Therapeutic itineraries of quilombola adults for oral health care in a rural district of Bahia, Brazil

Souto, Ricardo de Almeida; Souzas, Raquel; Silva, Etna Kaliane Pereira da; Pereira, Lucelia Luiz; Nery, Joilda Silva

doi:10.1590/1413-81232024293.04302023

Abstract

This study examined the oral health-related therapeutic itineraries of quilombola adults in a rural district of Vitória da Conquista, Bahia. This qualitative study involved ten semi-structured interviews of adult members of the quilombola community, in May 2021, which were then transcribed and analysed using content analysis. The results showed little or poor oral hygiene at some stage of life, especially in childhood and adolescence, the use of popular oral health care practices, and experiences of professional care featuring tooth extraction. Use of health services was mostly reported only in the period prior to the COVID-19 pandemic. Responses as to perceived ease of access to health services in the community varied. One common complaint as to satisfaction with oral health was the need to use or replace dental prostheses. This study concluded that oral health must be promoted jointly with disease prevention, dental rehabilitation and recognition for the knowledge and worldview of the quilombola population.

Key words:
Health knowledge; attitudes; practices; Oral health; African Continental Ancestry Group; Ethnicity and health

Introduction

The expression “remnants of quilombo communities” in Article 68 of the Transitional Constitutional Provisions Act (Ato das Disposições Constitucionais Transitórias, ADCT) of Brazil’s 1988 Federal Constitution is associated with the struggle of parliamentarians and black militants committed to the anti-racist cause for broad rights, which go beyond the struggle for land title¹1 Brasil. Constituição da República Federativa do Brasil de 1988. Diário Oficial da União 1988; 5 out.^,²2 Leite IB. Os quilombos no Brasil: questões conceituais e normativas. Etnográfica 2000; 4(2):333-354.. The term quilombo is not restricted just to an archaeological vestige of temporary occupation or biological evidence, nor to homogeneous or isolated groups, nor did its origin necessarily come from insurrectionary movements, but especially from groups that developed practices of resistance in reproducing and preserving their territories and ways of life³3 O'Dwyer EC. Quilombos: identidade étnica e territorialidade. Rio de Janeiro: Editora FGV; 2002..

The Organization of American States acknowledges that historical omission by the Brazilian State has allowed abuses of the rights of quilombola populations to take place, for lack of public policies and precarious service provision, or by violation of land rights, failure to consult these people or the nonexistence of any effective policy of reparation for the discrimination to which they have been subjected historically⁴4 Comissão Interamericana de Direitos Humanos (CIDH). Situação de Direitos Humanos no Brasil. Washington, D.C.: CIDH; 2021.. The Racial Equality Statute promulgated in 2010 was one of the legal frameworks sanctioned to guide the actions of the Brazilian State in combating discrimination and various forms of ethnic intolerance, guaranteeing equal opportunities for the black population and defending collective, diffuse and individual ethnic rights⁵5 Brasil. Lei nº 12.288, de 20 de julho de 2010. Institui o Estatuto da Igualdade Racial. Diário Oficial da União; 2010..

Brazil’s National Policy for Comprehensive Health of the Black Population specified strategies to ensure improvements in quilombola populations’ health indicators and improve access to health services⁶6 Brasil. Ministério da Saúde (MS). Política Nacional de Saúde Integral da População Negra: uma política para o SUS. 3ª ed. Brasília: MS; 2017.. The National Policy for the Comprehensive Health of Rural and Forest Populations set targets for expanding these populations’ access to the Unified Health System (Sistema Único de Saúde, SUS) and stated the need to introduce specific indicators in monitoring and evaluating health measures and services for different populations, including quilombolas⁷7 Brasil. Ministério da Saúde (MS). Portaria nº 2.866, de 2 de dezembro de 2011. Institui, no âmbito do Sistema Único de Saúde (SUS), a Política Nacional de Saúde Integral das Populações do Campo e da Floresta. Diário Oficial da União; 2013..

Oral health is expressed physically, psychologically, emotionally and socially and plays an essential role in overall health and quality of life. Impaired oral conditions can influence not only diseases of the mouth and other organs, but also quality of diet and nutrition, as well as mental health, thus interfering in people’s social lives and in their ability to adapt, through self-care, to physiological life course changes⁸8 Peres MA, Macpherson LMD, Weyant RJ, Daly B, Venturelli R, Mathur MR, Listl S, Celeste RK, Guarnizo-Herreño CC, Kearns C, Benzian H, Allison P, Watt RG. Oral diseases: a global public health challenge. Lancet 2019; 394(10194):249-260.

9 Glick M, Williams DM, Kleinman DV, Vujicic M, Watt RG, Weyant RJ. A new definition for oral health developed by the FDI World Dental Federation opens the door to a universal definition of oral health. J Am Dent Assoc 2016; 147(12):915-917.^-¹⁰10 Petersen PE. The World Oral Health Report 2003: continuous improvement of oral health in the 21st century--the approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol 2003; 31(Supl. 1):3-23..

Unfavourable oral health conditions in, mostly rural, quilombo remnant communities (QRCs), are influenced by adverse life contexts, such as poor access to education and health services¹¹11 Oliveira VM, Lira CBC, Oliveira EB, Costa ERG, Gomes MRF, Crispin JCO, Dantas DS, Souza MOF. Saúde da mulher quilombola no Brasil: Uma revisão de literatura. Braz J Develop 2021; 7(10):100848-100866. and less coverage by sewerage systems, treated water and fluoridation of the water supply¹²12 Dias JG, Pereira BL, Ribeiro PC, Monteiro LRL. Flúor na água de abastecimento público em uma comunidade remanescente quilombola. J Bus Techn 2020; 13(1):57-69.. Miranda et al.¹³13 Miranda LP, Oliveira TL, Queiroz PSF, Oliveira PSD, Fagundes LS, Rodrigues Neto JF. Saúde bucal e acesso aos serviços odontológicos em idosos quilombolas: um estudo de base populacional. Rev Bras Geriatr Gerontol 2020; 23(2):e200146. identified a 52% prevalence of edentulism among older adults in a quilombola community and a need for dental prosthesis in 88%. Araújo et al.¹⁴14 Araújo RLMS, Araújo EM, Miranda SS, Chaves JNT, Araújo JA. Extrações dentárias autorrelatadas e fatores associados em comunidades quilombolas do Semiárido baiano, em 2016. Epidemiol Serv Saude 2020; 29(2):e2018428. found that 49.8% of adults in a QRC reported having extracted up to five teeth and 32.2%, more than five teeth. Souza et al.¹⁵15 Souza MFNS, Sandes LFF, Araújo AMB, Freitas DA. Autopercepção e práticas de saúde bucal entre idosas negras descendentes de escravos no Brasil. Rev Bras Med Fam Comunidade 2018; 13(40):1-10. concluded that more than 50% of older adults in a QRC were completely edentulous and only 17% wore complete dentures. Souza and Flório¹⁶16 Souza MCA, Flório FM. Evaluation of the history of caries and associated factors among quilombolas in Southeastern Brazil. Braz J Oral Sci 2014; 13(3):175-181. found that, in two QRC populations, no-one in the 35-59 and over-60 year age groups was free from dental caries. Silva et al.¹⁷17 Silva MEA, Rosa PCF, Neves ACC, Rode SM. Necessidade protética da população quilombola de Santo Antônio do Guaporé-Rondônia-Brasil. São José dos Campos-SP. Braz Dent Sci 2011; 14(1-2):62-66. found that 37.9% of a group of 29 individuals over 12 years of age from a QRC had never seen a dentist.

Studies based on therapeutic itinerary analysis help investigate, analyse and understand health practices in rural quilombola communities, which are conditioned by worldviews, interpretations of life and available social resources and influenced by material, social and subjective determinants¹⁸18 Santos RC, Silva MS. Condições de vida e itinerários terapêuticos de quilombolas de Goiás. Saude Soc 2014; 23(3):1049-1063.^,¹⁹19 Gerhartd TE, Riquinho DL. Sobre itinerários terapêuticos em contextos de iniquidade social: desafios e perspectivas contemporâneas. In: Trad LAB, Jorge MSB, Pinheiro R, Mota CS, Rocha AARM, organizadores. Contextos, Parcerias e Itinerários na Produção do Cuidado Integral: Diversidade e Interseções. Rio de Janeiro: CEPESC/IMS/UERJ/ABRASCO; 2015. p. 233-252.. Accordingly, this study examines the oral health-related therapeutic itineraries of quilombola adults in a rural community in the municipality of Vitória da Conquista, Bahia.

Methodology

An exploratory qualitative analytical study was carried out as part of the dissertation project “Therapeutic itineraries in oral health of quilombola adults in a rural district of Vitória da Conquista - Bahia”, based on semi-structured interviews ten quilombola adults living in the rural district of Pradoso and assisted by the Pradoso Family Health Team in the municipality of Vitória da Conquista, Bahia, Brazil.

