Abstract

Group Oral Health (GOH) is a specific phenomenon in time, separate from other “Alternative Odontology”, and a theoretical reference for dental practice in healthcare services. This study is an attempt to understand how long “Alternative Odontology” will remain with the social context of struggling for oral health in Brazil, based on the positions of the founding agents and their precursors, bearing in mind the concepts of GOH, GH (Group Health) and the SUS (Unified Healthcare System). We started out with Pierre Bourdieu’s Practice Theory, complemented with Gramsci’s concept of hegemony and counter-hegemony. We completed 12 in-depth interviews, reviewed the literature and analyzed the scientific output. We also looked at the trajectories of the agents and their capital between 1980 and 2013. The results show that the concept of GOC and GH as a breach with health practices, which gave rise to “Alternative Odontology”, prevailed among those with the political will to defend democracy and Healthcare Reforms. Although GOC is a critical proposal, the older “Odontology” remains in scientific journals, and in the practice of oral care.

Group oral health; The sociology of health; Oral health

Introduction

The expression Group Oral Health (GOH) emerged in Brazil in the late 1980s, and is used to describe a specific historical phenomenon, different from “Alternative Odontology”, such as: Sanitary Odontology, Preventive and Social Odontology (PSO), and Simplified Odontology, among others¹1. Narvai PC. Odontologia e saúde bucal coletiva. Rio de Janeiro: Hucitec; 1994.^,22. Narvai PC, Frazão P. Saúde bucal no Brasil: muito além do céu da boca. Rio de Janeiro: Fiocruz; 2008., and as a new name for these same movements³3. Pinto VG. Saúde bucal coletiva. 4. ed. São Paulo: Santos; 2000.. It has also become a reference for the practices underway in the nation’s public oral care serviceis⁴4. Figueiredo G. de O. Do fetichismo odontológico à utopia da saúde bucal [tese]. Rio de Janeiro: Universidade Federal do Rio de Janeiro; 2002.. It differs from any other type of “Odontology” as it proposes to address oral health from the point of view of the social determinants of health.

Although it proposes a specific social phenomenon, a review of the literature shows that most studies mentioning GOH are actually closer to PSO⁵5. Dias AA, Narvai PC, Rêgo DM. Tendências da produção científica em odontologia no Brasil. Rev Panam Salud Publica 2008; 24(1):54-60.. Furthermore, of the “Odontologies” mentioned, it has become the more important one in this country, at both the public and private level, as well as in the field of science and public policy, especially because of the activities of ABOPREV, the Brazilian Association for Oral Health Promotion.

These findings are reiterated in the work of Celeste and Warmeling⁶6. Celeste RK, Warmling CM. Produção bibliográfica brasileira de saúde coletiva em periódicos de saúde coletiva e de odontologia. Cien Saude Colet 2014; 19(6):1921-1932., which found an increase in GOH articles in dental journals, to a level similar to those on SPO. An analysis of oral health surveys at a dental congress, based on the abstracts published in the 27⁰ Annals of the SBPqO in 2010, shows that SPO is one of the more popular study subjects⁷7. Xavier AFC, Silva AMLO, Cavalcanti AL. Análise da produção científica em Odontologia no nordeste brasileiro com base em um congresso odontológico. Arq Cent Estud Curso Odontol 2011; 47(3):127-134.. Furthermore, reviews show that the older “Odontology” remain, under the GOH nomenclature⁵5. Dias AA, Narvai PC, Rêgo DM. Tendências da produção científica em odontologia no Brasil. Rev Panam Salud Publica 2008; 24(1):54-60.^,66. Celeste RK, Warmling CM. Produção bibliográfica brasileira de saúde coletiva em periódicos de saúde coletiva e de odontologia. Cien Saude Colet 2014; 19(6):1921-1932.^,88. Narvai PC. Saúde bucal coletiva: caminhos da odontologia sanitária à bucalidade. Rev Saude Publica 2006; 40(N Esp):141-147..

To support discussions of this issue, this article analyzed the concepts of GOH, Group Health (GH) and the SUS, based the precursors and founding agents of GOH and the dominant role of the scientific sub-space of GOH right now. We also analyzed scientific output on this theme, attempting to understand the permanence of older “Odontology” in the social space of the fight for oral health in Brazil.

