Abstract

Breastfeeding (BF) and the adequate introduction of complementary feeding (CF) are strategies that have been shown to improve oral health and prevent diseases. Therefore, activities to promote these practices must be carried out by all health professionals. This article addresses the opinion of the dentist about his or her education, knowledge and role in supporting and encouraging BF and CF. It was sought, through quantitative methodology, to analyze the result of a survey carried out with dentists registered with the Regional Dentistry Council of São Paulo about their academic and professional training in these themes. The major academic contents received at college were about the benefits of breastfeeding for the prevention of general health (74.6%). Among the professionals, 27.8% of them received in-service training on BF and 21.5% on CF, with more than 80% being able to apply their knowledge on a daily basis. When asked about providing guidance on BF, only 15% responded feeling prepared to do so. Regarding whether they consider it to be the dentist's responsibility to support BF and BF, 92.3% answered yes and 85% said they needed updating. It is concluded that there is a gap to be filled with academic training and training / updates so that the dentist can effectively act in the promotion and support of BF and CF.

Keywords:
Dentistry education; Breastfeeding; Healthy complementary food; Health promotion.

Introduction

The consolidation of the Unified Health System (SUS, in Brazil) has brought about numerous achievements over thirty years since its implementation as well as important challenges, such as professional training, to deal with the changes arising mainly from the new healthcare model. Regulating human resources training is one of the competences assigned to SUS and is expressed in the Health Organic Law, being considered a strategic issue not only in Brazil but also in countries that have a policy oriented to educational processes capable of filling the needs pointed out by the healthcare system (BRASIL, 1990BRASIL. Lei n. 8.080, de 19 de setembro de 1990. Dispõe sobre as condições para a promoção, proteção e recuperação da saúde, a organização e o funcionamento dos serviços correspondentes e dá outras providências. Diário Oficial da União, Brasília, DF, 20 set. 1990. Seção 1, p. 18055. ). These changes require professionals with skills to act in different subsectors, areas and services, so that they can contribute to improving the social and health indicators at any organizational level.

Collective healthcare is a form of intervention focused on promotion and prevention, and all health professionals, whether working in clinical, rehabilitation or care services, at some extent should incorporate these elements in their training and practice (CAMPOS, 2000CAMPOS, Gastão W. S. Saúde pública e saúde coletiva: campo e núcleo de saberes e práticas. Ciência & Saúde Coletiva, Rio de Janeiro, v. 5, n. 2, p. 219-230, 2000. ). Primary health care (PHC), the main regulatory agent of the system is organized into multidisciplinary and interdisciplinary health teams. This leads to an increased number of actions aimed at promoting, protecting and recovering health when each professional’s own knowledge and practice (nucleus of knowledge) are integrated with other members of the team and, together, are able to maximize the benefits provided to the population under their responsibility (field of action) aiming to integrality (ELLERY, 2013ELLERY, A. E. L.; PONTES, R. J. S.; LOIOLA, F. A. Campo comum de atuação dos profissionais da Estratégia Saúde da Família no Brasil: um cenário em construção. Physis, Rio de Janeiro, v. 23, n. 2, p. 415-437, 2013.). Knowing that the nucleus comprises the elements of singularity that define the identity of each professional or specialist, while the field is made up of the responsibilities and knowledges that are common and convergent to various professions or specialties, contributes to elucidating what is intended with the care model currently proposed for teamwork (CAMPOS, 1997CAMPOS, G. W. S.; CHAKOU, M.; SANTOS, R. C. Análise crítica sobre especialidades médicas e estratégias para integrá-las ao Sistema Único de Saúde (SUS). Cadernos de Saúde Pública, Rio de Janeiro, v. 13, n. 1, p. 141-144, 1997. ). Health professionals, in their workspaces, are faced with complex situations and need support, contrary to the logic of professionalization.

Breastfeeding (BF) and the introduction of healthy complementary foods (HCF) can be considered examples of these complex situations.

