Abstract

Introduction

Oral health care is one of the areas encompassed in the inventory of responsibilities of the Brazilian National Health System (SUS). In 2004, the National Oral Health Policy (PNSB) was instituted and recently enacted as an Ordinary Law, ensuring that the State has a duty to promote universal access to oral health services and respect for the principles of health ethics¹1 Brasil. Presidência da República. Lei Nº 14.572, de 8 de maio de 2023. Institui a Política Nacional de Saúde Bucal no âmbito do Sistema Único de Saúde (SUS) e altera a Lei nº 8.080, de 19 de setembro de 1990, para incluir a saúde bucal no campo de atuação do SUS. Brasília: Presidência da República Casa Civil, Secretaria Especial para Assuntos Jurídicos; 2023..

The health crisis caused by the Covid-19 pandemic has reduced dental care globally and increased costs as a result of the recommended requirements²2 Coulthard P, Thomson P, Dave M, Coulthard PF, Seoudi N, Hill M. The Covid-19 pandemic and dentistry: the clinical, legal and economic consequences - part 2: consequences of withholding dental care. Br Dent J. 2020; 229:801-5. doi: 10.1038/s41415-020-2406-9.
https://doi.org/10.1038/s41415-020-2406-...

3 Janakiram C, Nayar S, Varma B, Ramanarayanan V, Mathew A, Suresh R, et al. Dental Care Implications in Coronavirus Disease-19 Scenario: Perspectives. J Contemp Dent Pract. 2020; 21(8):935-41. doi: 10.5005/jp-journals-10024-2896.
https://doi.org/10.5005/jp-journals-1002...

4 Abdelrahman H, Atteya S, Ihab M, Nyan M, Maharani AD, Rahardjo A, et al. Dental practice closure during the first wave of Covid-19 and associated professional, practice and structural determinants: a multi-country survey. BMC Oral Health. 2021; 21(243):1-10. doi: 10.1186/s12903-021-01601-4.
https://doi.org/10.1186/s12903-021-01601... ^-55 Benzian H, Beltrán-Aguilar E, Mathur MR, Niederman R. Pandemic Considerations on Essential Oral Health Care. J Dent Res. 2021; 100(3):221-5. doi: 10.1177/0022034520979830.
https://doi.org/10.1177/0022034520979830... . Inequalities in access to oral health care for vulnerable populations have increased in Brazil⁶6 Johnson V, Brondani M, Von Bergmann H, Grossman S, Donnelly L. Dental Service and Resource Needs during Covid-19 among Underserved Populations. JDR Clin Trans Res. 2022; 7(3):315-25. doi: 10.1177/23800844221083965.
https://doi.org/10.1177/2380084422108396... ^,77 McGough E, Simon L. Is Oral Health Essential? AMA J Ethics. 2022; 24(1):80-8. doi: 10.1001/amajethics.2022.80.
https://doi.org/10.1001/amajethics.2022.... . There has been a decrease in specialized dental consultations and an increase in emergency care in the SUS⁸8 Zajkowski LA, Scarparo RK, Silva HGE, Celeste RK, Kopper PMP. Impact of Covid-19 pandemic on completed treatments and referrals during urgent dental visits. Braz Oral Res. 2023; 37:1-11. doi: 10.1590/1807-3107bor-2023.vol37.0087.
https://doi.org/10.1590/1807-3107bor-202... ^,99 Gondim RS, Melo LF, Vieira EWR, Rocha NB. Impactos da pandemia da Covid-19 nos atendimentos a urgências odontológicas na Atenção Primária à Saúde: um estudo ecológico. ABCS Health Sciences. 2023; 1-5. doi: 10.7322/abcshs.2022045.2101.
https://doi.org/10.7322/abcshs.2022045.2... . The spread of SARS-CoV-2 throughout the country was massive and severely impacted the population, revealing social injustices and reinforcing the assumption that efforts to promote equity must include the defense of oral health¹⁰10 Orellana JDY, Cunha GM, Marrero L, Moreira IR, Leite IC, Horta LB. Excesso de mortes durante a pandemia de COVID-19: subnotificação e desigualdades regionais no Brasil. Cad Saude Publica. 2021; 37(1):1-16. doi: 10.1590/0102-311X00259120.
https://doi.org/10.1590/0102-311X0025912... ^,1111 Cruz-Fierro N, Borges-Yáñez A, Duarte PCT, Cordell GA, Rodriguez-Garcia A. Covid-19: the impact on oral health care. Cienc Saude Colet. 2022; 27(8):3005-12. doi: 10.1590/1413-81232022278.03522021.
https://doi.org/10.1590/1413-81232022278... .