Methodology

This article was taken from a Ph.D. dissertation that analyzed the creation of GOH in Brazil. We looked at GOH in the past 24 years (1990 - 2014), looking at the permanence of the older odontology streams in the social fight for oral health. As a reference, we used the theory behind the practices of Pierre Bourdieu⁹9. Bourdieu P. Razões práticas: sobre a teoria da ação. Campinas: Papirus; 1996. and its fundamental concepts, complemented with the concepts of hegemony and counter-hegemony of Gramsci¹⁰10. Gramsci A. Cadernos do Cárcere. Rio de Janeiro: Civilização Brasileira; 1978..

The struggle for Oral Health was analyzed as a network of relationships between inserted agents, and trajectories that cross the various social spaces. Thus, we considered the scientific field as a social space, where what is in dispute is scientific authority, corresponding to the “technical skill or social power expressed in the ability to legitimately speak and act with authority, with socially assigned authorization”¹¹11. Bourdieu P. O Campo científico. In: Ortiz R. Pierre Bourdieu - Sociologia. São Paulo: Ática; 1994.. This involves relationship of strength, strategies, interest and profit⁹9. Bourdieu P. Razões práticas: sobre a teoria da ação. Campinas: Papirus; 1996.^,1111. Bourdieu P. O Campo científico. In: Ortiz R. Pierre Bourdieu - Sociologia. São Paulo: Ática; 1994.. The bureaucratic field was taken as the space for formulating and implementing public policies, represented in this case by the oral health policy (OHP). This sub-space is represented by the State, which legitimately owns physical and symbolic violence in a given territory and within a given population⁹9. Bourdieu P. Razões práticas: sobre a teoria da ação. Campinas: Papirus; 1996.. The State accumulates different sources of capital, such as physical strength, economic capital, cultural capital, and symbolic capital, becoming a sort of meta-capital that allows it to intervene in the different sub-spaces¹²12. Bourdieu P. Sobre o Estado. São Paulo: Companhia das Letras; 2012.. The political sub-space is a microcosm of relatively independent relationships, with a minority that is involved in the field (professional politicians), and a mass of the “profane”, with no social legitimacy to adopt policies, and which tends to interiorize and naturalize its own impotence¹³13. Bourdieu P. O campo político. Rev Bras Ciênc Política 2011; 5:193-216..

In this paper we considered three types of capital: scientific capital, aimed at analyzing scientific output, studies and prestige in problem selection (scientific and political), and methods (scientific strategies) accumulated through measures relevant to the scientific field¹¹11. Bourdieu P. O Campo científico. In: Ortiz R. Pierre Bourdieu - Sociologia. São Paulo: Ática; 1994.; b) bureaucratic capital based on the position occupied with the management of healthcare institutions or universities⁹9. Bourdieu P. Razões práticas: sobre a teoria da ação. Campinas: Papirus; 1996.^,1111. Bourdieu P. O Campo científico. In: Ortiz R. Pierre Bourdieu - Sociologia. São Paulo: Ática; 1994.; c) political capital, accumulated and expressed in the power of mobilization contained in the specification and militancy, aiming to occupy positions at healthcare institutions or associations, or participate in the Brazilian Movement for Renewal in Odontology (Movimento Brasileiro de Renovação Odontológica – MBRO), political parties or the Brazilian Center for Healthcare Studies (Centro Brasileiro de Estudos em Saúde – CEBES)¹³13. Bourdieu P. O campo político. Rev Bras Ciênc Política 2011; 5:193-216.^,1414. Matonti F, Poupeau F. Le capital militant. Essai de définition. Actes Recherche Sci Soc 2004; 155:5-11. (Tables 1 and 2).

These capitals were measured based on an analysis of the lattes CVs of selected agents, which provided input for analyses of the social, professional and political path of the interviewees, of the positions held by agents in the socials space under analysis, and of the volume of capital.

