[Impact of the Family Health Strategy: an analysis in cities in Northeast Brazil with more than 100,000 inhabitants]

Self-rated health among adolescents from vulnerable areas and their sociodemographic, lifestyle and contextual factors: A multilevel analysis

PURPOSE

Understanding self-rated health in young people can help orient global health actions, especially in regions of social vulnerability. The present study analysed individual and contextual factors associated with self-rated health in a sample of Brazilian adolescents.

DESIGN AND METHODS

Cross-sectional data from 1272 adolescents (aged 11-17; 48.5% of girls) in low human development index (HDI) neighbourhoods were analysed (HDI from 0.170 to 0.491). The outcome variable was self-rated health. Independent variables relating to individual factors (biological sex, age and economic class) and lifestyle (physical activity, alcohol, tobacco consumption and nutritional state) were measured using standardised instruments. The socio-environmental variables were measured using neighbourhood registered data where the adolescents studied. Multilevel regression was used to estimate the regression coefficients and their 95% confidence intervals (CI).

RESULTS

Good self-rated health prevalence was of 72.2%. Being male (B: -0.165; CI: -0.250 to -0.081), age (B: -0.040; CI: -0.073 to -0.007), weekly duration of moderate to vigorous physical activity (B: 0.074; CI: 0.048-0.099), body mass index (B: -0.025; CI: -0.036 to -0.015), number of family healthcare teams in the neighbourhood (B: 0.019; CI: 0.006-0.033) and dengue incidence (B: -0.001; CI: -0.002; -0.000) were factors associated with self-rated health among students from vulnerable areas.

CONCLUSIONS/PRACTICAL IMPLICATIONS

Approximately three in every 10 adolescents in areas of social vulnerability presented poor self-rated health. This fact was associated with biological sex and age (individual factors), physical activity levels and BMI (lifestyle) and the number of family healthcare teams in the neighbourhood (contextual).

Occupational Difference in Oral Health Status and Behaviors in Japanese Workers: A Literature Review

The occupational environment is an important factor for oral health because people spend a long time in the workplace throughout their lives and are affected by work-related stress and occupational health policies. This study aimed to review evidence for the association between occupation and oral health status and behaviors. A literature search of PubMed was conducted from February to May 2022, as well as a manual search analyzing the article origins. Articles were screened and considered eligible if they met the following criteria: (1) published in English; (2) epidemiological studies on humans; and (3) examined the association between occupation and oral health status and behaviors. All 23 articles identified met the eligibility criteria. After full-text assessments, ten articles from Japan were included in this review: four on the association between occupation and dental caries, three on occupation and periodontal disease, two on occupation and tooth loss, and one on occupation and oral health behaviors. An association was apparent between occupation, oral health status and behaviors among Japanese workers. In particular, skilled workers, salespersons, and drivers who work longer hours and often on nightshifts, tended to have poor oral health.

Inclusion of oral health teams in primary health care promotes early diagnosis of oral and oropharyngeal cancers: a nationwide study

Background

Oral and oropharyngeal cancers are considered important public health problems worldwide. This study aims to analyze the association between late diagnosis of oral and oropharyngeal cancers in Brazil and the contextual indicators of socioeconomic variables and coverage of Primary Health Care (PHC), and to assess the temporal trend of late diagnosis.

Methods

In this cross-sectional observational study, secondary data were evaluated with a time series analysis. All Brazilian cities that reported at least one case of oral and oropharyngeal cancers each year in the period between 2000 and 2013 were included; and the staging was analyzed by calculating the ratio risk for late diagnosis for each municipality. The association between staging and socioeconomic variables and offer of PHC was calculated using multiple linear regression. The time trend of the risk ratio for late-stage diagnosis was calculated using the Prais–Winsten method.

Results

One hundred and sixty Brazilian municipalities had at least one annual case of oral and oropharyngeal cancers notified to the INCA hospital system between 2000 and 2013. The adjusted model showed that the higher the Gini value (greater social inequality) and the lower the HDI value (less human development) was, the higher was the number of tumors diagnosed at a late stage, considering the size of the tumor. A greater risk for late diagnosis was identified, as early as at the stage of lymph node involvement, when there was a higher level of social inequality and lower level of coverage by Oral Health Teams (OHT) in PHC. The greater the social inequality, the greater was the risk of late diagnosis, as early as in the stage of metastasis.

Conclusions

We concluded that, during the evaluated period, there was an increase in the number of cases diagnosed at the most advanced stage. Furthermore, there was association between higher levels of social inequality and an increase in the proportion of late diagnosis of oral and oropharyngeal cancers. In addition, the inclusion of Oral Health Teams in Primary Health Care promoted the early diagnosis of these types of cancers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-021-01664-3.

