Who has the right to see the dentist? Limitations accessing dental services by older people in Brazil in the era of the National Health Policy for Elders

INTRODUCTION

Health is considered a human right, secured for Brazilians in the form of social and economic policies and through universal access to health care services providing health promotion, protection and rehabilitation, enshrined in the Constitution under article 196. Oral health is a key component of general health and therefore dental services are an integral part of the health services offered to the population.

In 2004, the National Oral Health Policy (PNSB) was implemented, establishing the need to expand access to dental services for the older population. The policy ensures care for this population via provision of a line of care based on the premise that oral health represents a key element for quality of life. As a framework for implementation, individual clinical treatment of older patients should be guaranteed, avoiding queues and bureaucratic procedures that may hamper access, including the setting aside of specific times and days for treatment of this patient group¹.

At a later date, in 2006, the National Health Policy for Elders (PNSPI) was implemented, an important instrument to help secure the integral universal right to health of the older population and prepare the National Health System (SUS) to cater for the growing demands placed on it due to population aging. Although the wording of this policy does not outline specific recommendations for dental care (or other specific care), this care is implicit in the integral care guidelines for the health of older individuals and provision of the resources required to assure quality health care for elders.

Although access to oral health in Brazil is guaranteed, delivering on this promise has been met with challenges, particularly with respect to the older population. According to 2019 data compiled by the Brazilian Institute of Geography and Statistics (IBGE), an estimated 693,000 older people had never seen a dentist at least once in their lifetime, representing 2% of the older population in Brazil. Another alarming statistic is that almost half of all older Brazilians (42.5%) had not visited the dentist in the last 3 years, representing 14 million people². These levels were even higher in previous years. In 1998, an estimated 6.1% of older adults in Brazil had never been to the dentist in their lifetime, a rate decreasing to 6.0% in 2003, 3.9% in 2008 and 4.8% in 2013³.

This reduction in the proportion never seeing a dentist reflects a steady improvement in access to dental services in the country between 1998 and 2019, a shift largely attributed to the implementation of the policies outlined earlier. However, challenges remain in attaining the goal of integral care for older people, particularly with regard to socioeconomic inequalities in the utilization of these services. Income-related inequalities in dental service utilization in Brazil persist, with lower reduction in disparities seen among the older population compared to other age groups, such as children, adolescents and adults, over the period analyzed³.

The specific profile of this population should be taken into account when analyzing access to dental services where, under the PNSPI, older users are classified according to level of functioning into individuals that are dependent, independent with some difficulties for instrumental activities of daily living, and frail. For frail individuals, besides making dental services available, strategies must be devised to ensure access to dental care.

A systematic review conducted on oral care provision in older people revealed that the main barriers to dental care faced by older frail adults was a lack of suitable facilities for treatment/transportation of patients. This barrier was perceived by patients, dentists and caregivers. The barriers most commonly-reported by dentists were the inconvenience of having to leave the dental office as the practice venue, lack of knowledge on specific care for this population, longer consultation time required, and little or no financial incentive. Patients refusing care was also perceived by dentists and caregivers, especially among people with dementia⁴.

Overcoming these barriers is addressed in the guidelines of the PNSPI, which ensure provision of the resources necessary to guarantee quality care and ongoing education and training of health professionals under the SUS in the area of health for elders. Nevertheless, practical challenges remain in the form of lack of suitable public transport, limited access to health services, shortages of equipment and supplies needed to implement visiting home dental care under the SUS, in addition to the need for training dental professionals to deal with the specific health needs of this population. This analysis reveals the need for further roll out of the PNSPI and PNSB with a view to securing the rights of older people to dental appointments in the Brazilian population.

However, there is encouraging news on this front. The final draft of the bill on Oral Health under the SUS⁵ (Brasil Sorridente/Smiling Brazil bill) has been approved. Once passed, the Smiling Brazil policy will no longer be a Federal Government program subject to constant cuts, but become enshrined in a robust national law. Consistent with the value advocated in 1986 at the 1^st National Conference on Oral Health, that there cannot be health without oral health, we should continue to strive for improvements in oral health of older people. Article 3 of the bill states that “Oral health actions and services shall be an integral part of the other public health policies”⁵. Thus, oral health should be coordinated with the PNSPI framework. Wider access and use of oral health services by older people is at the same time a historical measure redressing the mutilating legacy of the state´s failure to provide the population with oral health care, as well as a constitutional measure ensuring that future generations of older people can age with a smile.

REFERÊNCIAS

• ¹
  Brasil. Diretrizes da Política Nacional de Saúde Bucal. Brasília; 2004.
• ²
  IBGE. Pesquisa Nacional de Saúde - PNS [Internet]. [cited 2023 Mar 20]. Available from: https://www.ibge.gov.br/estatisticas/sociais/saude/9160-pesquisa-nacional-de-saude.html?edicao=28655&t=conceitos-e-metodos
  » https://www.ibge.gov.br/estatisticas/sociais/saude/9160-pesquisa-nacional-de-saude.html?edicao=28655&t=conceitos-e-metodos
• ³
  Galvão MHR, Roncalli AG. Does the implementation of a national oral health policy reduce inequalities in oral health services utilization? The Brazilian experience. BMC Public Health 2021 21:1 [Internet]. 2021 Mar 19 [cited 2023 Mar 20];21(1):1–8. Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-021-10586-2
• ⁴
  Göstemeyer G, Baker SR, Schwendicke F. Barriers and facilitators for provision of oral health care in dependent older people: a systematic review [Internet]. Vol. 23, Clinical Oral Investigations. Springer Verlag; 2019 [cited 2023 Mar 20]. p. 979–93. Available from: https://pubmed.ncbi.nlm.nih.gov/30707299/
• ⁵
  Brasil. Câmara dos Deputados. Redação Aprovada do Projeto de Lei Nº 08131/2017 de 17 de março de 2023. Institui a Política Nacional de Saúde Bucal no âmbito do Sistema Único de Saúde (SUS) e altera a Lei nº 8.080, de 19 de setembro de 1990, para incluir a saúde bucal no campo de atuação do SUS. Brasília: Câmara dos Deputados, 2023. Available from: https://www.camara.leg.br/proposicoesWeb/prop_mostrarintegra?codteor=2245660&filename=REDACAO%20FINAL%20PL%208131/2017
  » https://www.camara.leg.br/proposicoesWeb/prop_mostrarintegra?codteor=2245660&filename=REDACAO%20FINAL%20PL%208131/2017

Publication Dates

• Publication in this collection
  05 June 2023
• Date of issue
  2022