Multifactorial determinants (cultural, social and economic) of breastfeeding require multiple interventions involving various sectors of society, from legal and political directives and guidelines, legal protection support to women who work and breastfeed, to adequate training of health professionals to qualify primary health care (ALMEIDA, 2004ALMEIDA, J. A. G.; NOVAK, F. R. Amamentação: um híbrido natureza-cultura. Jornal de Pediatria, Rio de Janeiro, v. 80, n. 5 supl, p. S119-S115, 2004.; AMARAL , 2015AMARAL, L. J. X. et al. Fatores que influenciam na interrupção do aleitamento materno exclusivo em nutrizes. Revista Gaúcha de Enfermagem, Porto Alegre, v. 36, n. esp., p. 127-34, 2015. ; ROLLINS et al., 2016; CAPUCHO 2017CAPUCHO, L. B. et al. Fatores que interferem na amamentação exclusiva. Revista Brasileira de Pesquisa em Saúde, Vitória, v. 19, n. 1, p. 108-13, 2017. ). When actions are implemented in an articulated and integrated manner by the various sectors involved in healthcare, the results are achieved more easily, to the detriment of isolated actions that encounter precise limits.

Breastfeeding is the basis of life and its benefits reach people who live in high-, middle- and low-income countries and can be considered the most long-lasting investment in physical, cognitive and social capabilities of future generations (HANSEN, 2016HANSEN, K. Breastfeeding: a smart investment in people and in economies [Editorial]. Lancet. V. 387, n. 10017, p. 416, 2016.; VICTORA , 2016VICTORA, C. G. et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effects. Lancet, v. 387, n. 10017, p. 475-90, 2016.).

Breastfeeding is the single practice with the greatest impact on reducing infant mortality. At optimal levels, BF can reduce 12 to 13% of annual deaths of children under five years of age in the world, saving around 800 thousand lives (SANKAR et al., 2015SANKAR, M. J. et al. Optimal breastfeeding practices and infant and child mortality: a systematic review and meta-analysis. Acta Paediatric, v. 104, n. 467, p. 3-13, 2015.; VICTORA et al., 2016VICTORA, C. G. et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effects. Lancet, v. 387, n. 10017, p. 475-90, 2016.), due to the protection it provides against infections in childhood, reducing the risk of acute infections in general, respiratory diseases, otitis media, gastroenteritis, diarrhea, asthma (BOWATTE et al., 2015BOWATTE, G. et al. Breastfeeding and childhood acute otits media: a systematic review and meta-analysis. Acta Paediatrica, v. 104, n. 467, p. 85-95, 2015.); obesity (HASSIOTOU; GEDDES, 2014HASSIOTOU, F.; GEDDES, D. T. Programming of appetite control during breastfeeding as a preventative strategy Against the obesity epidemic. Journal Human Lactation, v. 30, n. 2, p. 136-142, 2014.); and other noncommunicable diseases (NCD) throughout lifetime (HORTA; VICTORA, 2013HORTA, B. L; VICTORA, C. G. Long-term effects of breastfeeding: a systematic review. Geneva: WHO, 2013.; VICTORA et al., 2016VICTORA, C. G. et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effects. Lancet, v. 387, n. 10017, p. 475-90, 2016.).

The World Health Organization (WHO), the United Nations Children’s Fund (UNICEF) and Ministry of Health of Brazil (MH) recommend exclusive breastfeeding in the first six months of life and complemented until two years or over, with introduction of quality solid/semisolid foods at proper time (WHO, 2015WORLD HEALTH ORGANIZATION. The optimal duration of exclusive breastfeeding: report of the expert consultation: Geneva, Switzerland, 28-30 March 2001. Geneva: WHO , 2015. Disponível em: Disponível em: https://www.who.int/nutrition/publications/optimal_duration_of_exc_bfeeding_report_eng.pdf . Acesso em: 12 ago. 2018.
https://www.who.int/nutrition/publicatio... ; BRASIL, 2019BRASIL. Ministério da Saúde. Secretaria de Atenção Primária à Saúde. Departamento de Promoção da Saúde. Guia alimentar para crianças brasileiras menores de 2 anos. Brasília, DF, 2019. ). The Dietary Guidelines for Brazilian Children Under Two Years of Age published by the Ministry of Health of Brazil provides important guidelines for families and professionals to encourage, support, protect and promote health and food and nutrition security. It contains 12 steps that explain the importance of BF and natural or minimally processed foods and a healthy diet, respecting the culture and seasonality of foods and family habits, considering that the dietary patterns established in the first years of life reflect on the eating habits of children and adults (BRASIL, 2019BRASIL. Ministério da Saúde. Secretaria de Atenção Primária à Saúde. Departamento de Promoção da Saúde. Guia alimentar para crianças brasileiras menores de 2 anos. Brasília, DF, 2019. ).