Formulation of the interview questions drew on sociodemographic factors, narratives of oral health conditions and care experiences, health service accessibility, self-perceived oral health and the relationship between oral and overall health. This data recording instrument helped to describe events, conversations and thinking that informed the researcher’s analysis and interpretations of what had been experienced²⁰20 Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 14ª ed. São Paulo: Hucitec; 2014..

Study participants were invited to take part by community health workers during home visits. Interview dates were scheduled to suit participants’ availability at home. In March 2021, six adults from the localities of Baixão and Lagoa de Maria Clemência, who were not part of the final sample, were pretested. The ten adults included in the research and interviewed in May 2021 were residents of the communities of Oiteiro, Malhada, Manoel Antônio and Saguim. Residents without at least 30 minutes available interview or who lived in a micro-area not served by a community health worker and one invitee who was not at home as scheduled were excluded from this research. Voluntary acceptance, indicated by signing a declaration of free and informed consent, was an ethical prerequisite for participant inclusion.

Determining the number of interviewees was challenging, given the comprehensive nature of the interconnections established in understanding a research object²¹21 Minayo MCS. Sampling and saturation in qualitative research: consensuses and controversies. Rev Pesqui Qual 2017; 5(7):1-12.. Equipment was used to record the interviews. The pre-test interviews and those of the final sample were conducted by a single researcher, who was male, a dentist and master’s student in collective health. The interview audios were transcribed by a company under contract and reviewed by the researcher who had conducted the interviews. Participant anonymity was ensured by omitting names and using the expression “interviewee” followed by a number. The study’s reliability was anchored in methodological transparency²²22 Fontanella BJB, Luchesi BM, Saidel MGB, Ricas J, Turato ER, Melo DG. Amostragem em pesquisas qualitativas: Proposta de procedimentos para constatar saturação teórica. Cad Saude Publica 2011; 27(2):389-394., achieved by describing in detail the empirical and theoretical procedures used in exploring the meanings²²22 Fontanella BJB, Luchesi BM, Saidel MGB, Ricas J, Turato ER, Melo DG. Amostragem em pesquisas qualitativas: Proposta de procedimentos para constatar saturação teórica. Cad Saude Publica 2011; 27(2):389-394. of the study population’s oral health and recognising the limits of this research.

Interview saturation was ascertained using a model proposed by Fontanella et al.²²22 Fontanella BJB, Luchesi BM, Saidel MGB, Ricas J, Turato ER, Melo DG. Amostragem em pesquisas qualitativas: Proposta de procedimentos para constatar saturação teórica. Cad Saude Publica 2011; 27(2):389-394., involving immersion in, and exploration of, each interview by listening to the audios of the interviews transcribed previously and compiling the specific meanings revealed in each interview, then grouping and classifying the meanings so identified and, finally, producing a visual representation of this saturation, as shown in Chart 1.

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Chart 1
Visual representation of interview saturation.

Content analysis started with preliminary analysis, which was followed by exploration of the material, treatment of results, inference and interpretation²⁰20 Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 14ª ed. São Paulo: Hucitec; 2014.. Exploration of the material was designed to identify meanings and nuclei of meaning, while the processing of results, inference and interpretation examined for relevance with the research objectives, questions and assumptions²³23 Minayo MCS, Deslandes SF, Gomes R, organizadores. Pesquisa Social: teoria, método e criatividade. Rio de Janeiro: Vozes; 2016..

The study was approved by the continued professional development centre of the municipality of Vitória da Conquista and the research ethics committee of the Multidisciplinary Health Institute of the Universidade Federal da Bahia.

Results and discussion

The quilombola adults interviewed were mostly between 40 and 59 years old and declared themselves to be black (brown in colour) and their marital status to be “in a stable union”. Seven participants were female, three were illiterate, two reported not having completed lower secondary school, two had completed lower secondary school, two had not completed upper secondary school and one had completed upper secondary school. Half the group were retirees. Half the interviewees declared family income of less than one minimum salary and the other half, one minimum wage.

As regards housing, the interviews revealed that nine interviewees owned their homes and eight had running water at home. All interviewees reported that the rural community had no rainwater drainage or sewerage system. Seven interviewees reported that refuse was collected on certain days of the week, but only one revealed that collection was selective, while four interviewees revealed that burning of refuse was a frequent practice.

The socioeconomic profile of quilombo remnant communities populations is generally notable for a context of vulnerability, commonly featuring dependence on social cash transfer programmes, subsistence family farming and restricted access to health, education and basic sanitation services²⁴24 Freitas DA, Caballero AD, Marques AS, Hernández CIV, Antunes SLNO. Saúde e comunidades quilombolas: uma revisão da literatura. Rev CEFAC 2011; 13(5):937-943.^,²⁵25 Bezerra VM, Medeiros DS, Gomes KO, Souzas R, Giatti L, Steffens AP, Kochergin CN, Souza CL, Moura CS, Soares DA, Santos LRCS, Cardoso LGV, Oliveira MV, Martins PC, Neves OSC, Guimarães MDC. Inquérito de Saúde em Comunidades Quilombolas de Vitória da Conquista, Bahia, Brasil (Projeto COMQUISTA): Aspectos metodológicos e análise descritiva. Cien Saude Colet 2014; 19(6):1835-1847..

Oral health care

In the therapeutic itineraries mentioned in the interviews, the participants took paths that combined the use of public and private oral health services, as well as resorting to popular practices and self-medication to meet care needs. In this regard, note that, in most of the reports of oral health care strategies, oral hygiene habits were absent or precarious at various different stages of life. In combination with the sociodemographic profile, this constitutes a context of social vulnerability to be overcome by civil society and public policymakers. Contemporary evidence has shown that so-called minority racial groups generally live with a greater burden of oral diseases, which differs significantly between socially advantaged and disadvantaged racial groups, and that racial inequalities in oral health are observed over time in several nations through structural racism, that is, a structure produced and maintained by laws, and political and economic systems, as well as social and cultural norms²⁶26 Jamieson LM. Racism and oral health inequities; An introduction. Community Dent Health 2021; 38(2):131..

Therapeutic itineraries reflect the pathways individuals take in search of health care contextualised by their worldviews, their ways of interpreting life and the health-disease-care process, the social support networks and social resources available to them¹⁸18 Santos RC, Silva MS. Condições de vida e itinerários terapêuticos de quilombolas de Goiás. Saude Soc 2014; 23(3):1049-1063.. Some interviewees reported precarious oral hygiene habits in childhood, whether in the family environment or at school (Chart 2). The reports revealed that health must be experienced in different social spaces. The family environment, school, health units, churches and community centres can be places for building/sharing information and strategies for promoting health. Tooth brushing, one of the strategic pillars of good oral health, was mentioned by all interviewees (Chart 2).

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Chart 2
Thematic category “oral health care”, according to empirical data from the interviews.

There was no mention of using dental floss in hygiene strategies, although such an accessory would be a desirable part of the interviewees’ routine, as a complement to oral hygiene. Silva et al.²⁷27 Silva EKP, Santos PS, Chequer TPR, Melo CMA, Santana KC, Amorim MM, Medeiros DS. Saúde bucal de adolescentes rurais quilombolas e não quilombolas: um estudo dos hábitos de higiene e fatores associados. Cien Saude Colet 2018; 23(9):2963-2978., in a study that included quilombola and non-quilombola adolescents, found that 46.7% of the adolescents studied did not use dental floss and that, although they found no distinction in prevalence between quilombolas and non-quilombolas, different factors were associated with this habit²⁷27 Silva EKP, Santos PS, Chequer TPR, Melo CMA, Santana KC, Amorim MM, Medeiros DS. Saúde bucal de adolescentes rurais quilombolas e não quilombolas: um estudo dos hábitos de higiene e fatores associados. Cien Saude Colet 2018; 23(9):2963-2978.. Interviewee 5 contrasted his experience of oral hygiene, based on his parents’ education, with current realities, as in the account below:

There are people who don’t have mouth problems. All their teeth are beautiful and they don’t even go to the dentist that much. I think it’s because they took good care when they were younger. [...] Brush at least two or three times a day. In my time, if you even asked your parents for a brush, your parents would beat you. “What do you want that for, boy?” Our parents were really ignorant. [...] If you asked for a toothbrush, Holy Mother! Today, our children, we give them everything, we try to keep them, because you know how things are today, too expensive. You have to take care of children, because if you leave it until they’re older, it’s too late (Interviewee 5).

It is reasonable to infer that, ideally, promoting oral health begins in childhood with parental encouragement/monitoring, understanding that this practice can be a determinant of good oral health at different stages of life, even without regular visits to a dentist and without minimising the importance of such monitoring. Over and above oral health care, clearly all citizens must be guaranteed good general conditions of life, such as housing, basic sanitation, transportation, food, education and so on, as basic prerequisites of human dignity.