We interviewed twelve dentists, agents who occupy the dominant position in OHP scientific output, and that were essential in creating GOH in Brazil. We also interviewed people who held prominent positions in the fight for Oral Care in Brazil in the 1980s. We later gathered the position of those who remained in this area since 2013. These same agents were asked about the concepts of GOH, GH and the SUS, and about the main problems GOH faces today. A comparison of the evidence enabled analyzing the correspondence between positions, dispositions and positions taken by the agents we looked at.

We also considered the concept of habitus as unconscious dispositions of the agents and their perception schemes, produced by the collective story and modified by each individual story¹⁵15. Bourdieu P. O Senso prático. São Paulo: Vozes; 2009.. In habitus we analyzed trajectories looking at participation in militant spaces, political parties, student associations and the MBRO, as well as the occupations of parents and grandparents. We also looked at illusio, viewed as recognition that the social game is worth playing⁹9. Bourdieu P. Razões práticas: sobre a teoria da ação. Campinas: Papirus; 1996.^,1515. Bourdieu P. O Senso prático. São Paulo: Vozes; 2009. within the fighting space of this study.

All interviewees signed an informed consent form, allowing publication of the data shared and their identifying information. The project was approved by the Research Ethics Committee of the Institute for Group Health, Universidade Federal da Bahia. The data was analyzed based on the concept of GOH within the social space, which could evidence a possible “genesis amnesia”⁹9. Bourdieu P. Razões práticas: sobre a teoria da ação. Campinas: Papirus; 1996., or a process of forgetting the origins, which in this case led to shutting off the space where one might have developed the desired counter-hegemony¹⁰10. Gramsci A. Cadernos do Cárcere. Rio de Janeiro: Civilização Brasileira; 1978.^,1616. Gramsci A. Maquiavel, a política e o Estado Moderno. 4ª ed. Rio de Janeiro: Civilização Brasileira; 1980. within the area of struggle, as per Gramsci.

Results and discussion

Precursors and Founders of Group Oral Health: contributions and field of battle

GOH emerged when a group of dentists included GOH and OHP practices in the São Paulo Institute of Health. Among them were Paulo Capel Narvai, Marco Manfredini, Paulo Frazão and Carlos Botazzo. The main contribution of these four scientists was to make the concept of GOH systematic, which they did in 1988. This was based on the experiences with “Alternative Odontology”, in particular Simplified Odontology and its critical version - Integrated Odontology, as guidance for dental practices in city oral healthcare services implemented by SUS. In the case of Paulo Capel Narvai in particular, his effort to summarize the issue in his Master’s dissertation opened up the scientific sub-space for this theoretical proposal, previously systematized by the four agents in the article entitled “Group Oral Health”, of limited circulation at the time. Furthermore, progress in implementing oral health as part of public healthcare, led by a number of city healthcare agents in São Paulo, Santos, Porto Alegre and Curitiba, in particular Marco Manfredini, Fernando Molinos Pires, Djalmo Sanzi Souza and Sylvio Gervaed, was key to develop the concept of GOH defended by this group (Figure 1).

Among the precursors, Volnei Garrafa and Jórge Córdon were responsible for introducing young dentists to the political sub-space of the BHR (Brazilian Health Reform) and SUS fight for oral health. Their articulations with the fights for democracy and the democratization process itself were elements that mobilized and brought people together, and fostered their involvement in organizing the MBRO, the creation and development of CEBES, and organizing the 1st National Oral Health Conference in Brazil.

In the 1980s, Vitor Gomes Pinto published the first work entitled “Saúde Bucal Coletiva” (Group Oral Health). However, this document was based on the same theories and epistemologies of the previous work entitled “Odontologia Preventiva e Social” (Preventive and Social Odontology), which, according to the author, was renamed at the request of the publisher, at the time claiming the specialty had changed names. This work was did not represent any type of rupture or breakthrough, nor did it help consolidate GOH.

In the political sub-space, the main contributor was Swedenberger Barbosa, known as Berger, who worked with the unions and especially the Inter-state Federation of Odonatologists, influencing several bureaucratic measures at the time the SUS was being created.

Furthermore, almost all the interviewees were involved, to some extent, in training dentists in the sub-space, with a critical and political view of the nation’s reality.

