Análise da produção ambulatorial em municípios com e sem centros de especialidades odontológicas no Brasil em 2010

Factors associated with the performance and achieving goals of specialized periodontal procedures in Brazilian dental specialties centers

BACKGROUND

The Brazilian Dental Specialty Centers (CEO, in Portuguese) represent the strategy of the National Oral Health Policy to provide secondary-level dental care. They offer more complex procedures, such as the treatment of periodontitis. This study aims to investigate the factors associated with the performance and the achievement goals of specialized procedures and the achievement gols of periodontics in CEO.

METHODOLOGY

Analytical and cross-sectional study using secondary data. The database of the second cycle of the External Evaluation of the National Program for Improving Access and Quality in CEO (PMAQ-CEO, in Portuguese), was utilized, which assessed 1,042 CEO on-site in 2018. The data were analyzed using multiple Poisson regression, estimating the prevalence ratio (PR) (p < 0.05).

RESULTS

A third of the CEO (n = 305) performed all specialized procedures, with a higher prevalence observed in those with more than one bicarbonate jet prophylaxis unit (RP = 2.12; 95% CI: 1.160-3.881; p = 0.015) and when they had a higher percentage of specialist professionals (RP = 1.004; 95% CI: 1.002-1.006; p < 0.001). The periodontics goal was achieved by 617 (59.2%) CEO, with a higher prevalence among those who had a manager with supplementary training (PR = 1.21; 95% CI: 1.100-1.335; p < 0.001) and with a higher workload for the periodontist dentist (PR = 1.15; 95% CI: 1.103-1.201; p < 0,001).

CONCLUSION

Although most CEOs do not perform allspecialized periodontics procedures, more than half achieved the established goals. The provision of specialized periodontics services in CEO and the achievement of goals are influenced by the quantity and professional qualifications, as well as the availability of equipment.

Association between socioeconomic contextual factor, dental care service availability, and prevalence of periodontitis in Brazil: a multilevel analysis

This study aimed to examine the effect of dental care services on periodontitis cases in Brazilian municipalities. The sample comprised 3,426 individuals aged 35-44 years. Moderate to severe periodontitis with clinical attachment loss and probing depth was the dependent variable, both > 3mm. Its exploratory variables were grouped into four categories: (1) individual characteristics; (2) contextual development indicators; (3) health service and structural factors; and (4) dental care use. Data were collected using the SBBrasil 2010 Project, the Brazilian Institute of Geography and Statistics, the Brazilian Information System of Primary and Secondary Care, and the Program to Improve Access and Quality of Dental Specialization Centers (PMAQ-CEO). Multilevel logistic regression was used to assess associations of periodontitis with individual and context variables. Municipalities with > 1 CEO or > 1 of any centers were associated with periodontitis, with OR = 0.97 (95%CI: 0.55-1.71) and OR = 0.41 (95%CI: 0.17-0.97), respectively. Prevalence of periodontitis was more likely in older people, lower education levels, and individuals that sought dental visits for pain/extraction and periodontal treatment. Other dental care services availability were not associated with the prevalence of periodontitis.

Prevalence and Genotyping of HPV in Oral Squamous Cell Carcinoma in Northern Brazil