Some interviewees highlighted the use of popular (homemade) treatments for combating dental pain or as a therapeutic resource post-operative to dental extractions or to alleviate gum inflammation (interviewees 1, 2, 4, 6, 8 and 10) (Chart 2). Oral health care practices were observed that are the result of popular knowledge and this community’s way of life and shared by family and/or friends. They include the use of mulungu peel or cashew leaf or vinegar mouthwash as a resource to reduce gum inflammation, as well as potato leaves or pomegranate peels to combat toothache. Understanding health care in quilombola communities is not limited to connecting items of popular knowledge as effects of systematic exclusionary processes experienced by this population, but there are also epistemologies that link health care to a broader dimension associated with ways of life²⁸28 Fernandes SL, Santos AO. Itinerários Terapêuticos e Formas de Cuidado em um Quilombo do Agreste Alagoano. Psicol Cien Prof 2019; 39 (n. esp.):e222592..

Souza et al.¹⁵15 Souza MFNS, Sandes LFF, Araújo AMB, Freitas DA. Autopercepção e práticas de saúde bucal entre idosas negras descendentes de escravos no Brasil. Rev Bras Med Fam Comunidade 2018; 13(40):1-10. identified reports of using wood stove ash and/or water, as well as tobacco chewing habits as oral hygiene strategies among nine elderly women from a QRC¹⁵15 Souza MFNS, Sandes LFF, Araújo AMB, Freitas DA. Autopercepção e práticas de saúde bucal entre idosas negras descendentes de escravos no Brasil. Rev Bras Med Fam Comunidade 2018; 13(40):1-10.. The use of herbal medicines, such as cloves, mallow, propolis, pomegranate, chamomile and cat’s claw, in dentistry has proven to be an efficient and low-cost alternative²⁹29 Gomes MS, Mendonça AKP, Cordeiro TO, Barbosa MM. Uso De Plantas Medicinais Na Odontologia: Uma Revisão Integrativa. Rev Cien Saude Nov Esper 2020; 18(2):118-126.^,³⁰30 Monteiro MH, Fraga S. Fitoterapia na Odontologia: Levantamento dos Principais Produtos de Origem Vegetal para Saúde Bucal. Rev Fitos 2015; 9(4):265-268.. Souza et al.¹⁵15 Souza MFNS, Sandes LFF, Araújo AMB, Freitas DA. Autopercepção e práticas de saúde bucal entre idosas negras descendentes de escravos no Brasil. Rev Bras Med Fam Comunidade 2018; 13(40):1-10. observed the use of acid from plants to combat dental pain among elderly quilombolas. Intermedicality, that is, the dialogue and intersection between academic, formal health knowledge and the knowhow produced by popular practices, can be fostered in quilombola communities by health policies that ensure strategies are implemented to favour such a meeting of bodies of knowledge³¹31 Arruti JM. Políticas públicas para quilombos: Terra, saúde e educação. In: Paula M, Heringer R, organizadores. Caminhos convergentes: Estado e sociedade na superação das desigualdades raciais. Rio de Janeiro: Fundação Heinrich Boll; 2009. p. 75-110..

Seven interviewees reported experiences of professional care involving numerous extractions over the course of their lives (Chart 2). Most of the stories narrated featured self-reported poor oral health conditions, particularly partial or total edentulism (tooth loss), underlining that tooth extractions predominated as a clinical dental procedure in the study group. Although this procedure is a therapeutic option, the narratives associating poor oral health conditions and tooth extractions reveal that other therapeutic options could have been implemented in a timely manner and contributed to a better oral health situation.

Araújo et al.¹⁴14 Araújo RLMS, Araújo EM, Miranda SS, Chaves JNT, Araújo JA. Extrações dentárias autorrelatadas e fatores associados em comunidades quilombolas do Semiárido baiano, em 2016. Epidemiol Serv Saude 2020; 29(2):e2018428. identified greater likelihood of tooth loss from extraction among older subjects in a QRC in the Bahia semi-arid, which can be explained as the effect of the accumulation of oral diseases not prevented nor treated in oral health services¹⁴14 Araújo RLMS, Araújo EM, Miranda SS, Chaves JNT, Araújo JA. Extrações dentárias autorrelatadas e fatores associados em comunidades quilombolas do Semiárido baiano, em 2016. Epidemiol Serv Saude 2020; 29(2):e2018428.. The higher prevalence of edentulism is related to situations of discrimination against subjects of low socioeconomic position and particularly black and brown people, in which situations of deprivation and social exclusion may occur, in addition to greater exposure to stressors and institutional discrimination, which can compromise both access to, and quality of, oral health services³²32 Gonçalves LG. Associação entre perda dentária e desigualdades relacionadas à cor da pele em adultos: resultados do estudo pró-saúde [dissertação]. Porto Alegre: Universidade Federal do Rio Grande do Sul; 2011.. Also, oral health care is independent of the presence or absence of teeth, because in cases of edentulism, in addition to regularly checking the use, or need for use, of dental prostheses, soft tissues must also be evaluated to prevent diseases of the oral mucosa, especially precancerous or cancerous lesions³³33 Maia LC, Costa SM, Martelli DRB, Caldeira AP. Edentulismo total em idosos: envelhecimento ou desigualdade social? Rev Bioetica 2020; 28(1):173-181..

Relationship between oral health and overall health

In connection with the concept of health, in some interviews, the expression “health” was associated with professional care, self-care (hygiene measures) and examinations as key factors in achieving or preserving good overall or oral health (Chart 3).

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Chart 3
Thematic category “relating oral health and overall health”, according to empirical data from the interviews.

There is a recognition of the value of appointments and diagnostic tests intended to achieve or preserve health, even though self-care has also been mentioned. Indeed, they are important, complementary and non-exclusionary aspects, which can also dialogue with the community’s traditional health practices.

Oral health is related to physical, psychological, emotional and social aspects and constitutes an important link in well-being and overall health, because it influences everyday activities, such as speaking, smiling, chewing, digestion, painless socialisation without pain, discomfort or embarrassment and reflects a person’s ability to adapt to physiological changes in their life course and, through self-care, to keep teeth and mouth in healthy condition⁸8 Peres MA, Macpherson LMD, Weyant RJ, Daly B, Venturelli R, Mathur MR, Listl S, Celeste RK, Guarnizo-Herreño CC, Kearns C, Benzian H, Allison P, Watt RG. Oral diseases: a global public health challenge. Lancet 2019; 394(10194):249-260.

9 Glick M, Williams DM, Kleinman DV, Vujicic M, Watt RG, Weyant RJ. A new definition for oral health developed by the FDI World Dental Federation opens the door to a universal definition of oral health. J Am Dent Assoc 2016; 147(12):915-917.^-¹⁰10 Petersen PE. The World Oral Health Report 2003: continuous improvement of oral health in the 21st century--the approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol 2003; 31(Supl. 1):3-23.. In a similar manner, this broad view of oral health was brought out by interviewees 5 and 6 when they mentioned the multidimensional nature of oral health and its possible impacts on overall health, such as difficulty chewing and the influence this can have on the ingestion and digestion of food:

[...] Your mouth is the most important thing. Have a nice smile. You will eat, eat well, manage to digest food, chew it well. Without teeth, all you can do is lick and you end up swallowing. And that food ends up not even doing you any good (Interviewee 5).

Because if you have a problem and don’t take care of it, you have a cavity, your tooth gets infected and ends up having other types of difficulties. If your mouth is infected, you can’t eat properly, [...], drink a liquid, drink water (Interview 6).

Four interviewees expressed concern about oral cancer and the repercussions it could have on a person’s overall health and only interviewee 10 mentioned the habits of smoking and drinking as risk factors for developing oral cancer (Chart 3). The mention of oral cancer and the perception that this disease can have more severe repercussions on a person’s overall health was an interesting point that emerged in the interviews. However, educational actions are needed to raise awareness of the main risk factors relating to oral cancer, because only one interviewee mentioned any these factors.

Access to oral health services

Travassos and Martins³⁴34 Travassos C, Martins M. Uma revisão sobre os conceitos de acesso e utilização de serviços de saúde. Cad Saude Publica 2004; 20(Supl. 2):190-198. argue that health service use is mediated by accessibility, that is, by characteristics of supply that relate to service use and user behaviour, which is influenced, in turn, by social, cultural, psychological and economic factors.

Four interviewees reported histories of oral health care provided exclusively in public services, four in private services and two, in both public and private services (Chart 4).

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Chart 4
Category “access to oral health services”, according to empirical data from the interviews.