The group from Sao Paulo was responsible for most of the contributions that led to the emergence of the scientific sub-space of GOH. Most of these agents received their Ph.D.s in the late 90s, and their dissertations contributed to developing the sub-space.

Position, disposition and position taking: GOH, GH, SUS

Among the agents analyzed, the founders and precursors, and those occupying positions in the bureaucratic field and involved in implementing oral health within public oral care and the SUS, and those with the political will – militancy within MBO, involvement in National Meetings of Dental Service Technicians and Administrators, and militancy in political parties –, have points of view that are the same or very close. The view of GOH that prevails among them is a breach with the dental practices developed in the 1980s. This may mean hegemonic market practices, those emerging from PSO, simplified Odontology or Integrated Odontology. The central question that binds this group, self-entitled the “mouth guys”, is their commitment to society, social rights, universal and equal health, and a breach with what is institutionalized, building a political practice compatible with the transformation of society as a whole.

GOH is theoretical reflection that was processed in the 1980s, and is based on a critique of all previous currents [...]. There was the understanding that the practices of GOH, Simplified Odontology, Integrated Odontology [...] the possibility emerged of considering a reference for organizing dental practices. (E 10).

As rupture requires critical content for the practices in question, the fundamentals originated in the ideas of GH and BHR, and the practical experiences underway in the 1980s. Added to that, is the political practice to defend and understand society.

[...] It should be a priority concept for the political exercise of oral health. Involving the cause of oral diseases and the care of problems that may emerge as a result in a broader, universal and inclusive, rather than exclusive, manner. [...] for me, it must include the concept of politicizing dental practices, and not only serve the community, but serve the community with a truly transforming commitment (E5).

Another vision is the denial of the dialectic of the dental field, as it does not question the field of origin, with content that while dental, restricts GOH to the initiated, or those with degrees in Dentistry or Odontology.

GOH is not Odontology, [...] Odontology is not oral care, and we do not necessarily want an epistemological break with Odontology, which in some form remains the natural place from whence we all came, as we all have degrees in Odontology. [...] GOH is more a movement, one of the movements that we are all involved with in social construction, relating to what exists, but also creating new things, developing new relationships and new ways of insertion, inclusion, interpretation and understanding of society (E 11).

Those who helped design the OHP at some point in time, but were not involved in the political movements within the social space, view GOH as synonymous with Public Health, responsible for achieving the highest possible levels of oral health.

I even have trouble defining GH, you know? Why [...] what is GH, I have dedicated myself to doing things. Yes, I like the concept of PH (E 8).

The main goal of a dentist’s job is to provide better oral health to patients. For dentistry as a whole, this means achieving adequate levels of oral health among the population of a given nation, region or location (E2).

Another point of view shows GOH as an expansion of PSO, and yet another has GOH as addressing the collectivity in all areas of human life, both public and private. These views correspond to agents who were ABOPREV militants, under the influence of PSO and the ideas emerging from Scandinavian nations.

I am not a fan of the expression GOH. I believe oral health at any level, either sponsored by a consultant or within a group or the population, must be the best possible oral health [...]. Here in Brazil the vision that PH is GH, and individual health is something else. In Scandinavia, everything is PH. The National PH Program controls activity to the level of consultant; because this includes health, they also contribute to people’s health. In my view, there is no dichotomy in several “healths”. There is only health; how we will deliver it to the largest number of people within a country community is a challenge, but in my view, everything should be collective, everything should be public, even private offices should be part of the PH program (E 3).

Agents involved in the political processes in the fight for democracy within the BHR considered, given the various specificities, GOH as critical content, a breach with what existed, with traditional dental practices that involved private dentistry, PSO and integrated odontology. It is essentially the expression of thoughts about society and its relationship with the economic, political and social. On the other hand, agents not involved in these fights considered it as an extension of traditional PH and, in the case of dental care, as a discipline of PH, closer to the Sanitary Odontology of the 1950s.

Those defining explicit concepts of traditional PH had large amounts of bureaucratic capital, holding high positions in the management of national and international oral health, and career paths in the scientific field related to Sanitary Odontology. None of them participated in MBRO or CEBES, taking different positions than those who see GOH as a disruption.