Highly oncogenic human papillomavirus (HPV) is well known to be associated with and a risk factor for various types of oral carcinomas such as oral squamous cell carcinoma (OSCC). The aim of this study was to evaluate and describe the HPV-induced OSCC prevalence and genotyping in the city of Belém, northern Brazil. This cross-sectional study features 101 participants who attended an oral pathology referral center in a dental college looking for diagnoses of oral lesions (OL). After signing the consent term and meeting the inclusion criteria, all participants went through a sociodemographic and epidemiological questionnaire. Then, OL were collected by excisional or incisional biopsy depending on OL size; after that, OL tissues were preserved in paraffin blocks to histopathological diagnoses. Afterwards, paraffin blocks were divided into benign and malignant/premalignant lesions based on the classification of potentially malignant disorders of the oral and oropharyngeal mucosa. Then, the paraffin blocks had DNA extraction performed by the ReliaPrep FFPE gDNA Miniprep method in order to identify HPV DNA of high oncogenic risk and low oncogenic risk. Then, the viral DNA was amplified and typed using the Inno-Lipa genotyping Extra II method, and the collected data were analyzed by Chi-square and G-tests. In total, 59/101 (58.4%) OL were malignant/premalignant lesions, of which OSCC was the most prevalent with 40/59 (67.7%) and 42/101 (41.6%) benign lesions. The most common area of OL incidence was upper gingiva 46/101 (45.5%). Regarding HPV DNA detection, approximately 27/101 (26.7%) had positive results; of these, 17/59 (28.8%) were malignant/premalignant lesions, and the most prevalent genotypes detected were 16, 18, 52 and 58, while among benign lesions, 10/42 (66.6%) had HPV-positive results, and the most prevalent genotypes detected were 6, 11 and 42. Age range was the only risk factor with a significant association between HPV and OSCC presence (p-value: 0.0004). A correlation between OSCC and oral HPV among analyzed samples could not be demonstrated in our small cohort.

Relationship between Professional Training of Dentists and Outpatient Clinical Production

Background. The aim was to evaluate the association between the professional training of dentists and their outpatient production (OP) of clinical and collective/preventive procedures and the total number of procedures registered in a health information system. Methods. It included all 19,947 primary dental care units participating in the Program for Improvement of Access and Quality of Primary Care (PMAQ-AB 2nd cycle) and the number of clinical procedures (CP), collective/preventive procedures (PP), and total procedures (TP) registered in the ambulatory information system between November 2013 and July 2014 for each participant oral health team. The outcome was being above the national median of procedures. The main variables related to training were the dentists specialising in family health, the level of training, and participation in permanent education. Effect estimates were calculated by multiple logistic regression. Results. In the final model, controlled by contextual factor work process, family health specialists had higher chances ( $\text{odds}\text{ratio}\left(\text{OR}\right)=1.13$ , 95% CI: 1.00; 1.27) of producing above the national median of CP than nonspecialists, $\text{OR}=1.06$ (0.96; 1.18) for PP and $\text{OR}=1.17$ (1.08; 1.27) for TP. Dentists taking permanent education had higher chances than those not taking it of producing above the national median for CP, PP, and TT, respectively, with $\text{OR}=1.40$ (1.20; 1.62), $\text{OR}=1.24$ (1.09; 1.40), and $\text{OR}=1.28$ (1.18; 1.39). Conclusion. Training in family health performs more procedures in primary care settings than those without training. However, this OP is influenced by variables related to the municipality and the work process, especially for PP. If the highest production observed is a consequence of training, then public health managers can not only encourage training policies such as permanent education policies to expand the use of services.

Contextual and local determinants associated with the achievement of goals in the endodontics specialty in Brazilian dental speciality centres: A multilevel analysis

OBJECTIVES

To assess which factors were associated with the achievement of endodontic goals.

METHODS

Cross-sectional study using secondary data from the second cycle of the Program for the Improvement of Access and Quality in the dental speciality centres-in Portuguese PMAQ-CEO. The independent variables extracted from this database were related to dental speciality centres (CEO in Portuguese). In addition, variables referring to the CEO host city were incorporated into the model. The outcome variable was the number of endodontic goals achieved calculated from the production of the CEO available in the Ambulatory Health Information System in 2018. Descriptive analyses and multilevel Poisson regression were performed with the software SPSS 23.0 and STATA 14.0.

RESULTS

CEOs with more than 20% of patients' absenteeism were 26% less likely to reach the goals of the endodontics specialty; CEOs with availability of endodontists for more than 40 hours a week were two times more likely to reach the goals than those with less than 40 hours in endodontics specialty. CEOs with a waiting time for endodontic procedures greater than 45 days achieved a number of goals 31% lower than those with a waiting time up to 45 days. CEO type I and CEO type II showed 2.10 and 1.20 higher likelihood to reach the number of goals of the endodontics specialty than CEO type III. The number of endodontic instruments in sufficient number was positively associated with the achievement of goals. CEOs located in municipalities that reached more than 5% in the supervised brushing indicator had 2.26 greater likelihood to achieve the goals than those that did not reach this percentage.