The consequences of a child’s poor diets are undernutrition, overweight or micronutrient deficiencies. In the short run, undernutrition in the early stages of life may enhance the severity and mortality caused by infectious diseases. As long-term impacts, undernutrition can reduce the height of adult individuals, the reproductive capacity and the economic income and productivity in adulthood (GONÇALVES ., 2019GONÇALVES, H. et al. Nutrição e crescimento infantil: tendências e desigualdades em quatro coortes de nascimento de base populacional em Pelotas, Brasil, 1982-2015. In: VICTORA, C. et al. (Orgs.). Epidemiologia da Desigualdade-quatro décadas de coortes de nascimentos. Rio de Janeiro: Fiocruz; ENSP, 2019.).

Much more efforts are still needed to reach the most acceptable and compatible indices recommended in the world, both for BF and consumption of healthier foods. Among these efforts is training of health professionals.

Support to BF and promotion of HCF unveil a multi-professional universe where dentists have gaps to fill in the promotion of these strategies and, together with other professional categories, have the responsibility to inform patients/parents about the best way to enjoy and ensure a long life without diseases (GUEDES, 2010GUEDES-PINTO, A. C. Educação do paciente em odontopediatria. In: GUEDES-PINTO, A. C. Odontopediatria. 8. ed. São Paulo: Santos, 2010. p. 399-416. ). A significant lack of knowledge on BF by health professionals means that women may receive inconsistent and often-conflicting information, resulting in early weaning and poor quality of diets when solid foods are introduced (NELSON, 2007NELSON, A. M. Maternal-newborn nurses’ experiences of inconsistent professional breastfeeding support. Journal of Advanced Nursing, Oxford, v. 60, n. 1, p. 29-38, 2007.). In contrast, when health professionals are confident in their own capacity to provide support to nursing women, they are more likely to promote BF and HCF to mothers (ALMEIDA, 2015ALMEIDA, J. M.; LUZ, S. A. B.; UED, F. V. Apoio ao aleitamento materno pelos profissionais de saúde: revisão integrativa da literatura. Revista Paulista de Pediatria. São Paulo, v. 33, n. 3, p. 355-62, 2015. ). In all profiles of health professionals, there are substantial gaps in knowledge and skills to support BF (LEVINIENE, 2009LEVINIENE, G. et al. The evaluation of knowledge and activities of primary health care professionals in promoting breast-feeding. Medicina, Kaunas, v. 45, n. 3, p. 238-247, 2009. ; FRANÇA et al., 2012; RENFREW 2006RENFREW, M. J. et al. Addressing the learning deficit in breastfeeding: strategies for change. Maternal Child Nutrition, Oxford, v. 2, n. 4, p. 23944, Oct. 2006. ).

Considering the dentists’ potential abilities to inform, support and influence BF and HCF, the aim of this survey was to examine the training path and knowledge of these professionals on this topic.

Method

This paper is part of the doctoral dissertation of the main author, who studied the inclusion of dentists in health promoting actions with a focus on BF and HCF, particularly when foods are introduced to children. A questionnaire with 41 questions was available on the website of the Regional Dentistry Council of São Paulo (CROSP, in Portuguese), after being authorized by the Training and Specialties Commission of this entity, from May 29 to June 29, 2017. The dentists registered at CROSP received an e-mail inviting them to participate in the survey. After reading and accepting the Free and Informed Consent, the survey was initiated.

The questionnaire comprised four blocks of questions: the first one, describing the professional’s characteristics, included the following variables: age, gender, kind of university (private or public) attended, time since graduation, specialty, if they were active of not in the profession at the time of survey and if at any point in their professional life they worked in public service. The specialties listed in the questionnaire were the ones recognized by the Federal Odontology Council, and the professionals could choose more than one option. The other block included questions about the respondents’ training, i.e., their educational background: if they received instructions on the benefits of BF and HCS for health in general and to prevent oral diseases; if such information was sufficient to enable them to work with diverse publics and if they could apply their knowledge in daily work. Other questions asked if the professional received in-service guidance on BF and complementary feeding (CF), number of training hours, if they could apply such knowledge in their routines and, also, if they spontaneously attended any course on BF and CF after graduation. The third block was designed to evaluate the professional’s knowledge on BF and CF: if as dentists they were asked to offer guidance on BF and CF and if they felt they were well-equipped to do so. A series of diseases were presented, and the professionals were asked to indicate those that they considered preventable by BF and healthy diets. Other three questions comprised the use of pacifiers, oral hygiene and continuity of BF after eruption of the first teeth.

