Abstract

Introduction

The undergraduate curriculum and the selection of knowledge contained in it are cultural artifacts and, as such, gravitate in fields of power dispute, influence and conquest of meanings, in the scope of the pursuit of cultural hegemony¹1. Silva TT. Currículo e identidade social: territórios contestados. In: Silva TT, organizador. Alienígenas na sala de aula: introdução aos estudos culturais em educação. 11a ed. Petrópolis: Vozes; 2018. in distinct fields in the academic time and space.

Curricular choices are impregnated with cultural representations that reveal hierarchies between knowledges and actions. Cultural representations establish habits and values according to collective interests, associated with the construction of identities, productions, consumptions and regulations, arranged in a continuous circuit²2. Du Gay P, Hall S, Janes L, Mackay H, Negus K. Doing cultural studies: the story of the Sony Walkman. 2a ed. London: Sage; 2013.,³3. Hall S. A identidade cultural na pós-modernidade. 10a ed. Rio de Janeiro: DP&A; 2016.. The set of knowledges considered important or secondary in the curricular guidelines involves different practices, which ensure institutionalization and the celebration of learning and specific competencies, as well as the graduates’ profile¹1. Silva TT. Currículo e identidade social: territórios contestados. In: Silva TT, organizador. Alienígenas na sala de aula: introdução aos estudos culturais em educação. 11a ed. Petrópolis: Vozes; 2018.,⁴4. Germinari GD, Pedroso D. Educação escolar e currículo: uma abordagem cultural. Rev Dialogo Educ. 2017; 17(53):843-65..

In dentistry education, which is (or used to be) predominantly established in the autonomous and private job market, without the possibility of analyzing its inclusion in the Brazilian National Health System (SUS), the tradition of more than a century is revealed in a culture that is solidly centered on technology and monopolized by the development of skills and attitudes for a competent biomechanical and specialized intervention in oral disease sequelae⁵5. Souza Nétto OB, Moura MS, Lima MDM, Lages GP, Mendes RG, Moura LFAD. O pró-saúde no curso de Odontologia na Universidade Federal do Piauí: relato de uma vivência de cinco anos. Cienc Cuid Saude. 2013; 12(2):391-7.

6. Haddad AE, Laganá DC, Assis EQ, Morita MC, Toledo OA, Rode SM, et al. A aderência dos cursos de graduação em Odontologia às Diretrizes Curriculares Nacionais. In: Brasil. Ministério da Saúde. Ministério da Educação. A aderência dos cursos de graduação em Enfermagem, Medicina e Odontologia às diretrizes curriculares nacionais. Brasília: Ministério da Saúde; 2006. p. 119-52. (Série F, Comunicação e Educação na Saúde).

7. Morita MC, Kriger L, Carvalho ACP, Haddad AE. Implantação das diretrizes curriculares nacionais em Odontologia. 2a ed. Maringá: Dental Press, Abeno, OPS, MS; 2013.-⁸8. Zilbovicius C, Araujo ME, Botazzo C, Frias AC, Junqueira SR, Junqueira CR. A paradigm shift in predoctoral dental curricula in Brazil: evaluating the process of change. J Dent Educ. 2011; 75(4):557-64..

The Brazilian Constitution of 1988, in its article 200, item III, highlights health as a right of all and a duty of the State, and the SUS’ organizing role in the education of human resources in the health sector⁹9. Brasil. Constituição (1988). Constituição da República Federativa do Brasil. Brasília, DF: Senado Federal; 1988.. The publication of the National Curricular Guidelines (DCN), in 2002¹⁰10. Brasil. Ministério da Educação. Resolução CNE/CES 3, de 19 de Fevereiro de 2002. Institui Diretrizes Curriculares Nacionais do Curso de Graduação em Odontologia. Brasília, DF: Ministério da Educação; 2002., and of different interministerial reorientation policies in the fields of education and health in the subsequent years, induced reformulation processes of pedagogical projects and curricula of the health courses¹¹11. Barreto LDSO, Guimarães Campos VD, Dal Poz MR. Interprofessional education in healthcare and health workforce (HRH) planning in Brazil: experiences and good practices. J Interprof Care. 2019; 33(4):369-81. Doi: http://dx.doi.org/10.1080/13561820.2019.1646230.
http://dx.doi.org/10.1080/13561820.2019.... ,¹²12. Silveira JLGC, Kremer MM, Silveira MEUC, Schneider ACTC. Percepções da integração ensino-serviço-comunidade: contribuições para a formação e o cuidado integral em saúde. Interface (Botucatu). 2020; 24:e190499.. All the legal frameworks had, as an image-objective in Dentistry, an education that problematizes the oral health conditions of the Brazilian population, the national, regional and local organizational arrangement of the public oral health systems, and the education of humanistic and critical-reflective dental surgeons¹⁰10. Brasil. Ministério da Educação. Resolução CNE/CES 3, de 19 de Fevereiro de 2002. Institui Diretrizes Curriculares Nacionais do Curso de Graduação em Odontologia. Brasília, DF: Ministério da Educação; 2002..