CONCLUSION

Contextual and local determinants are associated with the achievement of goals in the endodontic specialty in the dental speciality centres in Brazil.

Pay-for-performance and dental procedures: A longitudinal analysis of the Brazilian Program for the Improvement of Access and Quality of Dental Specialities Centres

OBJECTIVE

Evaluate the impact of a pay-for-performance program on changes in the number of dental procedures performed by public secondary dental care services in Brazil.

METHODS

A longitudinal study was carried out with 932 public Dental Specialities Centres (Centro de Especialidades Odontológicas - CEO) that participated in the pay-for-performance Program for the Improvement of Access and Quality of Dental Specialities Centres Services (PMAQ/CEO) and 379 non-CEO centres with secondary dental production. The non-CEO and a group of CEOs did not receive financial incentives from the PMAQ-CEO and served as control groups. Three CEOs groups received additional financial incentives of 20%, 60% or 100% over maintenance values, based on their performance scores. The outcome was the increase (yes/no) in the number of dental procedures between 2011/2013 and 2015/2017. Analyses were carried out using logistic regressions.

RESULTS

The number of specialized procedures increased in 48.4% of the services, 44.6% among non-CEO, 52.3% among CEO with no financial incentive and 59.1% among CEO with 100% incentive. The fully adjusted model showed that CEOs receiving 100% of the financial incentive had greater odds of increasing the production of dental procedures (OR = 1.65, 95%CI: 1.09-2.51). Services that increased the number of specialist dentists had (OR = 2.35, 95%CI 1.88-2.94). Municipalities that increased in coverage of private dental insurance had OR = 0.98 (95%CI: 0.94-1.02), and those with higher coverage of primary dental care had OR = 1.02 (95%CI: 0.99-1.05).

CONCLUSION

Pay-for-performance may increase the production of dental procedures by CEOs, and mechanisms explaining it must be further investigated.

[Performance of Brazilian municipalities in the supply of specialized oral health services]

The study aimed to analyze factors associated with the availability of specialized dental services in Brazilian municipalities. This was an ecological study with a sample of 776 municipalities that participated in the first cycle of the Program to Improve Access and Quality of Dental Specialization Centers (PMAQ-CEO, in Portuguese) survey held in 2014. The study's dependent variables consisted of a coefficient created with variables on the number of professionals and the workweek of dentists in the minimum set of specialties, per 10,000 inhabitants. Exploratory factor analysis was performed to create a score for the municipalities' performance with the availability of specialized dental services. Factors associated with the municipalities' performance were assessed with Pearson's chi-square test, with the following municipal indicators as independent variables, categorized in tertiles: per capita income, Municipal Human Development Index (HDI-M), resident population, total health spending per inhabitant, and Oral Health Teams per 10,000 inhabitants. Higher performance with the availability of specialized oral health services was associated with municipalities having smaller populations (67.3%; CI: 61.6-73.0; p < 0.001), lower HDI-M (41.9%; CI: 35.8-48.0; p < 0.001), lower per capita income (41.2%; CI: 35.2-47.3; p < 0.001), and higher mean number of oral health teams per 10,000 inhabitants (50.6%; CI: 46.0-58.4; p < 0.001). The results show positive impacts from the implementation of the National Oral Health Policy in Brazil, meeting the goal of expanding the supply of secondary care services according to the principle of equity in care.

[Presence of Specialized Dentistry Centers and the relationship with dental extractions in the oral healthcare network in Brazil]