Among the agents considering GOH as a disruption, there are varying levels of bureaucratic and scientific capital. Many hold management positions at the city or state level, and others have a range of scientific positions. Those who define GOH as collective health were members of ABOPREV, predominantly in the scientific field. Table 1 shows the unequal distribution of the various types of capital among those interviews, and their position regarding the meaning of GOH.

Regarding the concept of GH, it safeguards the same relationship of positions, dispositions and positions among those interviewed. For those participating in the political fights, the view of GH as content critical to traditional PH predominates, with content articulated with the BHR movement and the fight for democracy.

GH has acquired critical conceptual content that separates it from PH. This is why it cannot be mere dressing, a tag or a label applied to old healthcare practices. [...] consider segments of society, especially the needy, the poor, those of low income, those excluded and the like to think community, no! We had a universal concept, a concept of society and were revolutionizing through platforms within the BHR social movements involving health. (E 7)

GH is a theoretical movement within the scope of Brazilian public health [...] What is the project for GH in Brazil? [...] proposes to fight to build a universal access healthcare system, health as a right for all [...] (E 6).

GH as synonymous with PH is recognized among the interviewees involved in government procedures, working in healthcare policies but far from social movements, with traditional training in PH and Sanitary Odontology.

GH is the modern synonym of PH, the opposite of health taken from the individual point of view (E 2).

For ABOPREV members, GH means the collective health of all sub-sectors of economic production, whether public or private. Some members were unable to define it.

GH is everyone’s health. For me, GH should be a pleonasm, it should belong to all. It is obvious that GH belongs to all, but rivalries have been created: - I am about GH, not healthcare provided in an office, that’s not for me. I am a private dentist, I don’t subscribe to GH ... as I said before, this type of compartmentalization is bad (E 3).

As in the case of GOH, the view of GH as critical to healthcare and a breach with traditional PH is especially shared among agents who have had close experience with the problems of implementing policies in public healthcare, those emerging from social movements in dentistry, and those with political ambition. The view of GH as PH is common among those who have held positions the Ministry of Health and international bodies, and also among those with no involvement at all with the different political battles. ABOPREV members were either unable to conceptualize GH, or understood this to be different from “collective” health - those unable to pay and those able to pay.

Most of the interviewees viewed the SUS as a project to transform society, and a product of the rights and struggles on behalf of a democratic society. The view of the SUS as a universal, unified system that expresses social rights is also shared by agents not involved in specific political fights on behalf of oral health or even democratization, even while recognizing that the system still requires consolidation. Only in one cases is the system compared to the public system in Scandinavia.

We find congruence among the points of view of the different agents as to the interaction of this social space and their positions and dispositions. It is worth remembering that even those not part of the political fight to include oral health in SUS agree on the view of SUS as a universal system and the largest public healthcare system in the world.

Group Oral Health in Current Times

The permanence of the older “Odontology” is noted first when it is clear that the international plane does not favor GOH research in Brazil¹⁷17. Moysés SM. The current context for research in public oral health. Cad Saude Publica 2008; 24(4):718-719., as an analysis of the areas fostered by the International Dental Federation (IDF) does not include GOH goals.

However, even this expression is very Brazilian. Of course, we are familiar with the PSO, the US Preventive Medicine and Preventive Odontology movement; the social arrived in Latin America in the form of a loan. Odontology in Group Health is misunderstood (E 11).

This scenario is repeated in Brazil, as shown in the publication entitled “Saúde Bucal Coletiva Metodologia de Trabalho e Práticas” (Group Oral Health: Working Methodology and Practice)¹⁸18. Dias AA. Saúde bucal coletiva: metodologia de trabalho e práticas. São Paulo: Santos; 2007., a collection of papers by oral health professionals and professors, showing the positive points of consolidating a specific sub-space of GOH, however it also shows remnants of previous Odontology¹⁹19. Frazão P. Saúde bucal coletiva: metodologia de trabalho e práticas. Cad Saude Publica 2006; 22(11):2499-500..