The fourth and last part asked for the professionals’ opinion about the support to BF and CF as part of the dentist’s responsibility and if they needed further training on these topics. The last question presented a list of themes that could be considered important in training on BF and CF. Data were analyzed descriptively through distribution of frequencies. To explore the characteristics of courses that may have influenced the training on BF and CF, the variables “received information at college on the benefits of BF and CF for the promotion of the overall health and prevention of oral diseases” were analyzed based on the type of university and time since graduation, using the chi-square test at 5% significance level. The study was approved by the Ethics and Research Committee of the Public Health Faculty of São Paulo University - FSP/USP (CAEE: 80436217.4.0000.5421).

Results

Table 1 shows the results of the first block of questions about the professionals’ characteristics.

Diverse professionals accepted to participate in the survey (568), the majority aged between 31 and 40 years; – of respondents were female; 65% attended private universities and 63% had more than 10 years since graduation; general clinic was the specialty most cited by the dentists, and 93% were active in the profession when they answered the questionnaire and more than half worked in the public service. It was noteworthy that although most professionals reported attending adults, 64% of them also assisted pregnant women and babies.

Table 2 describes the results of the second block of questions, about having some contact with BF and CF contents at college and in-service trainings.

BF benefits for the overall health (74.6%) were more frequently discussed at college than benefits for oral health (66%). Although more than half of respondents (52.84%) considered the contents of this training insufficient, 70% used it routinely at work.

CF and oral health were the subjects less discussed at college (60.9%) but were cited as sufficient (74.5%) and were the ones most applied at work (84.1%).

It is noteworthy the small number of professionals that received in-service training: 27.8% on BF and 21.5% on CF, but more than 80% of the respondents applied the knowledge learned in their routine work.

Table 3 shows the results of the questions of the third block about the professional’s knowledge on BF and CF.

All diseases described above can be prevented at some degree by BF and good eating habits; therefore, one could expect that the respondents would mark all of them, which did not happen, although many options were chosen.

Some matters such as when to start cleaning baby’s mouth and use of pacifier are always controversial, and the results of the survey reflect this debate. On the other hand, about continuity of breastfeeding after 6 months of age, there was more consensus, with 85.6% of respondents agreeing that it should be maintained.

Table 4 shows the results of the fourth and last block of questions.

There was a 25% demand for dentists’ guidance on BF, and when they were asked to deliver advice on this topic, only 15% felt prepared to do so.

The percentage of dentists who consider it to be their responsibility to provide support to BF and HCF was surprisingly high (92.3%), and more than 85% of them admitted that they needed further training to be able to work on these issues, although a voluntary attendance to courses (updating, extension, online courses, of any duration) on these topics was low (35.7%).

All themes proposed (formation of the stomatognathic system [SS], BF benefits to oral health, mouth breathing syndrome, bad habits in children, pregnancy and postpartum counseling, interdisciplinary work, and indicators’ data) could be addressed in college as well as in-service permanent and continuing education.

In Table 5, the variables relating to training received on BF and HCF, especially on the benefits for the overall health and oral health, were evaluated according to the type of college attended and time since graduation.

A statistically significant association was found for type of college and training contents on BF and overall health and BF and oral health, but not for CF and overall health and CF and oral health.

There was also statistical significance in the analysis of the association between time since graduation and training received on BF and overall health, CF and overall health and CF and oral health. Time since graduation did not have an influence on information received on BF and oral health.

Discussion

The professionals who accepted the invitation to answer the questionnaire were probably those who have more affinity with the matters surveyed, which limits the interpretation of data but yet provides a direction to be followed about the themes discussed.