The data on health service use show a balance between public and private oral health-related services. Silva et al.¹⁷17 Silva MEA, Rosa PCF, Neves ACC, Rode SM. Necessidade protética da população quilombola de Santo Antônio do Guaporé-Rondônia-Brasil. São José dos Campos-SP. Braz Dent Sci 2011; 14(1-2):62-66. found that 41.3% of quilombola study participants reported having received dental care from public services. Souza and Flório¹⁶16 Souza MCA, Flório FM. Evaluation of the history of caries and associated factors among quilombolas in Southeastern Brazil. Braz J Oral Sci 2014; 13(3):175-181. found that 57.9% of quilombolas referred mainly to public health services for oral health care. Silva et al.²⁷27 Silva EKP, Santos PS, Chequer TPR, Melo CMA, Santana KC, Amorim MM, Medeiros DS. Saúde bucal de adolescentes rurais quilombolas e não quilombolas: um estudo dos hábitos de higiene e fatores associados. Cien Saude Colet 2018; 23(9):2963-2978. revealed that 22.7% of quilombola adolescents had never had a dental appointment in their lives, in contrast to 10.3% of non-quilombola adolescents. That same study showed that 69% of quilombola adolescents reported using public services for their last dental appointment²⁷27 Silva EKP, Santos PS, Chequer TPR, Melo CMA, Santana KC, Amorim MM, Medeiros DS. Saúde bucal de adolescentes rurais quilombolas e não quilombolas: um estudo dos hábitos de higiene e fatores associados. Cien Saude Colet 2018; 23(9):2963-2978..

When interviewees from the rural community were asked about the ease or difficulty in obtaining health care, seven interviewees reported ease in using health services, without, however, mentioning oral health specifically (Chart 4). In this respect, interviewees cited geographic, organisational and economic health service access barriers resulting from bureaucracy in care services, financial travel expenses and, when using a private service, high-cost treatment incompatible with family income. Interviewees who reported health service accessibility attributed this facility to factors such as more opportunities for being examined, the existence of community health workers to schedule appointments, provision of a dentist at the health post and good reception and care by health personnel.

Three interviewees reported difficulties in using health services (Chart 4), while interviewee 10 mentioned needing to being examined privately to expedite matters (Chart 4). A contrast was noted between the perceived ease of access reported by most of the adults interviewed and self-reported oral health, which was notable, for the most part, for histories of multiple tooth loss combined with the need to have dentures made or replaced (Chart 2). The most typical sociodemographic profile of these adults included low levels of education and income. Lack of education can influence occupation type and income, which are two fundamental predictors for evaluating health differences from an ethnic-racial perspective and for thinking about persisting health inequities¹⁸18 Santos RC, Silva MS. Condições de vida e itinerários terapêuticos de quilombolas de Goiás. Saude Soc 2014; 23(3):1049-1063.^,³⁵35 Williams DR, Jackson PB. Social sources of racial disparities in health. Health Aff 2005; 24(2):325-334..

None of the interviewees reported receiving care at the Dental Specialities Centre (Centro de Especialidades Odontológicas, CEO) in the municipality of Vitória da Conquista, 19 km from this rural district. A case study involving the only two Dental Speciality Centres in the Vitória da Conquista health region observed a lack of specialised oral health services, in addition to organisational difficulties, revealing service management weaknesses and bureaucratic and ritualistic practices incompatible with the coordination and continuity of oral health care³⁶36 Chequer TPR. Organização dos Centros de Especialidades Odontológicas e sua interface com a Atenção Primária à Saúde, na região de saúde de Vitória da Conquista, Bahia [dissertação]. Vitória da Conquista: Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia; 2019..

It was demonstrated that, during the COVID-19 pandemic, only one interviewee used a private dental service, although most interviewees reported some condition amenable to clinical treatment or monitoring (Chart 4). Interviewees 1 and 3 (Chart 4) mentioned being afraid to see a dentist during the pandemic period: It’s difficult for me to go to the dentist, you know? It’s really difficult to go to the dentist. Even more so now, with this pandemic, you’re scared, right? But I really need to (Interviewee 3).

Self-perceived oral health

Self-perceived oral health is considered a good indicator of individual health condition, because it comprises physical, cognitive and emotional aspects and derives from information, experiences and knowledge acquired in a given historical, cultural and social setting that inform the individual’s subjective ability to perceive and assess their own oral health³⁷37 Kreve S, D'Ávila GC, Santos LO, Cândido dos Reis A. Autopercepção da saúde bucal de idosos. Clin Lab Res Dent 2020; 1-9.^,³⁸38 Peres Neto J, Souza MF, Barbosa AMC, Loschiavo LM, Barbieri W, Palacio DC, Miraglia JL. Autopercepção de saúde bucal como indicador de necessidade de tratamento odontológico no Estado de São Paulo, Brasil. J Heal Biol Sci 2021; 9(1):1-6..

Respondents 4, 5 and 7 reported dissatisfaction at their oral health condition, particularly needing to have teeth extracted and to use dentures in order to be able to chew properly, but that they had not undergone these procedures yet, because of financial conditions (Chart 5).

Thumbnail

Chart 5
Category “self-perceived oral health”, according to empirical data from the interviews.

Interviewees also said they felt “weak” due to difficulties chewing and would be happy if they could eat properly and try foods that were hard to chew. These accounts show that oral health is related to aspects of overall health⁸8 Peres MA, Macpherson LMD, Weyant RJ, Daly B, Venturelli R, Mathur MR, Listl S, Celeste RK, Guarnizo-Herreño CC, Kearns C, Benzian H, Allison P, Watt RG. Oral diseases: a global public health challenge. Lancet 2019; 394(10194):249-260.

9 Glick M, Williams DM, Kleinman DV, Vujicic M, Watt RG, Weyant RJ. A new definition for oral health developed by the FDI World Dental Federation opens the door to a universal definition of oral health. J Am Dent Assoc 2016; 147(12):915-917.^-¹⁰10 Petersen PE. The World Oral Health Report 2003: continuous improvement of oral health in the 21st century--the approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol 2003; 31(Supl. 1):3-23.. Conditions favouring social vulnerability influence nutritional and health status, especially as regards food and nutrition security and oral health³⁹39 Braga KP, Dias JG, Oliveira SF, Melo ADS, Paiva SG, Ribeiro PCC. Segurança alimentar e saúde bucal: estudos interdisciplinares sobre limitações para garantia da saúde em uma comunidade quilombola do norte do Tocantins. Amaz Rev Antropol 2020; 12(1):165..

Other interviewees mentioned dental prosthetics. Interviewee 2 was satisfied with the state of his natural teeth, but dissatisfied with the condition of his partial denture, while interviewee 10 reported satisfaction at having extracted those teeth that were in poor condition, while recognising that his oral health could be improved by using a dental prosthesis (Chart 5). Interviewee 3 reported being satisfied with her oral health, even though mentioning that her prosthesis was impossible to use because it fit badly and she had a tooth in a very unhealthy condition (Chart 5).

Seven interviewees mentioned using or needing to use dentures and how to deal with partial or total tooth loss (edentulism). Miranda et al.¹³13 Miranda LP, Oliveira TL, Queiroz PSF, Oliveira PSD, Fagundes LS, Rodrigues Neto JF. Saúde bucal e acesso aos serviços odontológicos em idosos quilombolas: um estudo de base populacional. Rev Bras Geriatr Gerontol 2020; 23(2):e200146. identified a 52% rate of edentulism and 88% need for dental prostheses among elderly people in a QRC. Bidinotto et al.⁴⁰40 Bidinotto AB, D'Ávila OP, Martins AB, Hugo FN, Neutzling MG, Bairros FS, Hilgert JB. Autopercepção de saúde bucal em comunidades quilombolas no Rio Grande do Sul: um estudo transversal exploratório. Rev Bras Epidemiol 2017; 20(1):91-101. found an association between dissatisfaction with oral appearance and chewing ability and worse self-perceived oral health. Lira Júnior et al.⁴¹41 Lira Júnior C, Soares RSC, Menezes TN. Autopercepção de saúde bucal e sua associação com fatores socioeconômicos-demográficos e condição de saúde bucal de idosos quilombolas. Res Soc Develop 2019; 10(10):e116101018462. found that the majority of elderly people with negative self-perceived oral health was associated with the need to use dental prostheses.

Some interviewees reported satisfaction as to their own oral health without displaying clinical needs that might cause any discomfort (interviewees 6 and 9) (Chart 5). When asked about her perception of her oral health, interviewee 1 reported dissatisfaction with her front teeth and difficulty in getting treatment, aggravated by the pandemic context (Chart 5).

The perception of edentulism and use of dental prostheses proved to be common to most of the reports. Tooth extraction was sometimes described with a feeling of regret, sometimes as a strategy, combined with the use of prostheses, to achieve oral health. Souza et al.¹⁵15 Souza MFNS, Sandes LFF, Araújo AMB, Freitas DA. Autopercepção e práticas de saúde bucal entre idosas negras descendentes de escravos no Brasil. Rev Bras Med Fam Comunidade 2018; 13(40):1-10. found that all elderly quilombola women interviewed were partially or completely toothless and that most related tooth loss to natural aging.

Final remarks

Some reports contextualised the relationship between individuals’ oral health and overall health. In addition to tooth decay, oral cancer figured prominently among the oral diseases mentioned. Some interviewees associated health with professional care, self-care (hygiene measures) and being examined as fundamental to achieving or preserving good overall or oral health. This study also revealed popular therapeutic strategies. The results indicated an absence and/or deficiency in oral hygiene at some stage of life, especially in childhood and adolescence. The reports indicated that health services were used, for the most part, in the period before the COVID-19 pandemic and that the procedures most performed were tooth extractions. Respondents from the rural community differed in their perceptions of ease of access to health services.