The formulation and implementation of teaching-service-community integration (TSCI), through articulation efforts between the health system and the higher education system, are materialized in the inclusion of students and teachers in the healthcare networks under development in Brazil, with interesting experiences discussed both in the national¹¹11. Barreto LDSO, Guimarães Campos VD, Dal Poz MR. Interprofessional education in healthcare and health workforce (HRH) planning in Brazil: experiences and good practices. J Interprof Care. 2019; 33(4):369-81. Doi: http://dx.doi.org/10.1080/13561820.2019.1646230.
http://dx.doi.org/10.1080/13561820.2019....

12. Silveira JLGC, Kremer MM, Silveira MEUC, Schneider ACTC. Percepções da integração ensino-serviço-comunidade: contribuições para a formação e o cuidado integral em saúde. Interface (Botucatu). 2020; 24:e190499.-¹³13. Vendruscolo C, Ferraz F, Prado ML, Kleba ME, Reibnitz KS. Teaching-service integration and its interface in the context of reorienting health education. Interface (Botucatu). 2016; 20(59):1015-25. and international¹⁴14. Hobson RS. A view of European challenges in dental education. Br Dent J. 2009; 206(2):65-6.

15. Piskorowski WA, Stenafac SJ, Fitzgerald M, Green TG, Krell RE. Influence of community-based dental education on dental students’ preparation and intent to treat underserved populations. J Dent Educ. 2012; 76(4):534-9.

16. McQuistan MR, Mohamad A, Kuthy RA. Association between dentists’ participation in charitable care and community-based dental education. J Dent Educ. 2014; 78(1):110-8.-¹⁷17. Formicola AJ, Bailit HL. Community-based dental education: history, current status, and future. J Dent Educ. 2012; 76(1):98-106. spheres. This two-way regulation (education-health) also implies the development of curricular components, research and extension projects, and the amplified and diversified education of students, with all the complexities involved, inclusively in the field of the established narrative and cultural disputes¹²12. Silveira JLGC, Kremer MM, Silveira MEUC, Schneider ACTC. Percepções da integração ensino-serviço-comunidade: contribuições para a formação e o cuidado integral em saúde. Interface (Botucatu). 2020; 24:e190499.,¹³13. Vendruscolo C, Ferraz F, Prado ML, Kleba ME, Reibnitz KS. Teaching-service integration and its interface in the context of reorienting health education. Interface (Botucatu). 2016; 20(59):1015-25..

The presence of students and teachers in supervised internships in the SUS, democratically articulated with municipal governments and multiprofessional health teams, potentializes reciprocal learning and contributes to the outline of an educational culture that addresses the daily challenges of the public health policy, whether they are related to healthcare, surveillance, management, permanent education or regulation, among others.

Supervised internships bring singular issues to the educational dynamics, such as: the pedagogical roles of the preceptor (worker); the polyphony of the triptych teaching-learning setting: primary care unit-territory-catchment population; and, last but not least, the interaction with the plurality of working processes and conditions, like a realistic academic rehearsal of professionalism.

Paradoxically, the supervised internships have been undergoing a semantic and identity crisis since the publication of the DCN: they should not be understood, in a utilitarian way, solely as educational practices of colonizing hygienist bonomy nor as clinical exercises performed outside the university environment¹⁸18. Werneck MAF, Senna MIB, Drumond MM, Lucas SD. Nem tudo é estágio: contribuições para o debate. Cienc Saude Colet. 2010; 15(1):221-31., but as polysemic experiences in health territories.

The study aimed to analyze teaching-service-community integration in a Dentistry course based on curricular internships, seen in the perspective of health workers, students, users, managers and teachers.