In August 2020, the World Health Organization (WHO) published global recommendations for the public and private sectors responsible for oral health actions. Preventive activities should continue to be a priority, but carried out through remote consultations or social networks, but non-urgent routine care such as examinations, cleanings and cosmetic treatments should be postponed until community transmission rates are reduced. On the other hand, urgent interventions to manage severe pain should be ensured¹²12 World Health Organization. Considerations for the provision of essential oral health services in the context of Covid-19 [internet]. 2020 [citado 3 Out 2023]. Disponível em: https://www.who.int/publications/i/item/who-2019-nCoV-oral-health-2020.1
https://www.who.int/publications/i/item/... .

The Brazilian Ministry of Health recommended guidelines for the operation of outpatient oral health services through Technical Note (TN) No. 04 of the National Health Surveillance Agency, published on March 31, 2020. The TN restricted dental care to emergencies, emphasized care with anamnesis, waiting room, Personal Protective Equipment (PPE) and generation of aerosols¹³13 Brasil. Agência Nacional de Vigilância Sanitária (ANVISA). Nota Técnica GVIMS/GGTES/ANVISA n° 04/2020. Orientações para serviços de saúde: Medidas de prevenção e controle que devem ser adotadas durante a assistência aos casos suspeitos ou confirmados de Infecção pelo novo Coronavírus (SARS-CoV-2) [Internet]. Rio de Janeiro: Anvisa; 2020 [citado 3 Jan 2023]. Disponível em: https://www.gov.br/anvisa/pt-br/centraisdeconteudo/publicacoes/servicosdesaude/notas-tecnicas/2020/nota-tecnica-gvims_ggtes_anvisa-04_2020-25-02-para-o-site.pdf
https://www.gov.br/anvisa/pt-br/centrais... , and was updated eleven times by March 2023¹⁴14 Brasil. Agência Nacional de Vigilância Sanitária (ANVISA). Nota técnica GVIMS/GGTES/ANVISA nº 04/2020. Orientações Para Serviços de Saúde: Medidas de prevenção e controle que devem ser adotadas durante a assistência aos casos suspeitos ou confirmados de Covid-19: atualizada em 31/03/2023 [Internet]. Rio de Janeiro: Anvisa; 2023 [citado 18 Out 2023]. Disponível em: https://www.gov.br/anvisa/pt-br/centraisdeconteudo/publicacoes/servicosdesaude/notas-tecnicas/notas-tecnicas-vigentes/NT042020covid31.03.2023.pdf.
https://www.gov.br/anvisa/pt-br/centrais... .