Estudo comparativo entre indicadores assistenciais de saúde bucal na Atenção Básica em Recife, Pernambuco

RESUMO A rede de atenção à Saúde Bucal (SB) se ampliou com a Política Nacional de Saúde Bucal, sendo os indicadores ferramentas para avaliar conquistas ou necessidade de mudanças. Este trabalho objetivou analisar indicadores de SB da Atenção Básica por tipo de organização das unidades de saúde em Recife, 2018. Trata-se de um estudo transversal, de natureza descritiva e analítica com base em dados secundários. Analisou-se a associação entre tipos de organização da Atenção Básica (Unidade de Saúde da Família - USF; Upinha e Unidade Básica Tradicional - UBT) e indicadores assistenciais de SB, através dos testes qui-quadrado e Kruskal-Wallis (p<0,05). A cobertura de primeira consulta odontológica e os procedimentos odontológicos per capita apresentaram mediana maior nas UBT, 31,8% (p=0,00) e 0,6 (p=0,127), respectivamente. A proporção de exodontia e procedimentos clínicos foi maior nas USF com mediana 8,2% (p=0,703). As USF foram as que realizaram o maior número de atividades coletivas de escovação dental supervisionada (45,3%, p=0,082) e aplicação de flúor (44,6%, p=0,174). Conclui-se que as UBT apresentaram melhores resultados nos indicadores relacionados ao acesso ao tratamento clínico e as USF realizaram mais ações coletivas de prevenção.

Monitoring of oral health teams after National Primary Care Policy 2017

OBJECTIVE

To monitor the number of oral health teams implemented in the Family Health Strategy after National Primary Care Policy 2017.

METHODS

This is a study of quantitative, descriptive and analytical nature that used the data from the public reports of the history of oral health coverage available in the e-Manager platform of Primary Care of the Ministry of Health of all Brazilian municipalities (5,570). The survival rate of the municipalities that did not reduce the number of oral health teams was analyzed according to the region of the country, human development index, Gini inequality index and population size. Cox regression was used to analyze the factors associated with the decrease in the number of teams implanted after 1, 3, 6, 9, 12, 15, 18 and 21 months of publication of the 2017 national policy ordinance, considering the hazard ratio (HR) and p < 0.05.

RESULTS

After 21 months of publication of the policy, 6.7% of Brazilian municipalities reduced the number of oral health teams. This reduction was higher in the South (6.7%) and Northeast (4.8%), in municipalities with the highest human development index, i.e., greater than or equal to 0.7 (5.6%), more unequal in terms of income distribution (Gini index > 0.62) and larger population size (more than 100,000 inhabitants). Municipalities in the Northeast (HR = 1.220) and South (HR = 1.771) regions had a higher chance of reducing the number of teams compared with those in the North region. More unequal municipalities (HR = 6.405) and with larger population size (HR = 4.273) were also more likely to reduce the coverage of oral health teams.

CONCLUSION

The municipalities that reduced the number of oral health teams in the Family Health Strategy are from the South and Northeast regions, with greater social inequality and larger population size. This scenario can significantly affect the population's access to dental health services in the Unified Health System, especially among those in need.

Education and income-based inequality in tooth loss among Brazilian adults: does the place you live make a difference?

BACKGROUND

Socioeconomic inequalities in tooth loss might be minimized or potentialized by the characteristics of the context where people live. We examined whether there is contextual variation in socioeconomic inequalities in tooth loss across Brazilian municipalities.

METHODS

Data from the 2010 National Oral Health Survey of 9633 adults living in 157 Brazilian municipalities were used. The individual socioeconomic indicators were education and household income. At the municipal level, we used the Municipal Human Development Index (HDI) as our contextual indicator of socioeconomic status (low:< 0.699 versus high: > 0.70). The Relative (RII) and Slope (SII) Indexes of Inequality, Relative (RCI), and Absolute (ACI) Concentration Indexes were calculated to compare the magnitude of education and income-based inequalities among municipalities with low versus high HDI. Multilevel Poisson regression models with random intercepts and slopes were developed.

RESULTS

At the individual level, adults with lower education & income reported more tooth loss. The mean number of missing teeth was 9.52 (95% CI: 7.93-11.13) and 6.95 (95% CI: 6.43-7.49) in municipalities with low and high HDI, respectively. Municipalities with high HDI showed higher relative and absolute education-based inequality. For income-based inequalities, higher SII and RCI was observed in municipalities with lower HDI. A significant cross-level interaction indicated that high-education adults reported fewer missing teeth when they lived in municipalities with high HDI compared to adults with the same education level living in low HDI municipalities. For individuals with the lowest education level, there was no difference in the number of teeth between those from municipalities with high and low HDI.

CONCLUSIONS

There was a social gradient in tooth loss by education and income. Living in disadvantaged municipalities cannot overcome the risk associated with low schooling. The protective effect of higher education can be reduced when people live in disadvantaged areas.

[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.