The National Policy for Oral Health (PNSB, in Portuguese) defines that dentists and oral health teams should provide care in all cycles of life, that their services should not be limited to oral health, and that they should be incorporated to the health teams in Primary Health Care (PHC) (BRASIL, 2004BRASIL. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Coordenação Nacional de Saúde Bucal. Diretrizes da política nacional de saúde bucal. Brasília: MS , 2004a. ). The presence of the dentists’ work in all phases of life was outstanding, according to the results, i.e., 64% of the professionals reported that they provided care to adults, pregnant women and babies. The proposed interdisciplinary work, devised to increase the efficiency of the actions developed, continues to be a challenge in health services, being a powerful resource for dealing with the change of the healthcare model and workforce (MATUDA et al., 2014).

According to the survey, training contents, when provided, were often insufficient but could be applied at daily work as well as information on BF and overall health (70%) and BF and oral health (72.2%).

Addressing themes such as the benefits of BF and CF for overall health at college or other educational programs enable the dentist to exercise interprofessional collaboration. During pregnancy, for example, the dentist can provide prenatal dental care and sensitize women and guide them on theirs and their baby’s oral health, offering guidance on matters such as oral hygiene and diet in pregnancy, complementing the approaches of other professionals involved in care. After the baby’s birth, the dentist has the opportunity to assist on BF, participating in groups of new mothers and emphasizing the numerous benefits that can be achieved with this practice. Guidance on CF introduction is especially important when teeth erupt in order to ensure that a good facial development continues by stimulating the masticatory system with hard, dry and fibrous foods (CARVALHO, 2003CARVALHO, G. D. SOS respirador bucal: uma visão funcional e clínica da amamentação. São Paulo: Lovise, 2003. ). Dentists are strategically positioned to reach a large number of the population in less urgent conditions, during the regular appointments of their clients, which are good opportunities for education, discussion and motivation for a healthy life, and should be included in the challenge of improving the BF and HCF practices (JULIEN, 2000JULIEN, M. Nutrition: its role in dental training and practice. Journal of the Canadian Dental Association, Toronto, v. 66, n. 2, p. 979, 2000. ). Changing the attitudes and beliefs of health professionals in college is key to increase the support to BF and its promotion. Education of health professionals is associated with increased breastfeeding success rates and maternal satisfaction and a higher level of practitioner’s knowledge and professional skills of (RADZYMINSKI; CALLISTER, 2015RADZYMINSKI, S.; CALLISTER, L. C. Health professionals’ attitudes and beliefs about breastfeeding. Journal of Perinatal Education, Washington, DC, v. 24, n. 2, p. 102-109, 2015.). In Brazil, the implementation of the National Curricular Guidelines (NCG) (BRASIL, 2002BRASIL. Ministério da Educação. CNE/CES 3/2002, de 19 de fevereiro de 2002. Institui as Diretrizes Curriculares Nacionais dos Cursos de Farmácia e Odontologia. Diário Oficial da União, Brasília, DF, 4 mar. 2002. Seção 1, p. 10. ) signaled an important change in the training of health professionals to prepare them to deal with the problems of the health/disease process in the population, respecting SUS principles and working with full responsibility, with an emphasis on the promotion of health and prevention of diseases. This can explain our findings that professionals who had graduated from college less than ten years ago were the ones who most received information on BF and CF at college. The reflexes of NCD will have more impact as the higher education institutions actually materialize their pedagogical processes and train professionals in line with their proposals and SUS demands (BROCKVELD; VENANCIO, 2020BROCKVELD L. S. M.; VENANCIO, S. I. Avanços e desafios na formação do cirurgião-dentista para sua inserção nas práticas de promoção de saúde. Physis: Revista de Saúde Coletiva, Rio de Janeiro, v. 30, n. 3, p. e300326, 2020.).

The results showed that BF and HCF benefits in the prevention of diseases are not yet well known by dentists, indicating a gap in higher education and in updating these professionals.

About the diseases that can be prevented with BF and HCS, as described in Table 3, all of them could have been marked. Diabetes mellitus was the disease less identified (34%) as well as dental enamel defects (33.1%). When we pointed the diseases prevented by healthy diets, we found 12.9% who did not mark dental caries, in disagreement with robust scientific evidences on the subject (SHEIHAM, 2015SHEIHAM, A.; JAMES, P. Diet and dental caries: the pivotal role of free sugars reemphasized. Journal of Dental Research, v.94, n.10, p.1.341-1347, 2015.; KARJALAINEN , 2001KARJALAINEN, S. et al. A prospective study on sucrose consumption, visible plaque and caries in children from 3 to 6 years of age. Community Dentistry and Oral Epidemiolgy, v. 29, n. 2, p. 136-142, 2001.; MEURMAN; PIENIHÄKKINEN, 2010MEURMAN, P.; PIENIHÄKKINEN, K. Factors associated with caries increment: a longitudinal study from 18 months to 5 years age. Caries Research, v. 44, n.6, p.519-524, 2010.).