We call attention to the effort to build a social theory for oral health, first proposed by Carlos Botazzo, one of the founders of SBC, introducing the theme of “bucality”²⁰20. Botazzo C. Sobre a bucalidade: notas para a pesquisa e contribuição ao debate. Cien Saude Colet 2006; 11(1):7-17.. However, there is no agreement of what such a proposal would consist of within GOH. Some authors believe this would be something other than GOH²¹21. Narvai PC. Saúde bucal coletiva, bucalidade e antropofagia. Cien Saude Colet 2006; 11(1):18-21.

22. Moysés SJ. Assim é se lhe parece! Cien Saude Colet 2006; 11(1):21-24.^-2323. Werneck MAF. Bucalidade e existência. Cien Saude Colet 2006; 11(1):28-31., suggesting a certain crisis of identity within GOH today.

We have found a conflict in the scientific production on GOH, reflected in the practice of oral health by healthcare services. According to its agents, GOH remains subject to traditional dental practices in the private and public environment, which reinforce traditional practices.

GOH emerges as GH, traveling the paths of public oral health policy at all levels of the city, state and federal governments. [...] These are policies captured by Market Odontology. [...] competing along the paths of public policy. Market Odontology is hegemonic within Brazilian healthcare policy. GOH proposals are not hegemonic in the national oral health policy, they are actually contra-hegemonic. They are continuously competing and losing (E 6).

[...] the odonatological root, people at the limit arrive at community and preventive Odontology, perhaps because they are trying to prevent cavities or periodontal disease. When considering health education, people think about community programs for children, but now they are looking at entering a field that is vaster and theoretically and practically more conflictive, I mean the theory of practical action (E 11).

An analysis of GOH practices shows that contradictions remain in the dental field. In other words, technological advances and eminently restorative practices, difficulty breaking with traditional dental practices, and the incorporation of the oral health team as part of family health (ESB/ESF)²⁴24. Moretti-Pires RO, Lima LAM, Machado MH. Sociologia das profissões e percepção de acadêmicos e odontologia sobre o Agente Comunitário de Saúde em saúde bucal. Interface (Botucatu) 2011; 15(39):1085-1095.. In fact, this conception of GOH is not consolidated in Brazil or in any other country, adding to the challenge of expanding the GOH scientific community.

As a concept, GOH may be shared by few. There is no epistemic community considering GOH. [...] You can’t talk about this outside Brazil. If I use it in an English language paper, in something I plan to publish abroad, the reviewers are perplexed, they don’t know what I’m talking about and think I may have made a mistake when translating a concept. They ask me to replace it with “Dental Public Health, Oral Health” [...] (E 11).

In this case, awareness of the concept by a limited number of dentists is one of the main problems for maintaining this social space, as in its origination. Other people “reproduce” the term and adopt it, but really don’t understand how it is different from the “older Odontology”. Old habits remain and allow the reproduction of PSO in Brazil. Unawareness of the theoretical-political construct of GOH enables it in some ways to be interpreted as the old OPS under a new name.

Although we are aware of theoretical articles on GOH, this is not a sub-field of GH or Odontology. The most recent educational reform, enabled by the New Curriculum Guidelines – PRO-HEALTH –, fostering change in the various dental course curricula, enabled inserting GOH in a small number of these, in some cases as “Odontology in Group Health” or “Group Health”, stating the different points of view of researchers in this area.

This problem was investigated by Rodrigues et al.²⁵25. Rodrigues RPCB, Saliba NA, Moimaz SAS. Saúde Coletiva nas estruturas curriculares dos cursos de Odontologia do Brasil. Rev ABENO 2006; 6(1):81-87., and involved the analysis of the curricula of 123 dental courses graduating at least one class by 2003. The authors conclude that the prevailing nomenclature for GH is PSO.

Thus, we find that concerns with changing dental practices were not left behind. It continues at stake. It corresponds to the daily struggle inherent to oral health practices within public dental services, as GOH is committed to public healthcare, social justice and the right to health.

Whatever is done in this area is hegemonized in private practice. Healthcare plan operators have expanded significantly. [...] In the ten years between 1998 and 2008 the population covered by private dental plans grew over 400%. These are the prevailing interests. What are the hurdles for GOH to reproduce itself as a movement within the field of knowledge output and social practices, strengthening itself for this confrontation? (E 6)

Some of the founders are committed to strengthening the scientific sub-space and create the “field” of GOH. This premise is consistent with the professional goals of these founders, illustrating the illusio within this space.

