Southeastern regions and worse outcomes in the North. In addition, significant improvement was observed in the period investigated in the Northeastern region.

    • 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.

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    Edited by

    • Academic Editor:
      Wilton Wilney Nascimento Padilha

    Publication Dates

    • Publication in this collection
      28 Nov 2025
    • Date of issue
      2026

    History

    • Received
      04 Oct 2023
    • Reviewed
      10 Nov 2024
    • Accepted
      28 Feb 2025
    Creative Common - by 4.0
    This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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