It is clear from the therapeutic itineraries of the adults studied that an enormous challenge needs to be met to promote oral health at all stages of life, jointly with social inclusion actions to assure basic sanitation, education, plus employment and income promotion policies and others, in order to overcome social inequities, especially those experienced by rural communities of quilombo remnants and also present in this rural community which was studied.

It is necessary to pursue social inclusion strategies as a way of guaranteeing special protection to traditional Afro-descendant populations and, in that way, promote reparation for the historical oppression black Brazilians have been subjected to, given that the denial of these people’s rights and cultural and historical identity has resulted from historical discrimination and structural inequality⁶6 Brasil. Ministério da Saúde (MS). Política Nacional de Saúde Integral da População Negra: uma política para o SUS. 3ª ed. Brasília: MS; 2017.^,⁴²42 Chiavegatto Filho ADP, Beltran-Sánchez H, Kawachi I. Racial disparities in life expectancy in Brazil: Challenges from a multiracial society. Am J Public Health 2014; 104(11):2156-2162.^,⁴³43 Constante HM, Marinho GL, Bastos JL. The door is open, but not everyone may enter: Racial inequities in healthcare access across three brazilian surveys. Cien Saude Colet 2021; 26(9):3981-3990..

This study, based on narratives of experiences of oral health care, examined the interviewees’ experiences in depth. Health situations considered significant from a technical standpoint may not be remembered or valued from the health user’s perspective. This may be considered a limitation of this type of study. However, the lack of standardisation allowed interviewees to choose the course of their narrative, from which the researcher could then recognise the intentionality of the discourse. Silencing can conceal structural violence and historical inequalities. Informed listening, in addition to sensitising family health teams and health managers, gives researchers opportunities to evaluate the results of their day-to-day work, understand the connections between different levels of complexity of Brazil’s Unified Health System and obstacles to health service access and, lastly, obtain an understanding of cosmopolitics, which integrates the health service and the territory. The barriers to accessing health can be understood only by recognising the Other at the different levels of his or her existence.

References

¹
Brasil. Constituição da República Federativa do Brasil de 1988. Diário Oficial da União 1988; 5 out.
²
Leite IB. Os quilombos no Brasil: questões conceituais e normativas. Etnográfica 2000; 4(2):333-354.
³
O'Dwyer EC. Quilombos: identidade étnica e territorialidade. Rio de Janeiro: Editora FGV; 2002.
⁴
Comissão Interamericana de Direitos Humanos (CIDH). Situação de Direitos Humanos no Brasil. Washington, D.C.: CIDH; 2021.
⁵
Brasil. Lei nº 12.288, de 20 de julho de 2010. Institui o Estatuto da Igualdade Racial. Diário Oficial da União; 2010.
⁶
Brasil. Ministério da Saúde (MS). Política Nacional de Saúde Integral da População Negra: uma política para o SUS. 3ª ed. Brasília: MS; 2017.
⁷
Brasil. Ministério da Saúde (MS). Portaria nº 2.866, de 2 de dezembro de 2011. Institui, no âmbito do Sistema Único de Saúde (SUS), a Política Nacional de Saúde Integral das Populações do Campo e da Floresta. Diário Oficial da União; 2013.
⁸
Peres MA, Macpherson LMD, Weyant RJ, Daly B, Venturelli R, Mathur MR, Listl S, Celeste RK, Guarnizo-Herreño CC, Kearns C, Benzian H, Allison P, Watt RG. Oral diseases: a global public health challenge. Lancet 2019; 394(10194):249-260.
⁹
Glick M, Williams DM, Kleinman DV, Vujicic M, Watt RG, Weyant RJ. A new definition for oral health developed by the FDI World Dental Federation opens the door to a universal definition of oral health. J Am Dent Assoc 2016; 147(12):915-917.
¹⁰
Petersen PE. The World Oral Health Report 2003: continuous improvement of oral health in the 21st century--the approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol 2003; 31(Supl. 1):3-23.
¹¹
Oliveira VM, Lira CBC, Oliveira EB, Costa ERG, Gomes MRF, Crispin JCO, Dantas DS, Souza MOF. Saúde da mulher quilombola no Brasil: Uma revisão de literatura. Braz J Develop 2021; 7(10):100848-100866.
¹²
Dias JG, Pereira BL, Ribeiro PC, Monteiro LRL. Flúor na água de abastecimento público em uma comunidade remanescente quilombola. J Bus Techn 2020; 13(1):57-69.
¹³
Miranda LP, Oliveira TL, Queiroz PSF, Oliveira PSD, Fagundes LS, Rodrigues Neto JF. Saúde bucal e acesso aos serviços odontológicos em idosos quilombolas: um estudo de base populacional. Rev Bras Geriatr Gerontol 2020; 23(2):e200146.
¹⁴
Araújo RLMS, Araújo EM, Miranda SS, Chaves JNT, Araújo JA. Extrações dentárias autorrelatadas e fatores associados em comunidades quilombolas do Semiárido baiano, em 2016. Epidemiol Serv Saude 2020; 29(2):e2018428.
¹⁵
Souza MFNS, Sandes LFF, Araújo AMB, Freitas DA. Autopercepção e práticas de saúde bucal entre idosas negras descendentes de escravos no Brasil. Rev Bras Med Fam Comunidade 2018; 13(40):1-10.
¹⁶
Souza MCA, Flório FM. Evaluation of the history of caries and associated factors among quilombolas in Southeastern Brazil. Braz J Oral Sci 2014; 13(3):175-181.
¹⁷
Silva MEA, Rosa PCF, Neves ACC, Rode SM. Necessidade protética da população quilombola de Santo Antônio do Guaporé-Rondônia-Brasil. São José dos Campos-SP. Braz Dent Sci 2011; 14(1-2):62-66.
¹⁸
Santos RC, Silva MS. Condições de vida e itinerários terapêuticos de quilombolas de Goiás. Saude Soc 2014; 23(3):1049-1063.
¹⁹
Gerhartd TE, Riquinho DL. Sobre itinerários terapêuticos em contextos de iniquidade social: desafios e perspectivas contemporâneas. In: Trad LAB, Jorge MSB, Pinheiro R, Mota CS, Rocha AARM, organizadores. Contextos, Parcerias e Itinerários na Produção do Cuidado Integral: Diversidade e Interseções. Rio de Janeiro: CEPESC/IMS/UERJ/ABRASCO; 2015. p. 233-252.
²⁰
Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 14ª ed. São Paulo: Hucitec; 2014.
²¹
Minayo MCS. Sampling and saturation in qualitative research: consensuses and controversies. Rev Pesqui Qual 2017; 5(7):1-12.
²²
Fontanella BJB, Luchesi BM, Saidel MGB, Ricas J, Turato ER, Melo DG. Amostragem em pesquisas qualitativas: Proposta de procedimentos para constatar saturação teórica. Cad Saude Publica 2011; 27(2):389-394.
²³
Minayo MCS, Deslandes SF, Gomes R, organizadores. Pesquisa Social: teoria, método e criatividade. Rio de Janeiro: Vozes; 2016.
²⁴
Freitas DA, Caballero AD, Marques AS, Hernández CIV, Antunes SLNO. Saúde e comunidades quilombolas: uma revisão da literatura. Rev CEFAC 2011; 13(5):937-943.
²⁵
Bezerra VM, Medeiros DS, Gomes KO, Souzas R, Giatti L, Steffens AP, Kochergin CN, Souza CL, Moura CS, Soares DA, Santos LRCS, Cardoso LGV, Oliveira MV, Martins PC, Neves OSC, Guimarães MDC. Inquérito de Saúde em Comunidades Quilombolas de Vitória da Conquista, Bahia, Brasil (Projeto COMQUISTA): Aspectos metodológicos e análise descritiva. Cien Saude Colet 2014; 19(6):1835-1847.
²⁶
Jamieson LM. Racism and oral health inequities; An introduction. Community Dent Health 2021; 38(2):131.
²⁷
Silva EKP, Santos PS, Chequer TPR, Melo CMA, Santana KC, Amorim MM, Medeiros DS. Saúde bucal de adolescentes rurais quilombolas e não quilombolas: um estudo dos hábitos de higiene e fatores associados. Cien Saude Colet 2018; 23(9):2963-2978.
²⁸
Fernandes SL, Santos AO. Itinerários Terapêuticos e Formas de Cuidado em um Quilombo do Agreste Alagoano. Psicol Cien Prof 2019; 39 (n. esp.):e222592.
²⁹
Gomes MS, Mendonça AKP, Cordeiro TO, Barbosa MM. Uso De Plantas Medicinais Na Odontologia: Uma Revisão Integrativa. Rev Cien Saude Nov Esper 2020; 18(2):118-126.
³⁰
Monteiro MH, Fraga S. Fitoterapia na Odontologia: Levantamento dos Principais Produtos de Origem Vegetal para Saúde Bucal. Rev Fitos 2015; 9(4):265-268.
³¹
Arruti JM. Políticas públicas para quilombos: Terra, saúde e educação. In: Paula M, Heringer R, organizadores. Caminhos convergentes: Estado e sociedade na superação das desigualdades raciais. Rio de Janeiro: Fundação Heinrich Boll; 2009. p. 75-110.
³²
Gonçalves LG. Associação entre perda dentária e desigualdades relacionadas à cor da pele em adultos: resultados do estudo pró-saúde [dissertação]. Porto Alegre: Universidade Federal do Rio Grande do Sul; 2011.
³³
Maia LC, Costa SM, Martelli DRB, Caldeira AP. Edentulismo total em idosos: envelhecimento ou desigualdade social? Rev Bioetica 2020; 28(1):173-181.
³⁴
Travassos C, Martins M. Uma revisão sobre os conceitos de acesso e utilização de serviços de saúde. Cad Saude Publica 2004; 20(Supl. 2):190-198.
³⁵
Williams DR, Jackson PB. Social sources of racial disparities in health. Health Aff 2005; 24(2):325-334.
³⁶
Chequer TPR. Organização dos Centros de Especialidades Odontológicas e sua interface com a Atenção Primária à Saúde, na região de saúde de Vitória da Conquista, Bahia [dissertação]. Vitória da Conquista: Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia; 2019.
³⁷
Kreve S, D'Ávila GC, Santos LO, Cândido dos Reis A. Autopercepção da saúde bucal de idosos. Clin Lab Res Dent 2020; 1-9.
³⁸
Peres Neto J, Souza MF, Barbosa AMC, Loschiavo LM, Barbieri W, Palacio DC, Miraglia JL. Autopercepção de saúde bucal como indicador de necessidade de tratamento odontológico no Estado de São Paulo, Brasil. J Heal Biol Sci 2021; 9(1):1-6.
³⁹
Braga KP, Dias JG, Oliveira SF, Melo ADS, Paiva SG, Ribeiro PCC. Segurança alimentar e saúde bucal: estudos interdisciplinares sobre limitações para garantia da saúde em uma comunidade quilombola do norte do Tocantins. Amaz Rev Antropol 2020; 12(1):165.
⁴⁰
Bidinotto AB, D'Ávila OP, Martins AB, Hugo FN, Neutzling MG, Bairros FS, Hilgert JB. Autopercepção de saúde bucal em comunidades quilombolas no Rio Grande do Sul: um estudo transversal exploratório. Rev Bras Epidemiol 2017; 20(1):91-101.
⁴¹
Lira Júnior C, Soares RSC, Menezes TN. Autopercepção de saúde bucal e sua associação com fatores socioeconômicos-demográficos e condição de saúde bucal de idosos quilombolas. Res Soc Develop 2019; 10(10):e116101018462.
⁴²
Chiavegatto Filho ADP, Beltran-Sánchez H, Kawachi I. Racial disparities in life expectancy in Brazil: Challenges from a multiracial society. Am J Public Health 2014; 104(11):2156-2162.
⁴³
Constante HM, Marinho GL, Bastos JL. The door is open, but not everyone may enter: Racial inequities in healthcare access across three brazilian surveys. Cien Saude Colet 2021; 26(9):3981-3990.