Method

A case study¹⁹19. Yin RK. Estudo de caso: planejamento e métodos. 5a ed. Porto Alegre: Bookman; 2015. was carried out to investigate the meanings and intentions of the teaching-service-community integration (TSCI) process, based on the curricular internships of a Dentistry course, performed at a Family Health Unit of a capital city in the Brazilian Northeastern region.

It is a cultural representation study²2. Du Gay P, Hall S, Janes L, Mackay H, Negus K. Doing cultural studies: the story of the Sony Walkman. 2a ed. London: Sage; 2013.,³3. Hall S. A identidade cultural na pós-modernidade. 10a ed. Rio de Janeiro: DP&A; 2016. that aimed to amplify and diversify the investigations about TSCI - an important theme for the contemporary reforms of undergraduate Dentistry courses in Brazil. The importance of the study of cultural representations lies in the fact that they establish connections between the meanings of the knowledge contained in the undergraduate curriculum and the practices developed in curricular internships.

The Dentistry course investigated in the present research belongs to a federal higher education institution founded 65 years ago. In 2002, the institution proposed a curricular guideline that includes supervised internships, in which the first four modules are taken in the course’s initial two years and are under the responsibility of collective health teachers. The modules total 120 hours - 30 in each semester²⁰20. Forte FDS, Pontes AA, Morais HGF, Barbosa AS, Sousa Nétto OB. Olhar discente e a formação em Odontologia: interseções possíveis com a Estratégia Saúde da Família. Interface (Botucatu). 2019; 23:e170407.,²¹21. Forte FDS, Pessoa TRRF, Freitas CHSM, Barbosa AS, Morais MB, Braga CC, et al. Community-based education: experience in community health supervised clerkships at the Federal University of Paraíba Dentistry Course. In: Bollela VR, Germani ACCG, Campos HH, Amaral E, organizers. Community-based education for the health professions: learning from the Brazilian experience. Brasília: OPAS, PAHO; 2015. p. 220-33..

The pedagogical outline adopted by the supervised internships is grounded on active methodologies, which stimulate students to have a participative behavior, with relationships mediated by the reflective construction of knowledge. The point of departure is the complexity and diversity of the world of health work experienced in the Family Health Strategy territory, which has multiple social institutions like schools, day-care centers and community centers²⁰20. Forte FDS, Pontes AA, Morais HGF, Barbosa AS, Sousa Nétto OB. Olhar discente e a formação em Odontologia: interseções possíveis com a Estratégia Saúde da Família. Interface (Botucatu). 2019; 23:e170407.,²¹21. Forte FDS, Pessoa TRRF, Freitas CHSM, Barbosa AS, Morais MB, Braga CC, et al. Community-based education: experience in community health supervised clerkships at the Federal University of Paraíba Dentistry Course. In: Bollela VR, Germani ACCG, Campos HH, Amaral E, organizers. Community-based education for the health professions: learning from the Brazilian experience. Brasília: OPAS, PAHO; 2015. p. 220-33..

The syllabus contains important themes for the fields of collective health and of the Brazilian collective oral health: the SUS and its different sectoral policies, primary care, family health strategy and the program of community health agents, territorialization, humanization in the field of health, health education, general epidemiology and epidemiology of oral diseases.

This study was developed in a Primary Care Unit intentionally selected because it has been, since 2005, the setting of the National Program of Reorientation of Professional Health Education (PRÓ-SAÚDE) and of the Program of Education through Work for the Area of Health (PET-SAÚDE) of the supervised internships of the Dentistry, Nursing and Nutrition courses. It is a service where a Family Health Strategy team and an Oral Health Team provide assistance.

A total of 27 participants were interviewed: nine undergraduate students, six community health agents, one health professional with a higher education degree, one oral health assistant, five child education professionals, and five users of the Brazilian National Health System. The interviewees were selected according to their participation in the activities of the supervised internships, in the social institutions and/or in the Family Health Unit. The students were regularly enrolled in the course, and workers who were on vacation or on leave of absence were excluded from the study.