This study aimed to assess the association between the presence of Specialized Dentistry Centers and dental extractions as a proportion of all dental procedures in public services in Brazil. This was an ecological study that assessed sociodemographic data, oral health services, and outpatient production in 5,333 municipalities in 2000-2001 and 2015-2016. The principal exposure variable was the presence of Specialized Dentistry Centers, and the outcome was the mean national proportion of dental extractions in relation to all preventive and curative dental procedures. Interaction and multiple regression analyses were performed using a binomial model with log link function. The mean national proportions of dental extractions in relation to preventive and curative dental procedures were 27.07% and 15.11% in 2000-2001 and 2015-2016, respectively. In the analysis of interaction between the presence of Specialized Dentistry Centers and coverage greater than 80% by the oral health teams, there were lower proportions of dental extractions in relation to preventive and curative dental procedures (OR = 0.71; 95%CI: 0.71-0.72). In the multiple regression analysis, municipalities with Human Development Index of 0.6-0.7 (OR = 0.77; 95%CI: 0.77-0.77), annual per capita GDP greater than BRL 20,000 (OR = 0.45; 95%CI: 0.45-045), and proportionally higher urban populations (OR = 0.72; 95%CI: 0.72-0.72) showed fewer dental extractions as a proportion of all preventive and curative dental procedures in 2015-2016. In conclusion, there were lower proportions of tooth extractions in municipalities with at least one Specialized Dentistry Center and with a coverage of greater than 80% by the oral health teams, highlighting that municipalities with a consolidated Oral Health Care Network present better performance in the supply of dental care.

Política de Saúde Bucal no Brasil: as transformações no período 2015-2017

RESUMO Este estudo analisou a implementação da Política de Saúde Bucal no Brasil entre 2015 e 2017 em quatro componentes: ações institucionais, implantação, financiamento e resultados. Foram realizados acompanhamento dos sites do Ministério da Saúde (MS) e coleta de dados secundários sobre ações institucionais do MS, implantação dos serviços de Atenção Básica e Atenção Especializada, resultados alcançados (cobertura da primeira consulta odontológica, média de ação coletiva de escovação supervisionada e tratamentos especializados) e financiamento. Entre 2015 e 2017, houve aumento de 5,8% no número de Equipes de Saúde Bucal e de 6,4% no número de Centros de Especialidades Odontológicas. A cobertura de primeira consulta odontológica programática decresceu no período de 14,6% em 2015, para 10,5% em 2016 e 8,3% em 2017. Houve redução discreta do financiamento federal no ano de 2017, quando comparado a 2016. Verificou-se, em 2016, um cenário político restritivo para a saúde bucal na menor implantação de novos serviços, com mudanças sucessivas na coordenação nacional da política. É necessário aprofundar o estudo sobre o financiamento da política, visto que o aporte financeiro de 2016-2017 não está coerente com o pouco avanço na implantação e tendência de manutenção de resultados, com queda de indicadores específicos, como o de primeira consulta odontológica programática.

Cumprimento de metas dos Centros de Especialidades Odontológicas da Região Sul do Brasil

Objetivo El objetivo del estudio fue verificar: el cumplimento de las metas de tratamientos en las clínicas dentales especializadas (CDEs) en la Región Sur de Brasil y, los factores asociados a los procesos de trabajo.Método El estudio fue exploratorio transversal. Para la recolección de datos fueron consultadas las bases del datos provenientes de  DATA/SUS, CNES, SIOSP, IBGE y fue enviado un cuestionario semiestructurado para los gestores de las CDEs. Para comprobar  la asociación de los factores con el cumplimento de las metas de las CDEs se realizó el test de Kruskal Wallis.Resultados Fueron analizados 936 meses de tratamiento ambulatorio distribuidos en las 78 CDEs y la tasa de respuestas de los cuestionarios fue de 68%. Las variables: estado de Paraná, municipios con número de ciudadanos de 0-50 mil/hab, el cuarto quintil de los gastos totales en salud y PIB per cápita fueron asociados con el cumplimento de las metas de los procedimientos de periodoncia y, el tipo II de CDE presentó asociación con el cumplimento de las metas de los procedimientos básicos.Discusión El análisis de las variables que pueden estar asociadas al tratamiento ambulatorio en las CDEs es fundamental para comprobar tanto los problemas de acceso de los habitantes como la aplicabilidad de los recursos públicos en el área de la salud.Conclusiones El estudio indica un bajo cumplimento de las metas de tratamiento de las CDEs, entretanto apunta que pueden haber factores importantes asociados al mayor número de meses en las metas cumplidas.