SciELO Data link:
https://data.scielo.org/dataset.xhtml?persistentId=doi:10.48331/scielodata.GH6SME

Publication Dates

Publication in this collection
04 Mar 2024
Date of issue
Mar 2024

History

Received
11 Apr 2023
Accepted
13 June 2023
Published
15 June 2023

Este é um artigo publicado em acesso aberto sob uma licença Creative Commons

[1] ¹
Brasil. Constituição da República Federativa do Brasil de 1988. Diário Oficial da União 1988; 5 out.

[2] ²
Leite IB. Os quilombos no Brasil: questões conceituais e normativas. Etnográfica 2000; 4(2):333-354.

[3] ³
O'Dwyer EC. Quilombos: identidade étnica e territorialidade. Rio de Janeiro: Editora FGV; 2002.

[4] ⁴
Comissão Interamericana de Direitos Humanos (CIDH). Situação de Direitos Humanos no Brasil. Washington, D.C.: CIDH; 2021.

[5] ⁵
Brasil. Lei nº 12.288, de 20 de julho de 2010. Institui o Estatuto da Igualdade Racial. Diário Oficial da União; 2010.

[6] ⁶
Brasil. Ministério da Saúde (MS). Política Nacional de Saúde Integral da População Negra: uma política para o SUS. 3ª ed. Brasília: MS; 2017.

[7] ⁷
Brasil. Ministério da Saúde (MS). Portaria nº 2.866, de 2 de dezembro de 2011. Institui, no âmbito do Sistema Único de Saúde (SUS), a Política Nacional de Saúde Integral das Populações do Campo e da Floresta. Diário Oficial da União; 2013.

[8] ⁸
Peres MA, Macpherson LMD, Weyant RJ, Daly B, Venturelli R, Mathur MR, Listl S, Celeste RK, Guarnizo-Herreño CC, Kearns C, Benzian H, Allison P, Watt RG. Oral diseases: a global public health challenge. Lancet 2019; 394(10194):249-260.

[9] ⁹
Glick M, Williams DM, Kleinman DV, Vujicic M, Watt RG, Weyant RJ. A new definition for oral health developed by the FDI World Dental Federation opens the door to a universal definition of oral health. J Am Dent Assoc 2016; 147(12):915-917.

[10] ¹⁰
Petersen PE. The World Oral Health Report 2003: continuous improvement of oral health in the 21st century--the approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol 2003; 31(Supl. 1):3-23.

[11] ¹¹
Oliveira VM, Lira CBC, Oliveira EB, Costa ERG, Gomes MRF, Crispin JCO, Dantas DS, Souza MOF. Saúde da mulher quilombola no Brasil: Uma revisão de literatura. Braz J Develop 2021; 7(10):100848-100866.

[12] ¹²
Dias JG, Pereira BL, Ribeiro PC, Monteiro LRL. Flúor na água de abastecimento público em uma comunidade remanescente quilombola. J Bus Techn 2020; 13(1):57-69.

[13] ¹³
Miranda LP, Oliveira TL, Queiroz PSF, Oliveira PSD, Fagundes LS, Rodrigues Neto JF. Saúde bucal e acesso aos serviços odontológicos em idosos quilombolas: um estudo de base populacional. Rev Bras Geriatr Gerontol 2020; 23(2):e200146.

[14] ¹⁴
Araújo RLMS, Araújo EM, Miranda SS, Chaves JNT, Araújo JA. Extrações dentárias autorrelatadas e fatores associados em comunidades quilombolas do Semiárido baiano, em 2016. Epidemiol Serv Saude 2020; 29(2):e2018428.

[15] ¹⁵
Souza MFNS, Sandes LFF, Araújo AMB, Freitas DA. Autopercepção e práticas de saúde bucal entre idosas negras descendentes de escravos no Brasil. Rev Bras Med Fam Comunidade 2018; 13(40):1-10.

[16] ¹⁶
Souza MCA, Flório FM. Evaluation of the history of caries and associated factors among quilombolas in Southeastern Brazil. Braz J Oral Sci 2014; 13(3):175-181.

[17] ¹⁷
Silva MEA, Rosa PCF, Neves ACC, Rode SM. Necessidade protética da população quilombola de Santo Antônio do Guaporé-Rondônia-Brasil. São José dos Campos-SP. Braz Dent Sci 2011; 14(1-2):62-66.

[18] ¹⁸
Santos RC, Silva MS. Condições de vida e itinerários terapêuticos de quilombolas de Goiás. Saude Soc 2014; 23(3):1049-1063.

[19] ¹⁹
Gerhartd TE, Riquinho DL. Sobre itinerários terapêuticos em contextos de iniquidade social: desafios e perspectivas contemporâneas. In: Trad LAB, Jorge MSB, Pinheiro R, Mota CS, Rocha AARM, organizadores. Contextos, Parcerias e Itinerários na Produção do Cuidado Integral: Diversidade e Interseções. Rio de Janeiro: CEPESC/IMS/UERJ/ABRASCO; 2015. p. 233-252.

[20] ²⁰
Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 14ª ed. São Paulo: Hucitec; 2014.

[21] ²¹
Minayo MCS. Sampling and saturation in qualitative research: consensuses and controversies. Rev Pesqui Qual 2017; 5(7):1-12.

[22] ²²
Fontanella BJB, Luchesi BM, Saidel MGB, Ricas J, Turato ER, Melo DG. Amostragem em pesquisas qualitativas: Proposta de procedimentos para constatar saturação teórica. Cad Saude Publica 2011; 27(2):389-394.

[23] ²³
Minayo MCS, Deslandes SF, Gomes R, organizadores. Pesquisa Social: teoria, método e criatividade. Rio de Janeiro: Vozes; 2016.