The interviews were performed by three researchers (two undergraduate students and one teacher) from September 2016 to June 2017. Before the interviews, the researchers discussed the study’s presupposition, the interview as a data collection technique, and the ethos of qualitative research, in order to align the conduction of the work with the theoretical and conceptual framework of cultural studies²2. Du Gay P, Hall S, Janes L, Mackay H, Negus K. Doing cultural studies: the story of the Sony Walkman. 2a ed. London: Sage; 2013.,³3. Hall S. A identidade cultural na pós-modernidade. 10a ed. Rio de Janeiro: DP&A; 2016.. Interview simulation exercises and discussions about them were also carried out.

To participate in the research, all the subjects signed a consent document. The interviews were audio recorded and subsequently transcribed for analysis. The reading of the transcriptions revealed that the 27 interviewees had answered the research question and that, if we were to conduct new interviews, this could result in redundancy, as the saturation plateau for qualitative studies had been reached, leading to the non-emergence of new meanings about what was being studied²²22. Saunder B. Saturation in qualitative research: exploring its conceptualization and operationalization. Qual Quant. 2018; 52(4):1893-907..

The interviews were fully transcribed and thematic content analysis was applied²³23. Bardin L. Análise de conteúdo. Lisboa: Edições 70; 2014., in three stages: pre-analysis, exploration of the material and treatment of the results. Pre-analysis meant the organization of the collected material and aimed to operationalize and systematize the initial ideas. The free-floating reading of the transcriptions consisted of establishing contact in order to know, analyze and explore them better. The third stage was the treatment of the obtained results. Codification was the process through which the data were systematically transformed and aggregated into units that enabled a description of the pertinent characteristics of the content. The fragments of the interviews used in this article were presented with the name of the participant’s category followed by a random number.

The project was approved by the Ethics Committee of Research with Human Beings of the higher education institution involved in the study, protocol number 1.653.507.

Results and discussion

The concept of culture is broad and diverse. In this article, it is seen as a way of understanding the sets of practices associated with power and hegemony²2. Du Gay P, Hall S, Janes L, Mackay H, Negus K. Doing cultural studies: the story of the Sony Walkman. 2a ed. London: Sage; 2013.,³3. Hall S. A identidade cultural na pós-modernidade. 10a ed. Rio de Janeiro: DP&A; 2016., which enables to discuss the cultural representations of TSCI, unveiling their presence in dentistry education.

To Williams²⁴24. Williams R. Cultura e sociedade: de Coleridge a Orwell. Petrópolis: Vozes; 2011., culture produces reality as the subjects involved in this movement of education, training and health interact, converse, do, plan, articulate and produce significant practices in a visited territory, which is never merely a health territory¹²12. Silveira JLGC, Kremer MM, Silveira MEUC, Schneider ACTC. Percepções da integração ensino-serviço-comunidade: contribuições para a formação e o cuidado integral em saúde. Interface (Botucatu). 2020; 24:e190499.,¹³13. Vendruscolo C, Ferraz F, Prado ML, Kleba ME, Reibnitz KS. Teaching-service integration and its interface in the context of reorienting health education. Interface (Botucatu). 2016; 20(59):1015-25.,²¹21. Forte FDS, Pessoa TRRF, Freitas CHSM, Barbosa AS, Morais MB, Braga CC, et al. Community-based education: experience in community health supervised clerkships at the Federal University of Paraíba Dentistry Course. In: Bollela VR, Germani ACCG, Campos HH, Amaral E, organizers. Community-based education for the health professions: learning from the Brazilian experience. Brasília: OPAS, PAHO; 2015. p. 220-33.,²⁵25. Hall S. A identidade cultural na pós-modernidade. 12a ed. Rio de Janeiro: Lamparina; 2015..

Cultural analysis is also a political analysis, and every health education is based on choices of knowledges, pedagogies and paradigms, which manifest themselves in the importance given to certain teaching-learning modes and in the invisibility given to others¹1. Silva TT. Currículo e identidade social: territórios contestados. In: Silva TT, organizador. Alienígenas na sala de aula: introdução aos estudos culturais em educação. 11a ed. Petrópolis: Vozes; 2018.. Curricular guidelines illuminate things remembered and forgotten, reveal and hide knowledges and practices in specific contexts¹1. Silva TT. Currículo e identidade social: territórios contestados. In: Silva TT, organizador. Alienígenas na sala de aula: introdução aos estudos culturais em educação. 11a ed. Petrópolis: Vozes; 2018..