[...] my goal is to disturb the practice [...] to interfere with the conceptual burden and check the extent to which this can be transformed into practice (E 4).

Furthermore, some of the founders, like Carlos Botazzo, Paulo Capel and Paulo Frazão²¹21. Narvai PC. Saúde bucal coletiva, bucalidade e antropofagia. Cien Saude Colet 2006; 11(1):18-21.^,2626. Narvai PC. Saúde bucal coletiva: um conceito. Odont Soc 2001; 3(1/2):47-52.^,2727. Chaves SCL, Botazzo C. Prevenção, atenção e vigilância da saúde bucal. In: Paim JS, Almeida Filho A, organizadores. Saúde Coletiva: teoria e prática. Rio de Janeiro: MedBook; 2014. p. 465-497., continue to emphasize the theme of GOH, publishing “Diálogos sobre a boca” (Dialogs on the Mouth) in 2013, an effort to recover the concept and path of GOH²⁸28. Botazzo C. Diálogos sobre a boca. São Paulo: Hucitec; 2013., as well as a paper entitled “Saúde Bucal Coletiva: antecedentes e estado da arte” (Group Oral Health: background and state of the art), which was included in a GH book, mentioning the authors as new agents addressing GOH²⁷27. Chaves SCL, Botazzo C. Prevenção, atenção e vigilância da saúde bucal. In: Paim JS, Almeida Filho A, organizadores. Saúde Coletiva: teoria e prática. Rio de Janeiro: MedBook; 2014. p. 465-497..

In the decades preceding GOH, other movements took place in the scientific sub-space, working to build a theoretical and methodological framework for the practice of GOH. Numerous articles have been published with this intention. In 2008, Simone Moysés, Leo Kriger and Simone Moysés published a collection of papers blending theoretical discussions and practical experience²⁹29. Moysés SJ, Krieger L, Moysés ST. Saúde bucal das famílias: trabalhando com evidências. São Paulo: Artes Médicas, 2008.. Recently, Samuel Moysés and Paulo Goes published: “Planejamento, Gestão e Avaliação em Saúde Bucal” (Planning, Management and Assessment in Oral Health), with the contribution of numerous of the agents mentioned in this paper³⁰30. Goes PSA, Moysés SJ, organizadores. Planejamento, gestão e avaliação em saúde bucal. São Paulo: Artes Médicas; 2012.. The term used most often in the title of the papers is GH³¹31. Moysés SM. Saúde Coletiva: políticas, epidemiologia da saúde bucal e redes de atenção odontológica. São Paulo: Artes Médicas, 2013. Série Abeno..

The answer to this problem may lie in the fact that GOH, while subscribing to the guidelines of GH, is far closer to “odontology” and its social practices, in particular those guided by OS and Sanitary Odontology. This being the case, one of the main challenges of GOH today is to articulate the bureaucratic and political sub-spaces so that theoretical development may provide subsidy for the practice of odontology in public healthcare services.

Among the agents we looked at, some have been there from the very first, but in different positions. These professionals, who in the 1980s were dominated are today dominant, heading discussions on the theme in the scientific sub-space. Some of them have also been participating in the bureaucratic sub-space through national policy advisory committees, or in planning and implementing epidemiological surveys in Brazil (Figure 2). All the agents who remain have taken a position regarding GOH as a break with prevailing odontological practice, and their main field is scientific (Tabela 2).

Recovery of the political facet should include an agenda for the agenda agents in this social space. The training of dentists committed to GH and changing odontological practices is the concern of some of the founding members. More dentists critically trained and committed to the practice of oral health, rather than “odontology”, could be a path to ensure new contra-hegemonic movements.

We must recover and update the criticisms of the origins of GOH, much like recovering the memory of the political genesis and matrix that was lost over time, in the period immediately following the constitution, in particular implementing OHP in the BHR process. Furthermore, the current configuration of odontology and the political, economic and social relationships that reflect in the hegemony of practices and the permanence of market odontology, and are some of the main problems the area faces today, while reinforcing “Alternative Odontology” in previous decades preserved the autonomy of the dental field.