A survey carried out in UK with 70 newly graduated dentists, when considering the benefits of breastfeeding for mothers, only one respondent identified correctly that BF reduces the risk of obesity, type II diabetes and ovarian and breast cancer. When considering the BF benefits to the babies, nearly half of respondents reported that BF could be used as a strategy to reduce the risk of malocclusion, tooth decay or halitosis (POLGLASS, 2019POLGLASS, L. et al. Promotion of breastfeeding by dental teams: a survey of early career dentists. Journal Health Visiting, London, v. 7, n. 1, p. 24-29, 2019. ).

Subjects such as the use of pacifier and the best time to begin oral hygiene are always controversial and discussed in numerous professional upgrading forums, without a consensus. A review of Cochrane (JAAFFAR, 2016) concluded that the use of pacifier in healthy, full-term infants, since birth or when lactation is established, did not affect significantly the prevalence or duration of exclusive breastfeeding up to four months of age, but recognize that there are few evidences to assess short-term breastfeeding difficulties and long-term effects of pacifier on infants’ health.

Current WHO recommendation is supported by a systematic review that indicated that the meta-analysis of observational studies pointed to the use of pacifier as a risk factor for weaning (BUCCINI, 2016BUCCINI, G. S. et al. Pacifier use and interruption of exclusive breastfeeding: Systematic review and meta-analysis. Matern Child Nutrition, v. 13, p. e12384, 2016.). Although the use of pacifier is a practice culturally accepted, it is a marker of maternal difficulties during lactation, such as anxiety and insecurity, with negative impact on breastfeeding (BOIANI , 2018BOIANI, M. B.; PAIM, J. S. L.; FREITAS, T. S. F. Fatores associados à prática e a duração do aleitamento materno no Brasil contemporâneo. Investigação, [S. l.], v. 17, n. 3, p. 66-74, 2018. ).

Regarding the best time to start mouth cleaning, it is known that during breastfeeding, milk reacts with saliva and produces a powerful combination of stimulating and inhibitory metabolites that prematurely regulate the oral and intestinal microbiota and, therefore, the advice would be not to remove it from the oral cavity before teeth eruption (BÖNECKER; CORRÊA, 2003BÖNECKER, M. J. S.; CORRÊA, M. S. N. P. Medidas educativas e preventivas para tratamento integral do bebê. In: Cardoso RJA, coordenador. Odontologia, conhecimento e arte: odontopediatria. São Paulo: Artes Médicas, 2003. v. 2, p. 31-9. ; AL-SHEHRI et al., 2015; GRITZ; BHANDARI, 2015GRITZ, E. C.; BHANDARI, V. The human neonatal gut microbiome: a brief review. Front Pediatric, v. 3, n. 17, 2015.).

Other current defends that mouth hygiene should be introduced right after birth so that the cleaning habit is incorporated early in the child’s life, preventing caries and other oral problems, although there is no evidence on this aspect (JESUS , 2020JESUS, D. M. et al. A higiene bucal de bebês edêntulos e sua influência na microbiota bucal: os profissionais de saúde devem preconizá-la? - revisão crítica. Revista da Faculdade de Odontologia de Porto Alegre. DOI https://doi.org/10.22456/2177-0018.101674. Porto Alegre, 2020.
https://doi.org/10.22456/2177-0018.10167... ).

It is noteworthy the demand for dentists’ guidance on BF (25%) when the two options were added together (often and constantly). When asked to give information, only 15% reported being prepared to do so, although 92.3% stated that supporting BF and CF are also the dentists’ responsibility. In other countries we also find weaknesses in knowledge: in the survey conducted in UK, only 13% of dentists reported that they promoted BF and its benefits and effects during their practices. The main reasons given for not encouraging breastfeeding were: not considering that it was applicable to their role (47%); lack of knowledge (44%) and lack of confidence (34%) (POLGLASS, 2019POLGLASS, L. et al. Promotion of breastfeeding by dental teams: a survey of early career dentists. Journal Health Visiting, London, v. 7, n. 1, p. 24-29, 2019. ).