[Dialogues on the work process in oral health in Brazil: an analysis based on the PMAQ-AB survey]

The study aimed to: (1) describe the work process in Brazil's oral health teams, based on the essential attributes of primary health care, according to geographic region, type of team, and the municipality's socioeconomic characteristics and (2) verify whether the data in the work process of the oral health teams in the Brazilian National Program to Improve Access and Quality in primary health (PMAQ-AB) were capable of measuring such attributes. This was a nationwide ecological study with data from cycle I of PMAQ-AB. The study included descriptive, exploratory factor, and confirmatory factor analyses (α = 5%). Constructs were analyzed in light of the essential attributes of primary health care (first contact, coordination of care, comprehensiveness, and continuity). The first three constructs and a fourth factor were formed, called dental prosthesis actions. However, the continuity attribute was not formed. The models' goodness-of-fit measures were satisfactory. Factor loads were greater than 0.5, except for the two variables in factor 3. The actions most frequently performed by the oral health teams (> 60%) were in first contact, and the least frequent were those in comprehensiveness, highlighting referrals to specialties (7.6%). There were differences in the work process in oral health teams between regions of the country, type of team, and certification strata (p < 0.05). In conclusion, data on the work process in oral health teams from cycle primary health care in the services' work routine. Further research is recommended on continuity of care. In addition, the oral health teams participating in cycle I of PMAQ-AB should make further progress in actions related to comprehensiveness and coordination of care.

Processo de trabalho em saúde bucal na atenção básica: desigualdades intermunicipais evidenciadas pelo PMAQ-AB

RESUMO O objetivo deste estudo exploratório foi identificar desigualdades na organização do processo de trabalho das Equipes de Saúde Bucal (ESB) na Estratégia Saúde da Família, comparando municípios do Estado do Paraná quanto à condição social, econômica e demográfica. Foram utilizados dados secundários obtidos na etapa de avaliação externa do Programa de Nacional do Acesso e da Qualidade da Atenção Básica (PMAQ-AB), referentes aos padrões de certificação de acesso, qualidade e organização do processo de trabalho das equipes. Os municípios foram estratificados segundo o índice proposto pelo programa. Houve ampla participação dos municípios no PMAQ-AB, com predominância de equipes de saúde da família com saúde bucal. Os resultados demonstram desigualdades desfavoráveis aos municípios menores e mais carentes, o que revela a necessidade de compreender o papel da gestão como apoiadora das ESB, favorecendo o resgate de competências e habilidades necessárias para a boa gestão da clínica e do cuidado na Atenção Primária à Saúde. Evidencia-se a necessidade da qualificação da gestão, com apoio federal e estadual, principalmente aos municípios menores e com baixa capacidade de resposta dos sistemas de saúde. É importante que a regionalização seja efetiva, e que a rede de atenção à saúde bucal seja organizada de forma equânime, para incluir esses municípios.

Oral health policy in Brazil between 2003 and 2014: scenarios, proposals, actions, and outcomes

This study examined the implementation of Brazil's National Oral Health Policy by the three governments during the period 2003 to 2014. It provides a general overview of oral health care scenarios and examines institutional proposals and actions developed by the executive branch based on the components of the health care system. A documental analysis was conducted using documents produced by key government agencies. The findings show that there was an increase in the provision and coverage of public dental services between 2003 and 2006 and that rates were maintained to a certain degree in subsequent periods (2007 to 2010 and 2011 to 2014). There was an expansion in government funding, human resources and infrastructure. The amount of funds transferred to state and local governments increased from 83.4 million in 2003 to 916 million in 2014, equivalent to a 10.9 fold increase. However, the use of public dental services remained stable, with only a slight increase from 29.7% in 2003 to 30.7% in 2008, while private service utilization increased from 64.4% in 2003 to 74.3% in 2013. The care model component was given lowest priority by the three governments. This shortcoming influences policy effectiveness and requires the adoption of future measures by healthcare managers and officials to correct the situation.

Primary Care Dentistry in Brazil: From Prevention to Comprehensive Care

This cross-sectional study aimed to evaluate the association between sociodemographic characteristics, health care indicators, work process characteristics, and the performance of preventive dental procedures by oral health care teams (OHCTs) assessed during the first phase of the PMAQ in Brazil. A census of 10 334 primary OHCTs was conducted. The outcome included topical application of fluoride, application of sealants, detection of oral lesions, and monitoring of suspected or confirmed cases of oral cancer. The multilevel Poisson regression model was used to obtain crude and adjusted prevalence ratios. The performance of preventive dental procedures was 29.46% (3044/10 334; 95% confidence interval, 28.57-30.33), which was considered low.

Oral Health in the Family Health Strategy: analysis of articles published in the period 2004-2014

Abstract This study aimed to conduct an integrative review of scientific literature on the topic of Oral Health in the Family Health Strategy in the period 2004-2014. Articles published in national and international journals (n = 141) were consulted and selected from the electronic Library the Scientific Electronic Library Online (SciELO) and from electronic databases PubMed, Lilacs, BBO and Cochrane. The implementation process of oral health teams in the Family Health Strategy was the most frequent thematic variable (18%) of the 15 variables identified. The Northeast was the Brazilian macro-region where the largest number of published articles originated (n = 61). The studies were predominantly quantitative, and the highest number of publications occurred in 2010 (n = 26). We concluded that there is an increasing interest in investigating the context of oral health implementation in the Family Health Strategy, with particular emphasis on theme categories related to the micro-process work and the redefinition of professional identities arising from multidisciplinary work in primary care.

