Abstract

The Brazilian population is aging and in a feminization process. Among the most prevalent chronic diseases in the elderly, depression directly impacts the perception of oral health, with reflexes on self-image and self-esteem. This descriptive study, with a qualitative approach, aimed to analyze the perception of elderly women with symptoms of depressive disorders at a family health unit, about access and care in oral health and self-perception of oral health and its relationship with quality of life. The study included 20 women aged 60 or over, registered at a family health unit in Ribeirão Preto-SP. Audio-recorded semi-structured interviews were carried out, later transcribed, and analyzed through the Content Analysis technique. The results expressed an important relationship between self-perceived oral health and quality of life, barriers to access to oral health care, the importance of popular knowledge in self-care practices, self-perception of the mouth as part of their general health, and feelings of dissatisfaction and insecurity due to the lack of information, associated with the experience of a mutilating curative model. The importance of actions with an expanded approach and in a multidisciplinary team is emphasized, focusing on integrative care and quality of life for the elderly.

Keywords:
Aged; Mental health; Health Care Quality; Access and Evaluation; Dental Care

Introduction

Brazil has been facing a change in the sociodemographic profile and life expectancy increase scenario includes a population with more elderly women (Miranda; Mendes; Silva, 2017MIRANDA, G. M. D.; MENDES, A. da C. G.; SILVA, A. L. A. Public policies challenges on the background of demographic transition and social changes in Brazil. Interface (Botucatu), Botucatu, v. 21, n. 61, p. 309-320, 2017. http://dx.doi.org/10.1590/1807-57622016.0136.
http://dx.doi.org/10.1590/1807-57622016.... ; Rocha ., 2019ROCHA, M. L. C. et al. Quality of life and cognition in elderly: a systematic review. Estud. psicol. (Campinas), Campinas, v. 36, e180100, 2019. https://doi.org/10.1590/1982-0275201936e180100.
https://doi.org/10.1590/1982-0275201936e... ; Hellwig; Munhoz; Tomasi, 2016HELLWIG, Natália; MUNHOZ, Tiago Neuenfeld; TOMASI, Elaine. Sintomas depressivos em idosos: estudo transversal de base populacional. Ciência & Saúde Coletiva, Rio de Janeiro, v. 21, n. 11, p. 3575-3584, 2016. https://doi.org/10.1590/1413-812320152111.19552015.
https://doi.org/10.1590/1413-81232015211... ), which impacts oral health, as well as income, more presence of toothache, the use of public services, and demand for treatment (Bulgareli ., 2018BULGARELI, J. V. et al. Fatores que influenciam o impacto da saúde bucal nas atividades diárias de adolescentes, adultos e idosos. Revista Saúde Pública, São Paulo, v. 52, n. 44, 2018. https://doi.org/10.11606/s1518-8787.2018052000042.
https://doi.org/10.11606/s1518-8787.2018... ). Brazilian population aging involves economic and social changes for society as a whole and increasingly demands a multidisciplinary team approach focused on comprehensive care. At this stage of life, the development of chronic diseases - and their sequels - does not necessarily interfere with the life expectancy of individuals, but it can restrict functional and mental capacity during aging (Hellwig; Munhoz; Tomasi, 2016).

Among the diseases associated with aging, common mental disorders stand out, which are considered an important public health problem because they intensify during the aging process and are more likely to be present in women, such as anxiety, insomnia, forgetfulness, and cognitive decline (Silva ., 2018SILVA, P. A. dos S. et al. Prevalência de transtornos mentais comuns e fatores associados entre idosos de um município do Brasil. Ciência & Saúde Coletiva, v. 23, n. 2, p. 639-646, fev. 2018. doi: https://doi.org/10.1590/1413-81232018232.12852016
https://doi.org/10.1590/1413-81232018232... ). A population-based study conducted in southern Brazil with elderly people showed that 15.2% of the population studied had some depressive symptom, more present in women, and among those with worse economic status, who did not work, who were physically inactive or had some functional disability, and those with worse self-rated health (Hellwig; Munhoz; Tomasi, 2016HELLWIG, Natália; MUNHOZ, Tiago Neuenfeld; TOMASI, Elaine. Sintomas depressivos em idosos: estudo transversal de base populacional. Ciência & Saúde Coletiva, Rio de Janeiro, v. 21, n. 11, p. 3575-3584, 2016. https://doi.org/10.1590/1413-812320152111.19552015.
https://doi.org/10.1590/1413-81232015211... ). The increase in the number of elderly with depressive disorders demands multidisciplinary teams’ interventions, that commit to this population’s quality of life, considering it is a multifactorial event that involves the different dimensions of life, including physical, mental, functional, and psychological well-being, and has influences health-disease process, care, decision-making, and the individual's independence to perform activities of daily living (Martins ., 2016MARTINS, A. M. E. de B. L. et al. Associação entre transtornos mentais comuns e condições subjetivas de saúde entre idosos. Ciência & Saúde Coletiva, v. 21, n. 11, p. 3387-3398, nov. 2016. https://doi.org/10.1590/1413-812320152111.07842015
https://doi.org/10.1590/1413-81232015211... ).