[24] ²⁴
Freitas DA, Caballero AD, Marques AS, Hernández CIV, Antunes SLNO. Saúde e comunidades quilombolas: uma revisão da literatura. Rev CEFAC 2011; 13(5):937-943.

[25] ²⁵
Bezerra VM, Medeiros DS, Gomes KO, Souzas R, Giatti L, Steffens AP, Kochergin CN, Souza CL, Moura CS, Soares DA, Santos LRCS, Cardoso LGV, Oliveira MV, Martins PC, Neves OSC, Guimarães MDC. Inquérito de Saúde em Comunidades Quilombolas de Vitória da Conquista, Bahia, Brasil (Projeto COMQUISTA): Aspectos metodológicos e análise descritiva. Cien Saude Colet 2014; 19(6):1835-1847.

[26] ²⁶
Jamieson LM. Racism and oral health inequities; An introduction. Community Dent Health 2021; 38(2):131.

[27] ²⁷
Silva EKP, Santos PS, Chequer TPR, Melo CMA, Santana KC, Amorim MM, Medeiros DS. Saúde bucal de adolescentes rurais quilombolas e não quilombolas: um estudo dos hábitos de higiene e fatores associados. Cien Saude Colet 2018; 23(9):2963-2978.

[28] ²⁸
Fernandes SL, Santos AO. Itinerários Terapêuticos e Formas de Cuidado em um Quilombo do Agreste Alagoano. Psicol Cien Prof 2019; 39 (n. esp.):e222592.

[29] ²⁹
Gomes MS, Mendonça AKP, Cordeiro TO, Barbosa MM. Uso De Plantas Medicinais Na Odontologia: Uma Revisão Integrativa. Rev Cien Saude Nov Esper 2020; 18(2):118-126.

[30] ³⁰
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[31] ³¹
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Theme	Core meanings	Interviews					Total recurrences
Theme	Core meanings		2	3	4	5	6	7	8	9	10
Therapeutic itineraries in oral health for quilombola adults in a rural district of Vitória da Conquista, Bahia.	Oral health care	x	x	x	x	x	x	x	x	x	x	10
	Toothache as a clinical complaint at a certain point in life	x		x	x	x	x	x	x		x	8
	Accessibility of oral health services	x	x	x	x	x	x	x	x	x	x	10
	Report of poor oral health conditions at a certain stage of life	x		x	x	x		x	x		x	7
	Relationship between oral health and overall health	x	x	x	x	x	x	x	x	x	x	10
	Report of the possibility of an oral health condition adversely affecting a person’s social life	x		x	x	x	x	x	x	x		8
	Popular oral health practices	x	x		x	x	x		x		x	7
	Report of gum disease	x	x	x	x		x				x	6
	Report of cavities		x		x	x	x	x				5
	Report of oral cancer		x		x						x	3
	Self-perceived oral health	x	x	x	x	x	x	x	x	x	x	10
	Report of current use of dental prosthesis		x	x					x			3
	Report of a history of support from friends or family for interviewee or someone else to access oral health services		x	x		x			x		x	5
	Regular visits to the dentist to have oral health			x		x				x	x	4
	Report of the need to use or replace a dental prosthesis				x	x		x			x	4
Frequency of appearance of new types of statement (meanings) in each interview		9	4	1	1	0	0	0	0	0	0

Theme	Therapeutic itineraries in oral health of quilombola adults in a rural district of Vitória da Conquista, Bahia
Thematic category	Record Units
Oral health care	Interviewer: Talk about your life story, from childhood to the present day, thinking of the condition of your mouth and teeth and oral health care. Interviewee 01: “[...] So, before, it was very difficult for us to go to a dentist and when we went to the dentist, it was to have the tooth pulled out, there was no such thing as treatment”. Interviewee 02: “In my day, when I was a teenager, I generally had a lot of toothache, didn’t I? I would even have treatment, get a filling. Then, soon after, again I’d have to have another filling done. Now, in my adult life, it’s better [...]”. Interviewee 03: “From when I was ten, I already looked after my health”. Interviewee 04: “[...] My mother always took care of us, didn’t she? [...] There were times when we didn’t even brush our teeth, back then. We’d splash some water in our mouths, go to school and ‘cleaned them’ [...]”. Interviewee 05: “The care was very precarious, because it was up to us ourselves. [...] We used to go out to the fields, with our father, come back. [...] We’d get there (to school), the teachers didn’t care either at that time, people had almost no oral hygiene. So, today I suffer the consequences. All my teeth are falling out [...]”. Interviewee 06: “[...] In terms of oral care, I think that when we were children we didn’t take much care, because parents used to go out to work and didn’t have the time to be helping their children. [...] There was hygiene, but it wasn’t like what we do today. Sometimes I would even go all day without cleaning or even more than a day [...]”. Interviewee 07: “[...] And our mothers didn’t care, almost didn’t bother, did they? Then you’d get a toothache and we’d put some medicine on to relieve the pain. [...] Today, people are charging R$ 50.00, R$ 40.00 to pull a tooth. Money is really, really scarce. There’s times when we can even pay for water, electricity, buy food at home. That’s the way things are.” Interviewee 08: “[..] I haven’t got any teeth anymore. [...] My mother used to brush our teeth when we was little. It was our mother who brushed our teeth. Then when we started to grow up, it’s us who brushed. We brushed.” Interviewee 09: “When I was a child, I didn’t use to go to the dentist, because there wasn’t one. Then we didn’t know what a dentist was. It’s not long I started going to the dentist. [...] My father and mother taught us to take care of our teeth, brush our teeth well and our tongue.” Interviewee 10: “She (mother) took care, because my mother bought us toothbrushes. Then I started to get old, my teeth started to go bad, so I had all my teeth out [...]”. Interviewer: How do you take care of your teeth or prosthesis (“plate”) on a daily basis? Interviewee 01: “I brush in the morning, after I get up, after breakfast I brush, I brush midday after lunch and at night, when I go to sleep [...]”. Interviewee 02: “[...] Every time I eat, I brush, I take off the prosthesis, I clean it well, brush it really thoroughly, understand? Just like I brush my teeth.” Interviewee 03: “[...] I brush three times a day”. Interviewee 04: “[...] I brush my teeth early in the morning, brush them midday and brush them at night. Before going to sleep, I brush my teeth well. You have to brush your tongue. [...]” Interviewee 05: “[...] Just brushing, that’s all”. Interviewee 06: “[...] During the day, only sometimes, when I eat something that really bothers me, but really brushing properly, which I do, I try to do the way I’ve learned, in the morning and at night”.
Oral health care	Interviewee 07: “I brush early, I brush midday, after lunch, I brush at night after I go in to sleep. Three times a day”. Interviewee 08: “[...] I finish eating, I brush. I go to sleep at night, I brush. Early in the morning I get up, I brush. It’s all brushed. I take good care of my (prosthesis). Interviewee 09: “I always brush, I use an ‘oral’ (mouthwash), I brush my tongue, my teeth and, every so often, I see a doctor for a cleaning, at the dentist’s”. Interviewee 10: “I clean. I brush everything, on my tongue, under my tongue, I brush my gums, I brush everything.” Interviewer: Have you ever used any tea or home remedy or charm to solve a problem in your mouth or teeth? Talk about that experience. Interviewee 01: “[...] there is a little bush, with a little flower, we used to pull off that little flower, I just don’t remember the name. Then, we’d take out that little piece and put it in the hole in the tooth, then you’d fall asleep. I even used it.” Interviewee 02: “I remember once I had a bad toothache. They recommended making potato leaf tea and rinsing your mouth with it. I made the tea, I did. I used it [...]”. Interviewee 04: “Only when we pulled off, [...] we were taught that potato leaves were good for rinsing, so as not to inflame too much. Just that. And Pedra hume [Myrcia sphaerocarpa]”. Interviewee 05: “[...] I used to rinse my mouth with vinegar, salt and some leaves of a bush we have, some roots, to bring down the swelling, to rinse, stop the pain. [...] I used the “desinchadeira” [plant with anti-inflamatory properties] and [...] I was in pain, I rinsed with it. I also use that pomegranate peel.” Interviewee 06: “[...] It was hurting, so I put water with salt on it, but I didn’t drink it. I just put it in [my mouth].” Interviewee 08: “[...] I washed with [Erythrina] mulungu bark, which is very good for bringing down inflammation of the gums and teeth”. Interviewee 10: “I remember. I remember. We used to rinse our teeth, something like that... salt water, [...]a remedy, a cashew leaf, something to reduce inflammation in our teeth”.