It should be noted that consensus on the definition of essential or urgent care has been difficult in dentistry⁵5 Benzian H, Beltrán-Aguilar E, Mathur MR, Niederman R. Pandemic Considerations on Essential Oral Health Care. J Dent Res. 2021; 100(3):221-5. doi: 10.1177/0022034520979830.
https://doi.org/10.1177/0022034520979830... . The suspension and resumption of dental care were problematic decisions to be made by health system managers⁷7 McGough E, Simon L. Is Oral Health Essential? AMA J Ethics. 2022; 24(1):80-8. doi: 10.1001/amajethics.2022.80.
https://doi.org/10.1001/amajethics.2022.... , also bearing in mind their responsibilities, especially as public service providers, in having to balance both individual needs and the epidemiological risk situation¹⁵15 Pinheiro FA, Coltri VM, Pereira DGJ, Silva RHA. Reflexões éticas e legais sobre a prática odontológica em tempos de pandemia de Covid-19. Saude Etica Justiça. 2021; 26(1):27-35. doi: 10.11606/issn.2317-2770.
https://doi.org/10.11606/issn.2317-2770... .

As the virus spread, the pandemic revealed historical negligence, both at national and international levels, including the devaluation of work and workers¹⁶16 Nunes HC, Cavalcante MLA, Campos SA, Cozendey-Silva EN, Mattos RCOC, Moura-Correa MJ, et al. Rede de Informações e Comunicação sobre a Exposição de Trabalhadores/Trabalhadoras ao Sars-CoV-2 no Brasil. Saude Debate. 2022; 46 Spe 1:411-22. doi: 10.1590/0103-11042022E128.
https://doi.org/10.1590/0103-11042022E12... ^,1717 Leite NS, Finkler M, Martini GJ, Heidemann I, Verdi M, Hellmann F, et al. Management of the health workforce in facing Covid-19: disinformation and absences in Brazil's Public Policies. Cienc Saude Colet]. 2021; 26(5):1873-84. doi: 10.1590/1413-81232021265.01252021.
https://doi.org/10.1590/1413-81232021265... . In this dramatic context, professional qualification has been strengthened as a key action for the continuity of health care. Despite dealing with obvious situations of devaluation, oral health workers were considered fundamental to maintaining people's well-being¹⁸18 Dziedzic A. Special care dentistry and covid-19 outbreak: what lesson should we learn? Dent J (Basel). 2020; 8(2):1-3. doi: 10.3390/dj8020046.
https://doi.org/10.3390/dj8020046... .

However, some of the challenges presented to dental practice in coping with the pandemic were later transformed into opportunities for reorganizing oral health care. Issues related to risks, screening, protocols, adaptability, tele-odontology, among others, became priority agendas as part of the actions to deal with the crisis, becoming possibilities for innovations or restructuring services¹⁸18 Dziedzic A. Special care dentistry and covid-19 outbreak: what lesson should we learn? Dent J (Basel). 2020; 8(2):1-3. doi: 10.3390/dj8020046.
https://doi.org/10.3390/dj8020046... . In this sense, in a challenging scenario, it is necessary to take advantage of the lessons learned as a result of the crisis to rethink care models, the scope of practice, what constitutes essential care, ethical issues involving dental practice and even defending the importance of the continued provision of oral health services⁷7 McGough E, Simon L. Is Oral Health Essential? AMA J Ethics. 2022; 24(1):80-8. doi: 10.1001/amajethics.2022.80.
https://doi.org/10.1001/amajethics.2022.... ^,1919 Elster N, Parsi K. Oral Health Matters: The ethics of providing oral health during covid-19. HEC Forum. 2021; 33(1-2):157-64. doi: 10.1007/s10730-020-09435-3.
https://doi.org/10.1007/s10730-020-09435... .