In a study carried out in the United States, 78% of dentists reported having already asked by their patients about food habits, and 64% considered important that patients had access to nutritional counseling from their dentists. But 81% of respondents did not deliver advice on eating habits, despite recognizing their importance; 57% argued lacking knowledge for this conduct (JULIEN, 2000JULIEN, M. Nutrition: its role in dental training and practice. Journal of the Canadian Dental Association, Toronto, v. 66, n. 2, p. 979, 2000. ). In our survey, we found 86.1% of interviewees stating that they needed refresher courses in BF. Among the proposed themes for an upgrading course, 92.1% of respondents pointed BF benefits for oral health and 86.4% indicated counseling for new mothers.

It is important to reflect on the National Policy on Permanent Education in Health (PNEPS, in Portuguese), which has the main purpose of reconceptualizing and reorienting undergraduate education and professional development, transforming the work process and having as learning axis collective discussions on daily work issues. It also plans to form a teaching-learning network in work practices and represents a milestone in the process of decentralization and dissemination of SUS’ pedagogical capabilities (BRASIL, 2003). Of the dentists who responded having already worked in public service, almost half of them did not receive any in-service training on BF and HCF. Based on PNEPS, training and upgrading on health promotion actions, especially healthy diets, have been increasingly present in the agenda of priorities. The Breastfeeding and Feeding Strategy in Brazil is an action that promotes adequate and healthy eating habits within the scope of the Primary Healthcare System, which proposes the qualification of the work process of health teams, aiming at enhancing the promotion of breastfeeding and healthy complementary diets for children under two years (JAIME; SANTOS, 2014JAIME, P. C.; SANTOS, L. M. P. Transição nutricional e a organização do cuidado em alimentação e nutrição na Atenção Básica em saúde. Divulgação em Saúde para Debate, Rio de Janeiro, n. 51, p. 72-85, 2014. ). Said strategy aims to contribute to reduce practices that discourage BF and HCF practices in the Primary Care Units, such as the unrestricted advertising of products that may interfere with healthy diets of children under two years of age and contribute to improving the nutritional status of these children, as a result of reduced nutritional deficiencies caused by low weight/obesity (BRASIL, 2013BRASIL. Ministério da Saúde. Portaria nº 1920, de 5 de setembro de 2013. Institui a Estratégia Nacional para Promoção do Aleitamento Materno e Alimentação Complementar Saudável no Sistema Único de Saúde (SUS) - Estratégia Amamenta e Alimenta Brasil. Diário Oficial da União, Brasília, DF, 2013. Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2013/prt1920_05_09_2013.html . Acesso em: 2 ago. 2019.
http://bvsms.saude.gov.br/bvs/saudelegis... ). The integration of dentists in this Strategy would have a major impact on their work and promotion of BF and HCF in primary healthcare services.

Final Remarks

Encouraging breastfeeding and healthy eating patterns as an ideal means of meeting the child’s nutritional needs and better development of SS is responsibility of all health professionals. It is important to know the background and the opinion of dentists graduated after the National Curricular Guidelines and review and come up with a new training framework to meet the new demands, aiming especially at a more integral care. Oral health professionals must be educators and facilitators for individuals, family and community, and have an enormous potential for this task, considering the broad space for action that they have, mainly in Primary Care. An important finding of this survey was the high percentage of professionals that consider that it is their responsibility to develop actions of support to BF and HCF, indicating a change in the profile of this category that until recently had training contents almost exclusively based on curative treatment.

Other positive aspect that must be considered by professors and managers is the recognition of professionals who said that they needed further training in BF and HCF, as well as the contents of undergraduate courses and continuing education.

This is the first survey carried out about dentists’ formal education, and other studies can indicate how new professionals receive and deal with the new challenges posed to their profession. Thinking over on how we could be more effective in diminishing the barriers to health promotion and prevention of diseases was the great motivation of this study. Changes in college education and attitudes of health providers, including dentists, can enhance the efficacy of professional support to breastfeeding and healthy eating patterns, contributing to diminish inequities and better health of our children and families.

References

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