Cultural representation is a form of creation and understanding that connects meanings and practices; “it is a central part of the process through which meanings are produced, shared (consumed) and re-signified among members of a cultural community”²2. Du Gay P, Hall S, Janes L, Mackay H, Negus K. Doing cultural studies: the story of the Sony Walkman. 2a ed. London: Sage; 2013.,²⁵25. Hall S. A identidade cultural na pós-modernidade. 12a ed. Rio de Janeiro: Lamparina; 2015.. Understanding the meaning and the cultural representations related to supervised internships enriches and amplifies the discussion about their role in the health education that is oriented by TSCI.

Supervised internships are social constructions that can translate an epistemic and political bond with the Brazilian healthcare reform - the endless fight for the democratization of healthcare and for the survival of the SUS in times that are, almost always, so adverse. The presence of the undergraduate Dentistry course in the SUS as part of the educational spectrum is a becoming, an invitation to a relationship, to an encounter, to change, to impermanence in the learning process.

What is the meaning, in cultural terms, of the integration of a traditional undergraduate course, like Dentistry, into the services of the Brazilian National Health System in a specific community?

TSCI is the product of a collective work articulated and agreed by teachers, students, preceptors, managers, by the community of SUS users, and by the agents of different social institutions. The thematic analysis of the interviewees’ discourse reveals that the people involved in TSCI are artisans of cultural representations²⁶26. Woodward K. A identidade e diferença: uma introdução: In: Silva TT, Woodward K, Hall S, organizadores. Identidade e diferença: a perspectiva dos estudos culturais. 15a ed. Petrópolis: Vozes; 2014.. The interviewees emphasize the need to include students in realities and contexts that are different from the academically familiar ones, showing them that it is necessary to ‘get out of the self’, of what they are used to seeing and doing, in order to be able to effectively see the other’s needs. The agents involved in TSCI expressed their representations, reflecting different positions assumed from their places of origin, educational backgrounds and life experiences, which compose their “symbolic representation system”²⁶26. Woodward K. A identidade e diferença: uma introdução: In: Silva TT, Woodward K, Hall S, organizadores. Identidade e diferença: a perspectiva dos estudos culturais. 15a ed. Petrópolis: Vozes; 2014..

One cultural representation of TSCI is that it is a practice or an ‘event’ with many positive aspects for the undergraduates’ education. According to the interviewees:

Knowledge production in the integrative experience is neither a neutral cultural field nor a consensually pacific field. It requires an intention that is mainly political and ethical, an activism¹²12. Silveira JLGC, Kremer MM, Silveira MEUC, Schneider ACTC. Percepções da integração ensino-serviço-comunidade: contribuições para a formação e o cuidado integral em saúde. Interface (Botucatu). 2020; 24:e190499.,²⁷27. Williams R. La larga revolución. Buenos Aires: Nueva Visión; 2003.,²⁸28. Neta Aguiar A, Alves MSCF. A comunidade como local de protagonismo na integração ensino-serviço e atuação multiprofissional. Trab Educ Saude. 2016; 14(1):221-3. committed to the defense of life, of health, of the SUS and of citizenship. TSCI enables that an entire theoretical-practical corpus is tested, from the reading of official documents (DCN, Organic Health Laws and National Health Policies⁹9. Brasil. Constituição (1988). Constituição da República Federativa do Brasil. Brasília, DF: Senado Federal; 1988.,¹²12. Silveira JLGC, Kremer MM, Silveira MEUC, Schneider ACTC. Percepções da integração ensino-serviço-comunidade: contribuições para a formação e o cuidado integral em saúde. Interface (Botucatu). 2020; 24:e190499.,¹³13. Vendruscolo C, Ferraz F, Prado ML, Kleba ME, Reibnitz KS. Teaching-service integration and its interface in the context of reorienting health education. Interface (Botucatu). 2016; 20(59):1015-25.) to the immersion in the working process of the Family Health Strategy, passing by the community ‘experiment’ of territorial wanderings, home visits and plural forms (experienced, (re)invented and (re)signified) of healthcare³3. Hall S. A identidade cultural na pós-modernidade. 10a ed. Rio de Janeiro: DP&A; 2016.,²⁵25. Hall S. A identidade cultural na pós-modernidade. 12a ed. Rio de Janeiro: Lamparina; 2015.. Each agent, in his or her own way, represented TSCI as a form of producing social changes:

TSCI, by offering support to transformations in the field of education, care production and strengthening of the SUS¹¹11. Barreto LDSO, Guimarães Campos VD, Dal Poz MR. Interprofessional education in healthcare and health workforce (HRH) planning in Brazil: experiences and good practices. J Interprof Care. 2019; 33(4):369-81. Doi: http://dx.doi.org/10.1080/13561820.2019.1646230.
http://dx.doi.org/10.1080/13561820.2019....