With the aim of joining forces to respond to the problems posed by the spread of the pandemic, the Southern Region Collaborative Oral Health Research Network (RedeSBC Sul) was set up, with the participation of institutions from the three southern states: Public Universities State University of Ponta Grossa (UEPG), Federal University of Paraná (UFPR), Federal University of Rio Grande do Sul (UFRGS) and Federal University of Santa Catarina (UFSC), Regional Dental Councils (CRO), Oral Health Coordinators of the State Health Departments and the Brazilian Dental Association²⁰20 Palma LZ, Valentim F, Velho GR, Pires FS, Baldani MH, Colussi FC, et al. How Brazilian oral health care workers face Covid-19: surveillance, biosafety, and education strategies. Braz J Oral Sci. 2023; 22:e237812. doi: 10.20396/bjos.v22i00.8667812.
https://doi.org/10.20396/bjos.v22i00.866... . RedeSBC Sul carried out a wide-ranging multicenter research project with the overall aim of analyzing the biosafety measures used in dentistry to combat Covid-19 and evaluating the practices of workers in the production of oral health²¹21 Warmling CM, Spin-Neto R, Palma LZ, Silva-Junior MF, Castro RG, Finkler M, et al. Impact of the Covid-19 pandemic on the oral health workforce: a multicenter study from the southern region of Brazil. Int J Environ Res Public Health. 2023; 20(2):1301. doi: 10.3390/ijerph20021301.
https://doi.org/10.3390/ijerph20021301... . Understanding that qualitative approaches to the topic of oral health are necessary in the face of contemporary global complexities²²22 Macdonald ME. The necessity of qualitative research for advancing oral health. Community Dent Oral Epidemiol. 2023; 51(1):67-70. doi: 10.1111/cdoe.12787.
https://doi.org/10.1111/cdoe.12787... , particularly in this case, those imposed by the pandemic, this component of the research carried out by RedeSBC Sul was developed and will be presented in this article with the aim of understanding how difficulties in the work process were perceived and felt by workers, sometimes generating ethical and mental health problems - in order to reflect on innovations in the oral health work process that the pandemic has revealed to be necessary.

Methods

The qualitative data analyzed was produced through a websurvey, with a structured questionnaire of complementary closed and open questions.

A total of 2,560 oral health workers took part in the study: 1,941 dental surgeons (DS), 401 oral health assistants (OHA) and 218 oral health technicians (OHT), with active registration with the Dentists Regional Councils of the states of Rio Grande do Sul, Santa Catarina and Paraná and who were working at the time of the study in direct contact with patients, in both the public and private sectors.

Between August 10 and October 7, 2020, the online form hosted on the Google Forms^® platform was made available to participants. The invitation with the link to participate in the study was sent three times to the e-mail addresses of the professionals registered with the Councils, 15 and 45 days apart from the first invitation. Information about the survey was also disseminated via social networks and conference calls.

Table 1 shows the characterization of the study participants, according to data from Block 1 of the online questionnaire. 44.5% had more than 10 years of training, 59% had a specialization degree (61% of them with an emphasis on clinical dentistry) and 69.9% reported having been absent from work during the pandemic.

The structured online questionnaire had a total of 50 questions organized into three blocks. Block 1: sociodemographic, educational, work and health profile. Block 2: surveillance and biosafety measures to control Covid-19 recommended by the Ministry of Health's Technical Note GVIMS/GGTES/ANVISA n. 04/2020¹¹11 Cruz-Fierro N, Borges-Yáñez A, Duarte PCT, Cordell GA, Rodriguez-Garcia A. Covid-19: the impact on oral health care. Cienc Saude Colet. 2022; 27(8):3005-12. doi: 10.1590/1413-81232022278.03522021.
https://doi.org/10.1590/1413-81232022278... . Block 3: Professional practice, management, education and teamwork. Of the total number of questions, 47 were closed, three questions (numbers 29, 30 and 48) were open-ended, non-mandatory and the subject of analysis in this study (Frame 1).

Discursive textual analysis was performed, aiming to move between content and discursive analysis²³23 Moraes R, Galiazzi MC. Análise textual discursiva: processo reconstrutivo de múltiplas faces. Cienc Educ. 2006; 12(1):117-28. doi: 10.1590/s1516-73132006000100009.
https://doi.org/10.1590/s1516-7313200600...