Theme	Therapeutic itineraries of quilombola adults for oral health in a rural district of Vitória da Conquista, Bahia
Thematic category	Record Units
Relationship between oral health and overall health	Interviewer: Comment on what it is to be healthy. Interviewee 01: “I think like this, we need to take more care, we need to go to a dentist. A mouth, tooth thing brings a lot of health problems. So, I think it’s good for us to go more to the dentist thing, because it’s much better these day to take care of your health.” Interviewee 02: “A person’s got to take care of themselves, isn’t that right? To be healthy, right? You generally have to examined when necessary [...]”. Interviewee 03: “Take care, right? Look after your body, look after your health, go to the doctor now and then, take the right medicine. I always worry about my health.” Interviewee 04: “What does it mean to be healthy? I think it’s always following the things you have to follow, the rules... the hygiene thing. I think that’s it.” Interviewee 06: “Being healthy is not only looking after your oral hygiene, your own hygiene, but also adapting some situations in your life to reduce things that lead to some kind of illness, like diet, exercise”. Interviewee 08: “[..] You have to take medicine, you have to be examined, you have to do all that”. Interviewee 09: “Take good care, of your health. [...] You have to do it, see a doctor, see a dentist to have better health”. Interviewee 10: “Health? It’s being... You have to take good care of yourself, look after your health, take good care..., wash your hands, wash them properly. Brushing... even if you’ve got no teeth, you brush your mouth just the same [...]”. Interviewer: Do you think the condition of your mouth and teeth can affect your health? Comment on your answer. Interviewee 01: “I think it can, it brings a lot of things, your mouth brings a lot of health problems, you have to take care. [...] It can even cause that cancer thing, which these days you can have, the mouth thing and you can get cancer, you can have other problems too”. Interviewee 02: “I think it’s important, because what commands... what really commands in part... other parts, right? It’s the mouth, right? You’ve always got to have ideal oral hygiene, always brush your teeth after eating. If you eat, you brush so as to keep your teeth, because generally if you don’t have good oral hygiene you can generally catch a serious disease in your mouth. Isn’t that right? And these diseases, there are certain types of diseases that are difficult to combat, especially cancer, right? Generally, you see in the statistics a lot of people having problems because of not having oral hygiene, you know? Causing mouth cancer. And when it actually causes cancer, it’s difficult to fight.” Interviewee 03: “Yes, it does have an effect. I mean you’re eating something, then whatever bacteria there are... they come and go down. [...] Because there are bacteria that go down. Some go to the lungs, others go to the heart vein. Dentists always warn you, don’t they?” Interviewee 04: “It can (have an effect). Even more like, the same glass you use. Even talking, I think it has an effect. [...] I have an idea, because like, when my grandchildren are here, my husband even then has this thing of taking food and eating, taking it from his mouth and putting it in the child’s mouth. Or blowing on it to cool it down, because I don’t do that.”.
Relationship between oral health and overall health	Interviewee 05: “It does have an effect. I’m not a doctor, I don’t have that much education, but I’m sure it has an effect. [...] It can. And if you don’t take care, there’s even danger of getting cancer in your mouth or tooth. [...] Interviewee 06: “I don’t know how to explain it like, in general, but if you don’t take good care of hygiene in your mouth, you can get bad breath and, when you get somewhere where you talk to someone closer, you can end up, right, spreading bad breath and that is upsetting, because it has happened to me and it happened like another person arriving at the same time as you’re talking and there’s that situation. So, that’s what I think.” Interviewee 07: “It can cause a lot of problems of disease in the body, headaches. Body pains. Migraine pain. And your mouth is most important. It brings you better health.” Interviewee 08: It does have an effect. [...] It can have an effect, because when I had some bad teeth in my mouth, I had headache. I felt so many things. After I pulled them... had them all out, it got better. I don’t feel any of that anymore.” Interviewee 09: “Yes, it can. [...] There’s no problem, many tooth problems harm your health.” Interviewee 10: “Yes. I think it can. Sure. [...] It can if your mouth is bad, you can get mouth cancer. There’s mouth cancer. There’s all sorts. And the person looks after their mouth, their health, you don’t get those things. [...] Not smoking, not drinking. Not doing any of that in your life to have a healthy mouth.”

Theme	Therapeutic itineraries of quilombola adults for oral health in a rural district of Vitória da Conquista, Bahia
Thematic category	Record Units
Accessibility to oral health services	Interviewer: For people living in a rural quilombola community, is it easier or more difficult to get healthcare services? Comment on your answer. Interviewee 01: “To me, I don’t think it’s very easy, no, because sometimes, when we need to, there’s so much democracy (bureaucracy) there for us to get over. [...] I think it’s more difficult, it’s a little difficult, because until we manage it, it’s difficult, at least through the post, or even privately, it’s difficult, because the business of teeth, when you set out to be able to get treatment, it’s very expensive. I mean, you know that a wage is for upkeep at home. So, no way is there any left over to be able to take care of your mouth.” Interviewee 02: “In my opinion, it makes it easier, because generally when you live in urban areas, the service in urban areas, I don’t think is the same as in rural areas. Understand? Because here... here whenever you need to here, you go to a clinic, you are seen. Understand? And there in urban areas, especially now, after this pandemic, for you to get to be examined, the bureaucracy’s tough”. Interviewee 03: “I think it’s more difficult. [...] Because... about the health posts, because here there’s only the posts over the other side of [...]. Everyone here goes there. Here (in the locality) there is none. There (at the main office) it’s difficult.” Interviewee 04: “It’s easier for those who live here in the quilombolas, because there’s a health worker. If you need to, you can go to them.” Interviewee 05: “I think it’s easier. I’m almost certain”. Interviewee 06: “I say this because I’m not familiar with the urban area, I believe that the difficulty here in the quilombo is just because of the financial aspect, because the doctors are not always in the area, but I believe it’s easier.” Interviewee 07: “Easier. [...] Because there are health workers who help us. There’s the... They come and warn us. Then it gets more difficult. Easier”. Interviewee 08: “It’s easier. [...] Every time we go to the [...] to be examined, we are well received there. Thank God. In the town too, at the posts too that I’ve been to, everything is well received.” Interviewee 09: “Certainly (easier)”. Interviewee 10: “I think it’s difficult. [...] There are times when you pay to be seen, because the SUS takes years to see you.” Interviewer: Before the COVID-19 pandemic, did you ever have treatment for your teeth or mouth from a dentist at the health centre or at the Dental Specialities Centre (Centro de Especialidades Odontológicas, CEO) or from a dentist in a private practice or from an association or union? If so, talk about your experience. Interviewee 1: “It was (at a health post). [...] Yes, I’ve done it privately [...]”. Interviewee 2: “I’ve heard of (the CEO), but I’ve never been. [...] The treatment by the (private) dentist there was very good, it was excellent. [...] That was before the pandemic”. Interviewee 3: “It was (dental care) before (the pandemic). Long before (the pandemic). [...]It was private. I paid”.
Accessibility to oral health services	Interviewee 4: “Only here (in the rural location) [...] and only at the time when I had a tooth out near Anagé [...] when the dentist used to come here and I just had the tooth out, that’s all. [...] He was a dentist (treatment when he was young) who came from Conquista. Then he used to come to rural areas and we would ‘‘took it out’’, but that was paid. We paid.” Interviewee 5: “Well before (the pandemic). [...] It was at the dentist at the post. [...] At the health post. It was actually my son who got me an appointment there in Barra do Choça. [...] In Conquista, I never had a tooth pulled. I had teeth out right here, on the farm.” Interviewee 6: “Yes. [...] It was at the dentist of the [health] team here, which is part of the locality. I was treated for cavities even though I was cleaning.” Interviewee 7: “It was always here at the health post”. Interviewee 8: “[...] A little [health] post there. [...] It was right here. [...]. I don’t think I’ve ever had a tooth out and had to pay for it, no. It was all covered by the municipal government.” Interviewee 9: “I went to a dentist. [...] Private”. Interviewee 10: “[...] It was at a private dentist, paid for. It was paid. I paid”. Interviewer: During the COVID-19 pandemic, did you ever have treatment for your teeth or mouth from a dentist at the health centre or at the Dental Specialties Centre (Centro de Especialidades Odontológicas, CEO) or from a dentist in a private practice or from an association or union? If so, talk about your experience. Interviewee 1: “Since then, I haven’t needed to. I have some problems in my mouth, as I’m telling you, which I still have, I have these cavities in these front teeth, but you leave it, you’re not feeling pain or anything and so you leave it. I wasn’t.. [...] Among other things, because of the pandemic, there are things that we are leaving to be desired, we are not going, because of the pandemic as well, because right away we are scared of going out”. Interviewee 2: “I went to the dentist, I even told you, that I did the... the tooth business,.... the restoration. [...] During the pandemic. [...] It was at the union.” Interviewee 3: “No”. Interviewee 4: “No”. Interviewee 5: “I did need to, but I didn’t, no, now during the pandemic”. Interviewee 6: “No”. Interviewee 7: “I never got to go.” Interviewee 8: “I didn’t do it, because, for now, there’s no problem.” Interviewee 9: “I didn’t need to”.

Saúde Pública

Saúde Pública

Therapeutic itineraries of quilombola adults for oral health care in a rural district of Bahia, Brazil

Abstract

Introduction

Methodology

Results and discussion

Oral health care

Relationship between oral health and overall health

Access to oral health services

Self-perceived oral health

Final remarks

References

SciELO Data link:

Publication Dates

History