12. Silveira JLGC, Kremer MM, Silveira MEUC, Schneider ACTC. Percepções da integração ensino-serviço-comunidade: contribuições para a formação e o cuidado integral em saúde. Interface (Botucatu). 2020; 24:e190499.-¹³13. Vendruscolo C, Ferraz F, Prado ML, Kleba ME, Reibnitz KS. Teaching-service integration and its interface in the context of reorienting health education. Interface (Botucatu). 2016; 20(59):1015-25.,²⁸28. Neta Aguiar A, Alves MSCF. A comunidade como local de protagonismo na integração ensino-serviço e atuação multiprofissional. Trab Educ Saude. 2016; 14(1):221-3.

29. Toassi RFC, Davoglio RS, Lemos VMA. Integração ensino-serviço-comunidade: o estágio na atenção básica da graduação em Odontologia. Educ Rev. 2012; 28(4):223-42.

30. Finkler M, Caetano JC, Ramos RFS. Integração “ensino-serviço” no processo de mudança na formação profissional em Odontologia. Interface (Botucatu). 2011; 15(39):1053-70.-³¹31. Warmiling CM, Rossoni E, Hugo FN, Toassi RFC, Lemos VA, Slavutzki SMB, et al. Estágios curriculares no SUS: experiências da faculdade de Odontologia da UFRGS. Rev ABENO. 2011; 11(2):63-70., breaks with crystallized cultural representations that consolidate stereotypes, impoverishing the understanding of the set of experiential possibilities contained in the cultural arrangements²2. Du Gay P, Hall S, Janes L, Mackay H, Negus K. Doing cultural studies: the story of the Sony Walkman. 2a ed. London: Sage; 2013.,²⁵25. Hall S. A identidade cultural na pós-modernidade. 12a ed. Rio de Janeiro: Lamparina; 2015.

26. Woodward K. A identidade e diferença: uma introdução: In: Silva TT, Woodward K, Hall S, organizadores. Identidade e diferença: a perspectiva dos estudos culturais. 15a ed. Petrópolis: Vozes; 2014.-²⁷27. Williams R. La larga revolución. Buenos Aires: Nueva Visión; 2003. of internships in health services and territories. According to the interviewees, involucres are broken when knowledges, skills and attitudes are modified and when social images are (re)signified. According to them:

'To Hall (2016)²⁵25. Hall S. A identidade cultural na pós-modernidade. 12a ed. Rio de Janeiro: Lamparina; 2015., culture is a constitutive condition of social life, with its communal symbolic values, and language is the means through which cultural representations are produced. The content analysis of the interviews enabled us to see that the researched subjects construct representations in a contingent way; therefore, such representations are not essentialized and have positionality.

In this direction, there is the construction of meanings of co-accountability with the population’s health, with the establishment of common agendas between the higher education institution and the team, and with the strengthening of bonds, which, through the continuity of the work, enable the reflective and critical maturation of all the individuals involved in the educational process²⁹29. Toassi RFC, Davoglio RS, Lemos VMA. Integração ensino-serviço-comunidade: o estágio na atenção básica da graduação em Odontologia. Educ Rev. 2012; 28(4):223-42.,³¹31. Warmiling CM, Rossoni E, Hugo FN, Toassi RFC, Lemos VA, Slavutzki SMB, et al. Estágios curriculares no SUS: experiências da faculdade de Odontologia da UFRGS. Rev ABENO. 2011; 11(2):63-70.,³²32. Lisboa Filho FF, Moraes ALC. Estudos Culturais aplicados a pesquisas em mídias audiovisuais: o circuito da cultura como instrumental analítico. Significação. 2014; 41(42):67-86..