24 Moraes R. Uma tempestade de luz: a compreensão possibilitada pela análise textual discursiva. Cienc Educ. 2003; 9(2):191-211. doi: 10.1590/s1516-73132003000200004.
https://doi.org/10.1590/s1516-7313200300... ^-2525 Cappelle MCA, Melo MCDOL, Gonçalves CA. Análise de conteúdo e análise de discurso nas ciências sociais. Organ Rurais Agroindustriais. 2003; 5(1):1-15. doi: 10.1590/S0102-69922010000100016.
https://doi.org/10.1590/S0102-6992201000... in order to understand the participants' answers to the open questions. The analytical processes were carried out as follows: (1) unitarization or separation into units of meaning: the NVivo^® software was used to count the frequency of words present in the texts of the answers to the three questions; (2) the most frequent units were grouped around similar meanings, generating sets of categorical units; (3) returning to the software, we went back to the individual texts of each answer, looking for the participants' “speeches/answers” with references to the most frequent words; 4) the analysis of the speeches highlighted with references to categories generated analytical and interpretative texts. The whole process was produced in dialogue with the empirical and theoretical experience of the researchers.

The research project was cleared by the Research Ethics Committees (CEP) of the educational institutions involved: UEPG (CAAE: 31720920.5.1001.0105), UFPR, (CAAE: 31720920.5.3001.0102), UFSC (CAAE: 31720920.5.2001.0121) and UFRGS (CAAE: 31720920.5.2002.5530). Participants were given access to the Informed Consent Form (ICF) via the online form, with information on how long it would take to complete, and confidentiality and privacy of the information were ensured. Access to the questionnaire was only made available to professionals who agreed to the ICF and agreed to take part in the study.

Results

Frame 2 shows the frequency of the most significant words present in the texts of the answers to the three open questions, which were then grouped around similar meanings, generating three sets of initial categorical units, namely: Feelings, Work and Biosafety.

Frame 3 presents in a systematized fashion, the categories resulting from the interpretative analysis of the corpus of data, based on the difficulties experienced by the workers (subcategories identified with #1), the ethical problems faced (subcategories identified with #2), as well as the subjective repercussions in terms of feelings and mental health (subcategories identified with #3). Some of the most representative statements from each subcategory are also presented in order to illustrate the raw data, in which each participant is referred to by a different number. It is worth noting that although they are interrelated, the difficulties experienced may or may not generate ethical problems, and that these may or may not generate suffering. It was therefore decided to analyze the data while maintaining the possibility of understanding the results based on their origin in the questionnaire.

Discussion

The main results of the study show that, for the participating workers, providing oral health care during the pandemic involved decisions that brought together conflicting social interests, moral values, public health and economic issues, as McGough and Simon⁷7 McGough E, Simon L. Is Oral Health Essential? AMA J Ethics. 2022; 24(1):80-8. doi: 10.1001/amajethics.2022.80.
https://doi.org/10.1001/amajethics.2022.... also found. An analysis of the discourses produced in the open-ended responses of workers in both public and private services, when referring to the issues of reorganizing access to oral health services, suspending elective procedures and decisions on essential or emergency care, showed how the difficulties of understanding the suspension of care generated stressful clashes.

The quantitative component of this same survey reaffirmed the difficulties described in the open questions and analyzed here, regarding the exclusivity of essential care, since only 37.5% of the participating workers said they had suspended elective care, as well as the characterization of this care, since only a little more than half of the workers (56.8%) said that urgent care was based on pre-established clinical protocols²¹21 Warmling CM, Spin-Neto R, Palma LZ, Silva-Junior MF, Castro RG, Finkler M, et al. Impact of the Covid-19 pandemic on the oral health workforce: a multicenter study from the southern region of Brazil. Int J Environ Res Public Health. 2023; 20(2):1301. doi: 10.3390/ijerph20021301.
https://doi.org/10.3390/ijerph20021301... .