[...] Market Odontology in the country has changed [...] When I was in dental school and private dental practice was discussed, it was restricted to dentists or groups of dentists who paid for their own offices. [...] The growth of dental insurance and plans introduced a new capital relationship. [...] (E 10).

This hegemony is reinforced by the National Oral Health Policy (NOHP), or the bureaucratic sub-space is led today by those emerging from “Group Health Odontology”, an ideological movement that preceded and originated GOH.

Educate, clean [...] everything is right there, preserved, even if the NOHP does not necessarily go down this path ... the tradition is there. [...] The rest of private odontology is preserved. So [...] distributing oral hygiene kits [...] Colgate is doing very well (E 4).

Just as GH, GOH is a unique case, that emerges influenced by the ideas and agents of GH. Articulating the two social spaces maintains the networks and relationships of the time, which have been stronger and broader over time, and are seen in the advice given to dissertations, where GH agents advise the work of GOH agents, in the involvement of dentists in GH graduate programs, in the organization and participation in ABRASCO meetings, culminating in 2007 with the Oral Health Working Group at this organization.

Final considerations

GOH as a socio-historical phenomenon is a social space that emerged from a network of relationships among GOH agents emerging from BHR, GH and PSO, and is more sensitive to community practices. It is a reflection of the inability of the dental currents in place in the 1970s and 80s to change the practice of odontology, and the status of oral health in Brazil.

One might say that this space emerged as a criticism to practices linked to primate market odontology, and as a criticism to “Alternative Odontology”, and thus constitutes a movement to politicize odontology in Brazil, evolving to a critical reflection of the dental practice models used during that period, in particular simplified and integrated odontology. It is also a theoretical reference for oral health practice and policies within SUS, as it proposes to intervene in social determinants, admitting social practices of different nature, including technical ideological and political. It is in the rhetoric of political and scientific speeches, but is not yet a practice in healthcare services.

We point out that this group of dentists, initially dominated, have become the dominant pole of the space and the current fight for oral health in Brazil. This is because they now occupy important positions in the bureaucratic and political sub-spaces, either because of the position they hold or their involvement in advisory committees, helping formulate and implement the NOHP and helping draft the discourse of the main industry associations. The scientific sub-space however, had to adapt to the standards in odontological journals, and/or take on a subordinate position in GH journals. In fact, creating the specific Oral Health working group within Abrasco has been questioned by several members.

Another possible reading is that these dentists in a space dominated by struggles for oral health in the 1980s, broke with the OPS and tried to find another space, where GOH would be a dominant topic. This new space, using references to GH³²32. Vieira-da-Silva LM, Pinell P. The genesis of collective health in Brazil. Sociol Health Iln 2014; 36(3):432-446. as their platform, was unable to effectively change practices, although it did give rise to a critique of the odontological approach. Working processes in healthcare or health management remain limited to dentists and the oral hygiene practices emerging from PSO, expanding occasionally to oral health assistants. Thinking and practicing oral health remain the exclusive provenance of dentists and dental assistances, with no involvement of other healthcare areas or other sectors of society. There is no multi-disciplinary approach, and any intersectoral activities are limited to schools.

One may also reflect on the epistemological nature of GOH. Considering GH as a space that is still building its autonomy³²32. Vieira-da-Silva LM, Pinell P. The genesis of collective health in Brazil. Sociol Health Iln 2014; 36(3):432-446., the proposed rupture within odontology would correspond to what we might temporarily call Oral Health in Group Health, or even Odontology in Group Health, given the absence of any multi-disciplinarity.

Even of GOH is a critical segment, an analysis of current oral health also points to an expansion of the private side of odontology. Here we find that GOH has not been able to develop the counter-hegemony required to reverse the direction of odontological practices underway.

The persistence of sanitary and preventive odontological practices may be related to the challenges revealed by their founders, such as expanding the number of dentists and training new ones, political training and critical views, commitment to practices other than odontology, and adding other healthcare professionals when thinking about and practicing oral health, and vice-versa. Thus, GOH remains embroiled in the struggle for hegemony of practices, as it was when it was born, fighting the paths of OHP in Brazil.

References

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