The undergraduate course, with its students and teachers, dives into the SUS, articulating bordering representational worlds, formed by teaching, work and other practices²¹21. Forte FDS, Pessoa TRRF, Freitas CHSM, Barbosa AS, Morais MB, Braga CC, et al. Community-based education: experience in community health supervised clerkships at the Federal University of Paraíba Dentistry Course. In: Bollela VR, Germani ACCG, Campos HH, Amaral E, organizers. Community-based education for the health professions: learning from the Brazilian experience. Brasília: OPAS, PAHO; 2015. p. 220-33.. In dentistry education, there are socially defined professional roles that show, in advance, the place of recognized, valid and valued knowledge. Furthermore, they indicate the functional-instrumental character of learning, developed in a single way, and the modus operandi of the professional success that students must pursue. Students graduate aiming to provide clinical and individualized dental care, in the face of which ‘everything that exceeds’ is ‘alternative’, viewed as secondary and made invisible. These cultural representations proved to be insufficient, socially unsustainable and opposed to the DCN and SUS proposals.

The clash between representations potentializes the sliding of meanings in dentistry education. The value that has been historically placed on the biomedical know-how, exclusively intramural and intraoral, is amplified with the incorporation and recognition of a set of practices developed in collective health spaces and their challenging extramural know-how¹⁸18. Werneck MAF, Senna MIB, Drumond MM, Lucas SD. Nem tudo é estágio: contribuições para o debate. Cienc Saude Colet. 2010; 15(1):221-31., having as presuppositions: the amplified concept of health, the social determination of the health-disease-care process, and the presence of social and human sciences in the health context.

This sliding towards education via supervised internships, integrating teaching into the health work, does not happen easily and is not deprived of animosity; it is frequently accompanied by the feeling of annoyance and by explicit or veiled mistrust on the part of many agents involved in the education of dental surgeons. However, among the interviewees, supervised internships were culturally represented as a learning place:

In supervised internships, the pedagogical borders and limits are blurred and, given the existent porosities, the learning experience becomes ubiquitous. Students estrange the geographic and human territory, the rationalities and practices performed in the territory; but then they approach it, and familiarize themselves with it. There is an encounter of these students with ‘them’: indefinite, strange and ambivalent subjects of the work world (managers, workers and users). An encounter in motion, a crossing street that asks for translation, understanding and construction of meanings.

In the diaspora from the university to the health services (SUS), the cultural perspectives and the mental structures of the agents involved do not open pacifically and calmly from some individuals to others; when they do, labels and stereotypes can be present in view of the cultural difference between agents. Belonging to a culture means sharing the same conceptual and linguistic universe. It means belonging and being protected by symbolic understanding. Each interviewed subject, with his or her performativity, contributes a view of health education, as their cultural representations are an exercise of sociability in a culture of TSCI in the Dentistry course²2. Du Gay P, Hall S, Janes L, Mackay H, Negus K. Doing cultural studies: the story of the Sony Walkman. 2a ed. London: Sage; 2013.,³3. Hall S. A identidade cultural na pós-modernidade. 10a ed. Rio de Janeiro: DP&A; 2016.. To different agents, TSCI is represented as the experience of collective construction in the territory:

In addition, TSCI is understood, simultaneously, as a strategy for the implementation of permanent education actions¹¹11. Barreto LDSO, Guimarães Campos VD, Dal Poz MR. Interprofessional education in healthcare and health workforce (HRH) planning in Brazil: experiences and good practices. J Interprof Care. 2019; 33(4):369-81. Doi: http://dx.doi.org/10.1080/13561820.2019.1646230.
http://dx.doi.org/10.1080/13561820.2019....

12. Silveira JLGC, Kremer MM, Silveira MEUC, Schneider ACTC. Percepções da integração ensino-serviço-comunidade: contribuições para a formação e o cuidado integral em saúde. Interface (Botucatu). 2020; 24:e190499.-¹³13. Vendruscolo C, Ferraz F, Prado ML, Kleba ME, Reibnitz KS. Teaching-service integration and its interface in the context of reorienting health education. Interface (Botucatu). 2016; 20(59):1015-25., a learning process intended to last for life. To the students, the construction of TSCI via supervised internships represents “feeling progressively part of the Family Health Unit”, a formative experience that is qualitatively significant, with proactivity in the management of collective activities and communal bonds, with everything they have in terms of knowledge, skills, attitudes and possibilities of new ways of learning in the workplace, translated as care.