Concurring with the data from the quantitative analysis carried out in the same study²¹21 Warmling CM, Spin-Neto R, Palma LZ, Silva-Junior MF, Castro RG, Finkler M, et al. Impact of the Covid-19 pandemic on the oral health workforce: a multicenter study from the southern region of Brazil. Int J Environ Res Public Health. 2023; 20(2):1301. doi: 10.3390/ijerph20021301.
https://doi.org/10.3390/ijerph20021301... , the qualitative analysis showed that, even after the official suspension, the population continued to seek elective care, not understanding or underestimating the risks they were running and to which they would expose workers. This behavior of maintaining an apparent normality was also observed by Szwarcwald et al.²⁶26 Szwarcwald CL, Souza Júnior PRB, Damacena GN, Malta DC, Barros MBA, Romero DE, et al. ConVid - Pesquisa de Comportamentos pela Internet durante a pandemia de Covid-19 no Brasil: concepção e metodologia de aplicação. Cad Saude Publica. 2021; 37(3):1-15. doi: 10.1590/0102-311X00268320.
https://doi.org/10.1590/0102-311X0026832... in the survey that investigated behaviors and changes in the lifestyles and health conditions of Brazilians during the pandemic. In the United Kingdom, clinical, legal and economic issues were raised regarding the refusal of necessary but non-urgent clinical care, highlighting the expected worsening of oral diseases and the substantial financial repercussions for dental practices²2 Coulthard P, Thomson P, Dave M, Coulthard PF, Seoudi N, Hill M. The Covid-19 pandemic and dentistry: the clinical, legal and economic consequences - part 2: consequences of withholding dental care. Br Dent J. 2020; 229:801-5. doi: 10.1038/s41415-020-2406-9.
https://doi.org/10.1038/s41415-020-2406-... , as indicated by the participants in this study.

Not all oral health procedures are essential, and not all essential procedures are urgent as well⁵5 Benzian H, Beltrán-Aguilar E, Mathur MR, Niederman R. Pandemic Considerations on Essential Oral Health Care. J Dent Res. 2021; 100(3):221-5. doi: 10.1177/0022034520979830.
https://doi.org/10.1177/0022034520979830... ^,77 McGough E, Simon L. Is Oral Health Essential? AMA J Ethics. 2022; 24(1):80-8. doi: 10.1001/amajethics.2022.80.
https://doi.org/10.1001/amajethics.2022.... . This equation, which was already difficult in the context prior to the pandemic, was even more difficult to manage during the pandemic, not least because what is not urgent at a given moment may soon become so. The way in which oral health services were reorganized to deal with the pandemic led to the need to rethink the very concept of what is essential in care and the models of care⁵5 Benzian H, Beltrán-Aguilar E, Mathur MR, Niederman R. Pandemic Considerations on Essential Oral Health Care. J Dent Res. 2021; 100(3):221-5. doi: 10.1177/0022034520979830.
https://doi.org/10.1177/0022034520979830... ^,77 McGough E, Simon L. Is Oral Health Essential? AMA J Ethics. 2022; 24(1):80-8. doi: 10.1001/amajethics.2022.80.
https://doi.org/10.1001/amajethics.2022.... . At the time, postponing treatment was seen as an ethical necessity for the greater good of society, both to control the spread of Covid-19 and to avoid wasting scarce PPE. However, with a pandemic outcome looming and the damage resulting from indefinite postponement, the problems arising from suspending elective care have increased²⁷27 Ramanarayanan V, Sanjeevan V, Janakiram C. The Covid-19 uncertainty and ethical dilemmas in dental practice. Indian J Med Ethics. 2021; 6(2):1-3. doi: 10.20529/IJME.2020.105.
https://doi.org/10.20529/IJME.2020.105... .