Elderly people’a oral health is an integral and inseparable part of general health and is directly related to social and economic conditions (Brazil, 2004; Silva; Oliveira, 2018SILVA, P. A. dos S. et al. Prevalência de transtornos mentais comuns e fatores associados entre idosos de um município do Brasil. Ciência & Saúde Coletiva, v. 23, n. 2, p. 639-646, fev. 2018. doi: https://doi.org/10.1590/1413-81232018232.12852016
https://doi.org/10.1590/1413-81232018232... ). In the epidemiological survey of oral health conditions in the Brazilian population, SB Brazil 2010 (Brazil, 2012), 46% of the elderly between 65 to 74 years old reported feeling some impact of oral health in daily life, and the main complaint pointed out was difficulty to eat. Also, recently, there has been an increase in research to identify the relationship between oral health and the quality of life of the elderly, to improve health promotion action plans with multidisciplinary teams (Vargas; Vasconcelos; Ribeiro, 2011VARGAS, A. M. D.; VASCONCELOS, M.; RIBEIRO, M. T. de F. (Orgs). Saúde Bucal: atenção ao idoso. Belo Horizonte: Necon/UFMG, 2011.; Vasconcelos et al., 2012; Bulgareli ., 2018BULGARELI, J. V. et al. Fatores que influenciam o impacto da saúde bucal nas atividades diárias de adolescentes, adultos e idosos. Revista Saúde Pública, São Paulo, v. 52, n. 44, 2018. https://doi.org/10.11606/s1518-8787.2018052000042.
https://doi.org/10.11606/s1518-8787.2018... ; Ball; Correa; Toassi, 2019; Silva et al., 2019).

Regarding oral health and mental disorders, it is known that elderly people with symptoms of depressive disorders have a decline in their general health and oral health, with consequences mainly related to self-image and self-esteem, due to tooth loss, dry mouth, or pain (Vargas; Valencia; Ribeiro, 2011VARGAS, A. M. D.; VASCONCELOS, M.; RIBEIRO, M. T. de F. (Orgs). Saúde Bucal: atenção ao idoso. Belo Horizonte: Necon/UFMG, 2011.). Oral issues directly affect the individual's general health, with negative impact on quality of life (Bulgareli ., 2018BULGARELI, J. V. et al. Fatores que influenciam o impacto da saúde bucal nas atividades diárias de adolescentes, adultos e idosos. Revista Saúde Pública, São Paulo, v. 52, n. 44, 2018. https://doi.org/10.11606/s1518-8787.2018052000042.
https://doi.org/10.11606/s1518-8787.2018... ; Silva ., 2019SILVA, A. E. R. et al. A Saúde bucal está associada à presença de sintomas depressivos em idosos? Ciência & Saúde Coletiva, Rio de Janeiro, v. 24, n. 1, p. 181-188, jan. 2019. https://doi.org/10.1590/1413-81232018241.12662017.
https://doi.org/10.1590/1413-81232018241... ). However, to assess how much oral health interferes with quality of life, biological indices and clinical data are not enough for relevant results, since they do not assess, for example, pain and how much this condition affects daily life (Vargas; Valencia; Ribeiro, 2011). Studies indicate that self-perception of oral health is multifactorial, and should consider sociodemographic characteristics, such as age, race, education levels, and income, as well as self-perception of general health and acquired knowledge (Vasconcelos ., 2012VASCONCELOS, L. C. A. de et al. Autopercepção da saúde bucal de idosos de um município de médio porte do Nordeste brasileiro. Cadernos de Saúde Pública, Rio de Janeiro, v. 28, n. 6, p. 1101-1110, 2012. http://dx.doi.org/10.1590/S0102-311X2012000600009.
http://dx.doi.org/10.1590/S0102-311X2012... ; Ball; Correa; Toassi, 2019). Thus, it is possible to recognize how social, cultural and economic values interfere with their quality of life (Silva; Oliveira, 2018OLIVEIRA, M. B. et al. Associação entre fatores socioeconômicos, comportamentais, saúde geral e condição da mucosa bucal em idosos. Ciência & Saúde Coletiva, v. 23, n. 11, p. 3663-3674, 2018. https://doi.org/10.1590/1413-812320182311.26182016.
https://doi.org/10.1590/1413-81232018231... ). In this sense, the patient's account becomes a more comprehensive way of assessing the relationships between their health and their quality of life, as well as the associated factors (meanings, reasons, beliefs, values, and attitudes) (Mussolin ., 2020MUSSOLIN, M. G.; MESQUITA-LAGO, L. P.; SARAIVA, M. C. P.; MESTRINER, S. F. Impact of oral and mental health over the quality of life of older people in a Family Health Unit. RGO, Rev Gaúch Odontol., v. 68, p. e20200043, 2020. doi: http://dx.doi.org/10.1590/1981-86372020000433676
http://dx.doi.org/10.1590/1981-863720200... ).