Indicators for teenager's oral health's surveillance

The existence of a few indicators that could guide the evaluation of oral health surveillance in the primary health care attention, mainly in adolescence life cycle, raised the realization of this study. To develop indicators to this end, it was conducted: document analysis to guide the development of a logic model and selection of data to compose indicators. This selection and validation of the logic model were performed by a group of four experts that, from the perspective of the modified Delphi method, analyzed if the model illustrated the activities, results and expected impact of a primary oral health service to enable the adolescents oral health surveillance and assigned points (0-10) to each data proposed. Then, those data judged important by the consensus of experts (média≥7; standard deviation <3) were used to construct indicators. After individual analysis and group discussions, the logical model and 36 of the 48 data, initially proposed, were consensually important, resulting in 26 indicators. The indicators matrix intends to be a situational diagnostic tool to assess, plan and manage health actions to adolescents, but it can be used in other life cycles by its adaptation.

WITHDRAWN: Community-based population-level interventions for promoting child oral health

BACKGROUND

Dental caries and gingival and periodontal disease are commonly occurring, preventable chronic conditions. Even though much is known about how to treat oral disease, currently we do not know which community-based population-level interventions are most effective and equitable in preventing poor oral health.

OBJECTIVES

Primary • To determine the effectiveness of community-based population-level oral health promotion interventions in preventing dental caries and gingival and periodontal disease among children from birth to 18 years of age. Secondary • To determine the most effective types of interventions (environmental, social, community and multi-component) and guiding theoretical frameworks.• To identify interventions that reduce inequality in oral health outcomes.• To examine the influence of context in the design, delivery and outcomes of interventions.

SEARCH METHODS

We searched the following databases from January 1996 to April 2014: MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Education Resource Information Center (ERIC), BIOSIS Previews, Web of Science, the Database of Abstracts of Reviews of Effects (DARE), ScienceDirect, Sociological Abstracts, Social Science Citation Index, PsycINFO, SCOPUS, ProQuest Dissertations & Theses and Conference Proceedings Citation Index - Science.

SELECTION CRITERIA

Included studies were individual- and cluster-randomised controlled trials (RCTs), controlled before-and-after studies and quasi-experimental and interrupted time series. To be included, interventions had to target the primary outcomes: dental caries (measured as decayed, missing and filled deciduous teeth/surfaces, dmft/s; Decayed, Missing and Filled permanent teeth/surfaces, DMFT/S) and gingival or periodontal disease among children from birth to 18 years of age. Studies had to report on one or more of the primary outcomes at baseline and post intervention, or had to provide change scores for both intervention and control groups. Interventions were excluded if they were solely of a chemical nature (e.g. chlorhexidine, fluoride varnish), were delivered primarily in a dental clinical setting or comprised solely fluoridation.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed screening, data extraction and assessment of risk of bias of included studies (a team of six review authors - four review authors and two research assistants - assessed all studies). We calculated mean differences with 95% confidence intervals for continuous data. When data permitted, we undertook meta-analysis of primary outcome measures using a fixed-effect model to summarise results across studies. We used the I2 statistic as a measure of statistical heterogeneity.

MAIN RESULTS

This review includes findings from 38 studies (total n = 119,789 children, including one national study of 99,071 children, which contributed 80% of total participants) on community-based oral health promotion interventions delivered in a variety of settings and incorporating a range of health promotion strategies (e.g. policy, educational activities, professional oral health care, supervised toothbrushing programmes, motivational interviewing). We categorised interventions as dietary interventions (n = 3), oral health education (OHE) alone (n = 17), OHE in combination with supervised toothbrushing with fluoridated toothpaste (n = 8) and OHE in combination with a variety of other interventions (including professional preventive oral health care, n = 10). Interventions generally were implemented for less than one year (n = 26), and only 11 studies were RCTs. We graded the evidence as having moderate to very low quality.We conducted meta-analyses examining impact on dental caries of each intervention type, although not all studies provided sufficient data to allow pooling of effects across similar interventions. Meta-analyses of the effects of OHE alone on caries may show little or no effect on DMFT (two studies, mean difference (MD) 0.12, 95% confidence interval (CI) -0.11 to 0.36, low-quality evidence), dmft (three studies, MD -0.3, 95% CI -1.11 to 0.52, low-quality evidence) and DMFS (one study, MD -0.01, 95% CI -0.24 to 0.22, very low-quality evidence). Analysis of studies testing OHE in combination with supervised toothbrushing with fluoridated toothpaste may show a beneficial effect on dmfs (three studies, MD -1.59, 95% CI -2.67 to -0.52, low-quality evidence) and dmft (two studies, MD -0.97, 95% CI -1.06 to -0.89, low-quality evidence) but may show little effect on DMFS (two studies, MD -0.02, 95% CI -0.13 to 0.10, low-quality evidence) and DMFT (three studies, MD -0.02, 95% CI -0.11 to 0.07, moderate-quality evidence). Meta-analyses of two studies of OHE in an educational setting combined with professional preventive oral care in a dental clinic setting probably show a very small effect on DMFT (-0.09 weighted mean difference (WMD), 95% CI -0.1 to -0.08, moderate-quality evidence). Data were inadequate for meta-analyses on gingival health, although positive impact was reported.