Studies have shown the dialog (and the lack of it) between preceptors and students, in an invitation to re-signify knowledge crystallized in practices¹²12. Silveira JLGC, Kremer MM, Silveira MEUC, Schneider ACTC. Percepções da integração ensino-serviço-comunidade: contribuições para a formação e o cuidado integral em saúde. Interface (Botucatu). 2020; 24:e190499.,²⁸28. Neta Aguiar A, Alves MSCF. A comunidade como local de protagonismo na integração ensino-serviço e atuação multiprofissional. Trab Educ Saude. 2016; 14(1):221-3.

29. Toassi RFC, Davoglio RS, Lemos VMA. Integração ensino-serviço-comunidade: o estágio na atenção básica da graduação em Odontologia. Educ Rev. 2012; 28(4):223-42.

30. Finkler M, Caetano JC, Ramos RFS. Integração “ensino-serviço” no processo de mudança na formação profissional em Odontologia. Interface (Botucatu). 2011; 15(39):1053-70.-³¹31. Warmiling CM, Rossoni E, Hugo FN, Toassi RFC, Lemos VA, Slavutzki SMB, et al. Estágios curriculares no SUS: experiências da faculdade de Odontologia da UFRGS. Rev ABENO. 2011; 11(2):63-70.. In this study, supervised internships were spaces of dialog culturally represented as territories of producing and consuming exchanges of knowledges and actions regulated by legal parameters⁹9. Brasil. Constituição (1988). Constituição da República Federativa do Brasil. Brasília, DF: Senado Federal; 1988.,¹⁰10. Brasil. Ministério da Educação. Resolução CNE/CES 3, de 19 de Fevereiro de 2002. Institui Diretrizes Curriculares Nacionais do Curso de Graduação em Odontologia. Brasília, DF: Ministério da Educação; 2002., by healthcare and formative policies. According to two interviewees:

The reorientation of health education requires new practices in the education and health systems⁵5. Souza Nétto OB, Moura MS, Lima MDM, Lages GP, Mendes RG, Moura LFAD. O pró-saúde no curso de Odontologia na Universidade Federal do Piauí: relato de uma vivência de cinco anos. Cienc Cuid Saude. 2013; 12(2):391-7.,¹¹11. Barreto LDSO, Guimarães Campos VD, Dal Poz MR. Interprofessional education in healthcare and health workforce (HRH) planning in Brazil: experiences and good practices. J Interprof Care. 2019; 33(4):369-81. Doi: http://dx.doi.org/10.1080/13561820.2019.1646230.
http://dx.doi.org/10.1080/13561820.2019....

12. Silveira JLGC, Kremer MM, Silveira MEUC, Schneider ACTC. Percepções da integração ensino-serviço-comunidade: contribuições para a formação e o cuidado integral em saúde. Interface (Botucatu). 2020; 24:e190499.-¹³13. Vendruscolo C, Ferraz F, Prado ML, Kleba ME, Reibnitz KS. Teaching-service integration and its interface in the context of reorienting health education. Interface (Botucatu). 2016; 20(59):1015-25.. If, on the one hand, it is necessary to propose innovations in the pedagogical project grounded in the restructuring of the teaching-learning process, on the other hand, the healthcare model needs to reflect the public health policies in the perspective of comprehensive care and strengthening of the SUS. Thus, relations of autonomous interdependence between the health and education systems must be constructed in the dialogic spaces where critical and collective reflection on intentions takes place.

This study aimed to contribute to amplify the experience lived in the TSCI process in the path of the education of new dental surgeons. However, the study has limitations, as it considered one single territory where supervised internships occur. The selected Family Health Unit has already participated in previous editions of education reorientation programs and is the setting of many curricular internships of different professions.

Final remarks

This research studied the contemporary culture of dentistry education, based on the analysis of the cultural representation of regulating agents, producers and consumers of supervised internships in the teaching-service-community integration. Symbolic systems shelter cultural representations about TSCI that are internalized and re-signified, enabling the sliding of meanings based on the interaction between different agents present in the educational process.

Developing teaching in the undergraduate Dentistry course oriented by TSCI is still a challenge, and this happens in all the other professions in the field of health. It is necessary to raise agents’ awareness and pursue agendas that converge on the health problems of the collectivity. In addition, it is necessary to amplify opportunities and effective spaces of interlocution between the university, the health services and civil society, enabling the encounter of different agents.

Based on this study, teaching-service-community integration, fulfilled through supervised internships, is a place of education that enables students to “get out of the self” to experience theory-in-practice and practice-in-theory, with social changes that produce modernizations, co-accountability and collectively oriented knowledge productions.

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