It is important to highlight how the study understands and uses what it calls ethical problems. It is not necessarily referring to studies in the field of deontological ethics - which evaluates and rules on professional attitudes and actions using pre-established parameters. What is wanted is a problematization of the ethics of power, as something that forms and constitutes the subject himself in his condition and trajectory. “The context is not external to the problem: it conditions the form that the problem will take”²⁸28 Butler J. Relatar a si mesmo: crítica da violência ética. Belo Horizonte: Autêntica; 2017. (p. 16). In this sense, the subject's ethical deliberation would be related to a critical operation that seeks to understand existence itself²⁸28 Butler J. Relatar a si mesmo: crítica da violência ética. Belo Horizonte: Autêntica; 2017.. This was the meaning of the study, considering that the constitution of ethical problems in oral health care is naturalized in the common, everyday relationships and circumstances of health care.

The results showed that the atypical situation of the pandemic accentuated previously existing ethical problems, as well as introduced new ones. Among them are those related to making decisions about providing care or ensuring one's own safety, or balancing the professional commitment to provide the necessary professional care with the responsibility for the livelihood and health of one's family. When considering not providing care, thinking about the consequences for patients and colleagues was also an ethical issue that generated conflict, among others. As a health professional, there is a social expectation to maintain urgent health care, even in the face of a greater than usual risk to your own safety, health or life³3 Janakiram C, Nayar S, Varma B, Ramanarayanan V, Mathew A, Suresh R, et al. Dental Care Implications in Coronavirus Disease-19 Scenario: Perspectives. J Contemp Dent Pract. 2020; 21(8):935-41. doi: 10.5005/jp-journals-10024-2896.
https://doi.org/10.5005/jp-journals-1002... .

The institutional apparatus and structure of health services do not provide support for workers in situations of ethical problems, neither in the legal nor institutional spheres, nor in the construction of spaces aimed at their perception, analysis and solution, in such a way that they end up causing subjective precariousness for the worker, as also observed in the results of the study by Gomes and Finkler²⁹29 Gomes D, Molina LR, Finkler M. Vulneração social e problemas ético-políticos transversais à saúde bucal na Atenção Primária à Saúde. Saude Debate. 2022; 46(133):392-402. doi: 10.1590/0103-1104202213310.
https://doi.org/10.1590/0103-11042022133... . Thus, the ethical problems triggered in the context in question increased the workers' sense of powerlessness, characterizing moral distress.

The answers dealt intensely with the subjective context, with the question of the limits experienced in the process of implementing protocols and conduct appropriate to the health realities demanded by the pandemic. There were alternating difficulties in defining work processes and heterogeneous professional decisions, since all decision-making is based not only on facts, but also on the moral judgments we make and our individual and collective duties. All this sharpened the picture of the serious crisis that was emerging, the exhaustion and suffering.

Workers were also challenged to face the epidemic of disinformation - the infodemic. This scenario of unpredictability generated by the pandemic has produced worries and insecurity, which in several cases, in addition to affecting well-being, has damaged health, as evidenced by reports of seeking mental health care. The pandemic has made the importance of popularizing recommendations to control and protect workers' health more visible¹⁶16 Nunes HC, Cavalcante MLA, Campos SA, Cozendey-Silva EN, Mattos RCOC, Moura-Correa MJ, et al. Rede de Informações e Comunicação sobre a Exposição de Trabalhadores/Trabalhadoras ao Sars-CoV-2 no Brasil. Saude Debate. 2022; 46 Spe 1:411-22. doi: 10.1590/0103-11042022E128.
https://doi.org/10.1590/0103-11042022E12... , a fact that has been amplified in daily life during and after the pandemic.

Fear emerged forcefully in the speeches (1,146 quotes - Frame 2) and in different contexts. It was related to the possibility of contamination and uncertainties about living and working in the period before the vaccines arrived, and apprehension about changes at work. Oral health teams, due to the nature of their practice with aerosols and constant contact with saliva, were immediately considered to be a professional category at high risk of contamination by SARS-CoV-2. Later, when comparing data on confirmed cases among dental professionals with population rates in the country, a different reality was found, with a cumulative incidence not so high, around 5% higher among these workers³⁰30 Ferreira RC, Gomes VE, Rocha NBD, Rodrigues GL, Amaral LHJ, Senna BIM, et al. Covid-19 Morbidity Among Oral Health Professionals in Brazil. Int Dent J. 2022; 72(2):223-9. doi: 10.1016/j.identj.2021.05.005.
https://doi.org/10.1016/j.identj.2021.05... .