AUTHORS' CONCLUSIONS

This review provides evidence of low certainty suggesting that community-based oral health promotion interventions that combine oral health education with supervised toothbrushing or professional preventive oral care can reduce dental caries in children. Other interventions, such as those that aim to promote access to fluoride, improve children's diets or provide oral health education alone, show only limited impact. We found no clear indication of when is the most effective time to intervene during childhood. Cost-effectiveness, long-term sustainability and equity of impacts and adverse outcomes were not widely reported by study authors, limiting our ability to make inferences on these aspects. More rigorous measurement and reporting of study results would improve the quality of the evidence.

Community-based population-level interventions for promoting child oral health

BACKGROUND

Dental caries and gingival and periodontal disease are commonly occurring, preventable chronic conditions. Even though much is known about how to treat oral disease, currently we do not know which community-based population-level interventions are most effective and equitable in preventing poor oral health.

OBJECTIVES

Primary • To determine the effectiveness of community-based population-level oral health promotion interventions in preventing dental caries and gingival and periodontal disease among children from birth to 18 years of age. Secondary • To determine the most effective types of interventions (environmental, social, community and multi-component) and guiding theoretical frameworks.• To identify interventions that reduce inequality in oral health outcomes.• To examine the influence of context in the design, delivery and outcomes of interventions.

SEARCH METHODS

We searched the following databases from January 1996 to April 2014: MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Education Resource Information Center (ERIC), BIOSIS Previews, Web of Science, the Database of Abstracts of Reviews of Effects (DARE), ScienceDirect, Sociological Abstracts, Social Science Citation Index, PsycINFO, SCOPUS, ProQuest Dissertations & Theses and Conference Proceedings Citation Index - Science.

SELECTION CRITERIA

Included studies were individual- and cluster-randomised controlled trials (RCTs), controlled before-and-after studies and quasi-experimental and interrupted time series. To be included, interventions had to target the primary outcomes: dental caries (measured as decayed, missing and filled deciduous teeth/surfaces, dmft/s; Decayed, Missing and Filled permanent teeth/surfaces, DMFT/S) and gingival or periodontal disease among children from birth to 18 years of age. Studies had to report on one or more of the primary outcomes at baseline and post intervention, or had to provide change scores for both intervention and control groups. Interventions were excluded if they were solely of a chemical nature (e.g. chlorhexidine, fluoride varnish), were delivered primarily in a dental clinical setting or comprised solely fluoridation.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed screening, data extraction and assessment of risk of bias of included studies (a team of six review authors - four review authors and two research assistants - assessed all studies). We calculated mean differences with 95% confidence intervals for continuous data. When data permitted, we undertook meta-analysis of primary outcome measures using a fixed-effect model to summarise results across studies. We used the I2 statistic as a measure of statistical heterogeneity.

MAIN RESULTS

This review includes findings from 38 studies (total n = 119,789 children, including one national study of 99,071 children, which contributed 80% of total participants) on community-based oral health promotion interventions delivered in a variety of settings and incorporating a range of health promotion strategies (e.g. policy, educational activities, professional oral health care, supervised toothbrushing programmes, motivational interviewing). We categorised interventions as dietary interventions (n = 3), oral health education (OHE) alone (n = 17), OHE in combination with supervised toothbrushing with fluoridated toothpaste (n = 8) and OHE in combination with a variety of other interventions (including professional preventive oral health care, n = 10). Interventions generally were implemented for less than one year (n = 26), and only 11 studies were RCTs. We graded the evidence as having moderate to very low quality.We conducted meta-analyses examining impact on dental caries of each intervention type, although not all studies provided sufficient data to allow pooling of effects across similar interventions. Meta-analyses of the effects of OHE alone on caries may show little or no effect on DMFT (two studies, mean difference (MD) 0.12, 95% confidence interval (CI) -0.11 to 0.36, low-quality evidence), dmft (three studies, MD -0.3, 95% CI -1.11 to 0.52, low-quality evidence) and DMFS (one study, MD -0.01, 95% CI -0.24 to 0.22, very low-quality evidence). Analysis of studies testing OHE in combination with supervised toothbrushing with fluoridated toothpaste may show a beneficial effect on dmfs (three studies, MD -1.59, 95% CI -2.67 to -0.52, low-quality evidence) and dmft (two studies, MD -0.97, 95% CI -1.06 to -0.89, low-quality evidence) but may show little effect on DMFS (two studies, MD -0.02, 95% CI -0.13 to 0.10, low-quality evidence) and DMFT (three studies, MD -0.02, 95% CI -0.11 to 0.07, moderate-quality evidence). Meta-analyses of two studies of OHE in an educational setting combined with professional preventive oral care in a dental clinic setting probably show a very small effect on DMFT (-0.09 weighted mean difference (WMD), 95% CI -0.1 to -0.08, moderate-quality evidence). Data were inadequate for meta-analyses on gingival health, although positive impact was reported.