Relationship between Primary and Secondary Dental Care in Public Health Services in Brazil

This cross-sectional study evaluated the relationship between primary and secondary oral health care in Brazil. For this purpose, data from the National Program for Improving Access and Quality of Primary Care were used. Dentists from 12,403 oral health teams (OHTs) answered a structured questionnaire in 2012. The data were analyzed descriptively and by cluster analysis. Of the 12,387 (99.9%) OHTs that answered all the questions, 62.2% reported the existence of Dental Specialties Centers (DSCs) to which they could refer patients. The specialties with the highest frequencies were endodontics (68.4%), minor oral surgery (65.8%), periodontics (63.0%), radiology (46.8%), oral medicine (40.2%), orthodontics (20.5%) and implantology (6.2%). In all percentiles, the shortest wait time for secondary care was for radiology, followed by oral medicine and the other specialties. In the 50th percentile, the wait for endodontics, periodontics, minor oral surgery and orthodontics was 30 days, while for implantology, the wait was 60 days. Finally, in the 75th percentile, the wait for endodontics, orthodontics and implantology was 90 days or more. Two clusters, with different frequencies of OHT access to specialties, were identified. Cluster 1 (n = 7,913) included the OHTs with lower frequencies in all specialties except orthodontics and implantology compared with Cluster 2 (n = 4,474). Of the Brazilian regions, the South and Southeast regions had the highest frequencies for Cluster 2, with better rates for the relationship between primary and secondary care. This study suggests certain difficulties in the relationship between primary and secondary care in specific specialties in oral health, with a great number of OHTs with limited access to DSCs, in addition to different performance in terms of OHT access to DSCs across Brazilian regions.

Functional Dentition in Brazilian Adults: An Investigation of Social Determinants of Health (SDH) Using a Multilevel Approach

OBJECTIVES

Estimate the prevalence of functional dentition among Brazilian adults using four different definitions and identify associated factors.

METHODS

A cross-sectional study was conducted involving 9564 Brazilian adults aged 35-44 years who participated in the 2010 National Oral Health Survey. Data collection involved oral examinations and the administration of questionnaires. The following definitions were used: 1-WHO Functional Dentition (FDWHO: ≥ 20 teeth present); 2-well-distributed teeth (WDT: ≥ 10 teeth in each arch); 3 -Functional dentition classified by esthetics and occlusion (FDClass5: dentitions that sequentially exhibit at least one tooth in each arch, at least 10 teeth in each arch, all maxillary and mandibular anterior teeth, three or four premolar posterior occluding pairs [POPs], and at least one molar POP bilaterally); 4-Functional dentition classified by esthetics, occlusion and periodontal status (FDClass6: corresponds to FDClass5 with the addition of periodontal status of all sextants in the oral cavity with, at most, shallow pockets and/or clinical attachment level of 5 mm (CPI ≤ 3 and/or CAL ≤ 1). The independent variables were individual factors (gender, self-declared skin color, schooling, monthly household income, age group, self-rated treatment need, dental pain, dental appointment in the previous 12 months and dental services) and contextual factors (Municipal Human Development Index [MHDI]), Gini coefficient, fluoridated water supply and oral health coverage). Multilevel mixed-effect Poisson regression analyses were performed.

RESULTS

The prevalence of functional dentition based on the FDWHO, WDT, FDClass5 and FDClass6 definitions was 77.9%, 72.9%, 42.6% and 40.3%, respectively. Adults with ≥12 years of schooling and monthly household income from US$ 853 to 2557 had higher prevalence rates of FDWHO (PR: 1.41 and 1.10, respectively), WDT (PR: 1.58 and 1.14, respectively), FDClass5 (PR: 2.03 and 1.27, respectively) and FDClass6 (PR: 2.15 and 1.35, respectively). These values in the final models were adjusted for gender, self-declared skin color (FDClass5), age group, self-rated treatment need (FDWHO, FDClass5 and FDClass6), dental appointment in the previous 12 months (FDWHO and WDT), dental services (FDWHO and WDT) and contextual factors. A very high MHDI and presence of fluoridated water supply were associated with higher prevalence rates of the four outcomes.

CONCLUSIONS

The incorporation of the criteria of new definitions of functional dentition led to a lower prevalence rate among Brazilian adults. Striking individual and contextual inequalities were identified with regard to the four definitions analyzed, which need to be addressed through inter-sector efforts.