Although many of the challenges faced could have been minimized with improving the effective ways of controlling infections, collaborative work, the availability of PPE and the use of tele-odontology³¹31 Raskin SE, Diep VK, Chung-Bridges K, Heaton LJ, Frantsve-Hawley J. Dental safety net providers' experiences with service delivery during the first year of Covid-19 should inform dental pandemic preparedness. J Am Dent Assoc. 2022; 153(6):521-31. doi: 10.1016/j.adaj.2021.11.005.
https://doi.org/10.1016/j.adaj.2021.11.0... , the results showed that there was suffering due to the fact that they were active workers during the initial pandemic period. Service management contexts emerged in which political and economic aspects were not favorable and affected the coordination of services, producing inconsistencies in the information available. Decisions had to be made even in situations of uncertainty, which required the analysis of possible courses of action with an important ethical component. Caram et al.³²32 Caram CS, Ramos FRS, Almeida NG, Brito MJM. Sofrimento moral em profissionais de saúde:retrato do ambiente de trabalho em tempos de Covid-19. Rev Bras Enferm. 2021; 74 Suppl 1:1-8. doi: 10.1590/0034-7167-2020-0653.
https://doi.org/10.1590/0034-7167-2020-0... corroborate these results, stating that working on the front line was seen by health workers as an experience of moral distress, which occurs when workers perceive problems in their work but are unable to act according to their conscience.

Final considerations

The main hurdles included understanding the suspension of elective care and the prioritization of emergencies; access to services; the definition, implementation and guidance on biosafety protocols; the care of potentially contaminated patients; the interval in care; the availability of workers; supplies and infrastructure; as well as collaboration in teamwork.

Each of these hurdles was the basis on which some ethical problems were reported: feeling powerless; uncertainty in prioritizing cases; experiencing misunderstanding and prejudice; worsening illnesses or the complexity of treatments; conflicts over whether or not to carry out elective care; dealing with increased risks; with heterogeneous professional conduct; with colleagues who didn't follow the rules or take the necessary precautions; who didn't inform people who were infected; or who acted with disregard for users; dealing with patients who lied or omitted facts and with patients who didn't take care of themselves; the risk of the spread and cross-contamination of the disease; and the disregard of local and federal management.

Likewise, each of the difficulties reported was correlated with issues that affected the well-being or even the mental health of the workers, with many explicit mentions of falling ill as a result of being a health professional during the pandemic. There was anguish derived from the population's demands for care; exhaustion at work; fear of the general situation of the pandemic, contamination during care, illness and contamination of family members; as well as suffering associated with the necessary reorganization of work.

Despite the losses and damage caused by the pandemic, it was possible to realize the opportunities to learn from it. Particularly in relation to the scope of this study, it is an ethical imperative that oral health itself recognizes the difficulties experienced, objectively and subjectively, in the work process during the pandemic period and, based on them, re-establishes routines and protocols, especially those related to access to services, prioritization of care and biosafety regulations, thinking about the care that is due not only to patients, but also to health workers.

It is worth pointing out limitations related both to the sample of participants defined by convenience and the limitation to the southern region, but especially the choice to analyze the data independently of characterizations, such as public or private services, or technical or higher-level workers. We opted for a global analysis of the three open-ended questions because it allowed us to delve deeper into the quantitative component already published. Another point that strengthens the study is the high response rates to the open questions, even though they were not compulsory, which shows that the participants felt encouraged to talk about the topics covered.

References

Publication Dates

History