AUTHORS' CONCLUSIONS

This review provides evidence of low certainty suggesting that community-based oral health promotion interventions that combine oral health education with supervised toothbrushing or professional preventive oral care can reduce dental caries in children. Other interventions, such as those that aim to promote access to fluoride, improve children's diets or provide oral health education alone, show only limited impact. We found no clear indication of when is the most effective time to intervene during childhood. Cost-effectiveness, long-term sustainability and equity of impacts and adverse outcomes were not widely reported by study authors, limiting our ability to make inferences on these aspects. More rigorous measurement and reporting of study results would improve the quality of the evidence.

[Time standards of nursing in Primary Health Care: an observational study]

OBJECTIVE

To determine time standards for interventions and activities conducted by nursing professionals in Family Health Units (FHU) in Brazil to substantiate the calculation of work force.

METHOD

This was an observational study carried out in 27 FHU, in 12 municipalities in 10 states, in 2013. In each unit, nursing professionals were observed every 10 minutes, for eight work hours, on five consecutive days via the work sampling technique.

RESULTS

A total of 32,613 observations were made, involving 47 nurses and 93 nursing technicians/assistants. Appointments were the main intervention carried out by nurses, with a mean time of 25.3 minutes, followed by record-keeping, which corresponded to 9.7%. On average, nursing technicians/assistants spent 6.3% of their time keeping records and 30.6 intervention minutes on immunization/vaccination control.

CONCLUSION

The study resulted in standard times of interventions carried out by the FHU nursing team, which can underpin the determination of nursing staff size and human resource policies. Furthermore, the study showed the panorama of interventions currently employed, allowing for the work process to be reviewed and optimized.

Estudo comparativo de indicadores de saúde bucal em município do estado de São Paulo

Comparar indicadores de saúde bucal (Rendimento, Atrição, Ênfase em Prevenção Modificado, Relação Restauração/Extração) e Relação 1ª Consulta/Urgência entre 15 Unidades de Saúde da Família e 11 Unidades Básicas de Saúde de município do interior paulista, de 2008 a 2011. Os dados foram coletados a partir do Sistema de Informações Ambulatoriais do SUS (SIA-SUS) e comparados os modelos de atenção por meio de série histórica, teste não paramétrico (Mann-Whitney) e estatística descritiva. Embora haja o processo de fortalecimento da Estratégia Saúde da Família o modelo assistencial representado pelas Unidades Básica de Saúde se mostra mais efetivo em alguns aspectos da saúde bucal no serviço público.

Associação entre a cobertura de equipes de saúde bucal na saúde da família e o aumento na produção ambulatorial dos municípios brasileiros, 1999 e 2011

Resumo Analisar a associação entre a cobertura populacional de equipes de saúde bucal da Estratégia Saúde da Família (ESF) e a diferença nas taxas de uso de serviços odontológicos públicos nos municípios brasileiros em 1999 e 2011. A amostra contou com 5.507 municípios nos 2 anos. Foram utilizados dados de sistemas de informação oficiais e se procedeu à regressão logística para modelar o incremento nas taxas de procedimentos. Observou-se que 85% dos municípios possuíam equipes de saúde bucal da ESF em 2011 e houve aumentos nas taxas de recursos físicos, humanos e financeiros. A produção odontológica aumentou 49,5% no período. Os municípios que incorporaram mais que 3 equipes de saúde bucal/10 mil habitantes tiveram mais chances de aumentar as taxas de procedimentos coletivos (OR = 1,61; IC95%: 1,23-2,11), preventivos (OR = 2,05; IC95%: 1,56-2,69), restaurações (OR = 2,07; IC95%: 1,58-2,71) e extrações (OR = 1,53; IC95%: 1,19-1,97), após controle por fatores sociodemográficos e relacionados à variação de recursos físicos, humanos e financeiros. A incorporação de equipes de saúde bucal à ESF parece mais efetiva para o aumento de indicadores de uso de serviços odontológicos.

Dental caries in 12-year-old schoolchildren: multilevel analysis of individual and school environment factors in Goiânia

The aim of this study was to investigate the association between dental caries index among 12-year-old schoolchildren and individual and contextual factors related to the schools in the city of Goiânia, Goiás, Brazil. A cross-sectional study was carried out with 2,075 schoolchildren using the 2010 National Survey of Oral Health methodology. The dependent variable was the decayed, missing, and filled teeth (DMFT) index and the independent variables were individual (sex, race, and maternal education) and contextual ones (type of school, health district, and the presence of oral programs). Multilevel analysis and log-linear negative binominal regression were performed, considering the complex sampling design. Mean DMFT index was 1.51. Female students, whose mothers had lower schooling, those attending public schools, located in districts with the worst socioeconomic indicators, and covered by the Family Health Strategy had higher caries levels. The dental caries index was low and associated with the schoolchildren sociodemographic characteristics and factors related to the schools, showing inequalities in distribution.

[Building a "Smiling Brazil"? Implementation of the Brazilian National Oral Health Policy in a health region in the State of São Paulo]

This paper is a case study on the implementation of the Brazilian National Oral Health Policy (PNSB), known as "Smiling Brazil", in the cities of the Regional Health Department of Araraquara (DRS III) in São Paulo State. A structured questionnaire was given to the municipal oral health coordinators, an interview with oral health care professionals and managers was conducted, and the official data provided by the Brazilian Ministry of Health were coded to assess the policy's scope: (i) expansion and qualification of actions; (ii) work conditions; (iii) care; (iv) access; and (v) planning and management. The quantitative and qualitative analyses were linked by methods triangulation. In terms of PNSB implementation, the majority of the cities (52.6%) were classified as "good", with 42.1% classified as "bad". Approximately 10 years after launching the PNSB, despite strides in oral health care and access to different levels of care, the cities still experience difficulties in implementing the policy's principles.

Visita domiciliar e cuidado domiciliar na Atenção Básica: um olhar sobre a saúde bucal

O objetivo do presente trabalho foi analisar o processo de atenção domiciliar nas Equipes de Atenção Básica que aderiram ao Programa Nacional de Melhoria do Acesso e da Qualidade. Realizou-se um estudo a partir do banco de dados do programa relativos à dimensão que avaliou a realização de visita domiciliar e cuidado domiciliar, com ênfase nas práticas das Equipes de Saúde Bucal. Quase 100% das Equipes de Saúde da Família avaliadas realizam visita domiciliar. O cuidado no domicílio é realizado por mais de 90% dos profissionais da equipe mínima, e por aproximadamente 50% dos profissionais da saúde bucal. A saúde bucal tem desafios a superar em direção a novas práticas na Atenção Básica.

O trabalho do Cirurgião-Dentista na Atenção Primária à Saúde: entre o prescrito e o real

No cenário mundial, o Cirurgião-Dentista atua, sobretudo, no setor privado. No Brasil, esta realidade começa a mudar com a inclusão desse profissional na Estratégia Saúde da Família (ESF). Este estudo de caso realizado no Centro-Oeste do Brasil busca compreender o trabalho do dentista nesse contexto, através de análise documental, observação do trabalho e entrevistas. Da análise temática de conteúdo emergiram duas categorias: condições para o trabalho na ESF e modo de trabalho na ESF. A influência histórica do modelo de atenção individual, o contexto adverso do trabalho, as concepções de ESF dos profissionais e a autonomia que lhes é conferida restringem sua atuação.

Oral health care after the National Policy on Oral Health - "Smiling Brazil": a case study

In 2004, the National Oral Health Policy (PNSB) - Smiling Brazil was launched. Its guidelines seek to qualify Primary Health Care, ensure comprehensive actions, work on the basis of health surveillance, plan actions in accordance with the epidemiology and information available on the territory, financing and scheduling the research agenda so that the work can be based on scientific evidence. The purpose of this case study was to investigate the perspectives of health care professionals and managers on oral health care after launching the PNSB. For the gathering of information, an oral interview was conducted with health care professionals and managers and direct observation of oral health services. The interpretation of meaning method was used for analysis of the interviews. Approximately 10 years after launching the PNSB, even though the care and the oral health actions have been amplified and qualified, the cities still find it difficult to implement their basic premises.

Padrões de utilização de atendimento médico-ambulatorial no Brasil entre usuários do Sistema Único de Saúde, da saúde suplementar e de serviços privados

Indicadores de oferta, acesso e utilização são úteis para caracterizar os serviços, planejar ações e organizar a demanda. Este estudo descreve padrões de utilização de atendimento médico-ambulatorial e associação com variáveis sociodemográficas, de morbidade, porte do município e região, de acordo com a natureza jurídica do serviço. Trata-se de um estudo transversal de base populacional com 12.402 adultos brasileiros entre 20 e 59 anos, residentes nas áreas urbanas de 100 municípios nas cinco regiões brasileiras. A prevalência de atendimento médico-ambulatorial nos três meses anteriores à entrevista foi de 34,6%. O Sistema Único de Saúde foi responsável por mais da metade (53,6%) dos atendimentos, algum convênio de saúde foi utilizado por 34% da amostra e os serviços privados por 12,4%, independentemente da região, do porte populacional e da morbidade referida. Os padrões de utilização de serviços de saúde continuam socialmente determinados, resultando da oferta, das características sociodemográficas e do perfil de saúde dos usuários.

Evolution of post-deployment indicators of oral health on the Family Health Strategy

Objective

To evaluate the evolution of indicators after the implementation of 21 Oral Healthcare Teams in the Family Health Strategy.

Methods

We used data from outpatient services of Oral Healthcare Teams to evaluate efficiency, access, percentage of absences and emergencies of oral healthcare professionals who worked in the partnership between the Sociedade Beneficente Israelita Brasileira Hospital Albert Einstein and the Secretaria Municipal de Saúde de São Paulo, during the period 2009-2011.

Results

Percentages of emergencies, income, and access showed a significant difference during the period analyzed, but no difference for percentage of absences was found. When monthly analysis was made, it is noteworthy that at the beginning of service implementation a fluctuation occurred, which may indicate that the work was consolidated over the months, becoming capable of receiving new professionals and increasing the population served. Comparison of the indicators in that period with the goals agreed upon between the Sociedade Beneficente Israelita Brasileira Hospital Albert Einstein and the Secretaria Municipal de Saúde de São Paulo made it possible to notice that the Oral Health Teams had a good performance.

Conclusion

The results showed that the goals were achieved reflecting the increasing number of professionals, the maturing of work processes in the Oral Health Teams, and optimization of the manpower available to perform the activities. Understanding these results will be important to guide the actions of Oral Health Teams for the following years and to assess the achievement of goals.

Determinantes da utilização de serviços odontológicos entre adultos: um estudo de base populacional em Florianópolis, Santa Catarina, Brasil

Objetivou-se estimar a prevalência da utilização dos serviços odontológicos entre adultos e os fatores associados. Realizou-se um estudo transversal, de base populacional, com 1.720 adultos de Florianópolis, Santa Catarina, Brasil, em 2009. A associação entre a utilização de serviços odontológicos e fatores predisponentes, facilitadores e de necessidade, em nível individual, foi testada. A análise multivariável deu-se por meio de regressão de Poisson e estratificou-se por local da última consulta. A prevalência do uso de serviços odontológicos foi de 66% (IC95%: 62,9-70,7). A prevalência de consulta odontológica foi 20% maior entre as mulheres e 72% entre os mais escolarizados; estes, também foram a maioria nos serviços público e privado. A proporção de pessoas que tinham plano de saúde e utilizaram o serviço foi 13% maior do que as que não tinham. Em Florianópolis, o uso de serviços odontológicos é essencialmente privado e a escolaridade é a variável mais importante. Sugere-se um monitoramento dos fatores associados para que se obtenha uma utilização equitativa dos serviços.

Dental auxiliaries versus community health workers: similarities and contrasts

INTRODUCTION: The dental auxiliaries and the community health workers (CHWs) are practitioners that represent an important part in the Family Health Policy in Brazil and have several tasks. OBJECTIVE: To analyze the attributes of the dental auxiliaries and of the CHWs, regarding the application of their services and their education/training, to identify the similarities and contrasts between these health care practitioners. METHODOLOGY: Quantitative and census method data collection performed on the context of the Education Program for Health Workers - PET‑Saúde, 2010‑2012. The data collection method was a semi-structured questionnaire. The analysis has a level of significance of p<0.05. RESULT: In this paper, 29 dental auxiliaries and 241 CHWs have participated in the surveys. The assignments that take place on the community context, such as home visits were more associated to the CHWs (p<0.05). On the other hand, the activities that happen on a clinical environment, such as providing assistance to graduated health professionals and performing clinical procedures, are more commonly performed by the dental assistant (p<0.05). Both categories presented similarities performing preventive health care, teamwork analysis, informative initiatives and community mobilization routines (p>0.05). CONCLUSION: Similarities and contrasts were identified between these health care workers. The dental auxiliaries, despite being mostly issued to specific assignments on a clinical environment, are able to shift their praxis by taking actions on a family and community context once integrated to a family health team.

[Characteristics of the access and utilization of public dental services in medium-sized cities]

This cross-sectional study sought to describe the main characteristics of access and utilization of primary and specialized public dental services in two medium-sized cities in Bahia with 100% coverage of the Family Health Program. A survey of 952 households and 2.539 individuals aged over 15 years was conducted. The main variables analyzed were: perceived oral health needs, demand for the service, barriers of organizational access and the type of service and procedure utilized. The use of specialized public dental services was of 11.7% and primary care was 26%. In the city where there was greater use of public dental services, there was less use of private services. The main barrier to access remained in primary care (from 5.0% to 15.2%). There was little interface between secondary care a primary care, as only 16.6% of users returned to this level of care. In conclusion, the main barrier to access in cities with specific organizational and geographic realities appears to be in primary dental care. Individual preventive actions were little reported. It is recommended that barriers to access in primary care be eliminated, and also that a protocol (clinical guides) be established to foster the continuity and longitudinality of primary dental care.