This study aimed to analyze the perception of elderly women with symptoms of depressive disorders in a family health unit, regarding access to oral health care, as well as self-perception of oral health and its relationship with quality of life.

Methodology

This is a descriptive study, theoretically supported by the National Oral Health Policy (Brazil, 2004), with a qualitative methodological approach and the participation of elderly people registered in a Family Health Unit (FHU) in the city of Ribeirão Preto-SP. This unit is a field of teaching and research for undergraduate and graduate students from different areas of health at a public university. It is important to highlight that this FHU is registered in the Ministry of Health with a minimal Family Health Strategy (FHS) team that does not include an oral health team in the models the Ministry of Health proposes (USP, 2020), but counts with the participation of residents and preceptors of a multiprofessional residency program, that includes oral health professionals.

A total of 50 people aged 60 years or older, registered in the area covered by the FHU, were randomly selected. They were contacted by telephone or in-person and invited to participate. After five attempts, it was not possible to contact 8 participants for one of the following reasons: the telephone number was outdated, they did not accept the call, they were not present at the unit during the research period, and they were not at home for professional or personal reasons. The data was produced by questionnaires and interviews conducted by one of the researchers, a dental surgeon, resident in the same unit, after a pilot interview training. The Informed Consent Form (ICF) was read and signed, followed by data production. First, the Mini-Mental State Examination (MMSE) was applied, as an instrument to assess the degree of cognitive deficit in the elderly (Melo; Barbosa, 2015MELO, D. M. de; BARBOSA, A. J. G. O uso do Mini-Exame do Estado Mental em pesquisas com idosos no Brasil: uma revisão sistemática. Ciência & Saúde Coletiva, Rio de Janeiro, v. 20, n. 12, p. 3865-3876, 2015. https://doi.org/10.1590/1413-812320152012.06032015.
https://doi.org/10.1590/1413-81232015201... ) and those who did not present a minimum cut-off score were excluded from the study. Until data saturation was reached, 32 elderly men and women were invited to participate, of which 1 did not reach the minimum MMSE score and another 11 did not agree to participate in the research. Next, we applied the Patient Health Questionnaire - Two items (PHQ-2) (Kroenke; Spitzer; Williams, 2003KROENKE, K.; SPITZER, R. L.; WILLIAMS, J. B. W. The Patient Health Questionnaire-2: Validity of a Two-Item Depression Screener. Medical Care, v. 41, n. 11, p. 1284-1292, 2003. doi: 10.1097/01.MLR.0000093487.78664.3C
https://doi.org/10.1097/01.MLR.000009348... ). Those who had a positive score for symptoms of depressive disorders after responding to PHQ-2 (Kroenke; Spitzer; Williams, 2003) were included, that is a score greater than or equal to 3. Data were produced through audio-recorded semi-directed interviews, of approximately 30 minutes, at home or the FHU, according to each participant's choice, at a previously scheduled time, assuring comfort and privacy. A socioeconomic assessment questionnaire was applied to characterize the profile of the elderly population in terms of gender, age, education, income, self-reported diseases, and use of dental services (Brazil, 2012). For the interview, the script included questions about the perception of care and access to dental services in previous experiences and at the time of the interview, self-perception regarding the functionalities related to oral health (talking, smiling, chewing, swallowing) and their interference in quality of life.

The final number of participants formed an intentional sample reached by theoretical saturation. Thus, after reading the interviews, they were finished when the information obtained was already sufficient to bring consensus regarding the topic studied, along with the theoretical contexts involving the research issue and the type of study (Minayo, 2017MINAYO, M. C. de S. Amostragem e saturação em pesquisa qualitativa: consensos e controvérsias. Revista Pesquisa Qualitativa. São Paulo, v. 5, n. 7, p. 1-12, 2017. Disponível em: https://editora.sepq.org.br/index.php/rpq/article/view/82/59.
https://editora.sepq.org.br/index.php/rp... ; Fontanella ., 2011FONTANELLA, B. J. B. et al. Amostragem em pesquisas qualitativas: proposta de procedimentos para constatar saturação teórica. Cadernos de Saúde Pública, Rio de Janeiro, v. 27, n. 2, p. 388-394, 2011. https://doi.org/10.1590/S0102-311X2011000200020.
https://doi.org/10.1590/S0102-311X201100... ). In the end, the number of participants interviewed was 20, named “Participant”, followed by numbers from 1 to 20.

The interviews were transcribed into a Word (Microsoft Office) file and stored on a drive owned by the researchers. Data analysis began with the contact with the reality to be studied, in the interaction between researcher and participant, during the data production (Preti, 1993PRETI, D. Análise de textos orais. Projeto de estudo da norma linguística urbana culta de São Paulo (Projeto NURC/SP). São Paulo: FFLCH/USP, 1993.). After transcription, the data were systematized and analyzed using the Content Analysis technique (Bardin, 2011BARDIN, L. Análise de conteúdo. São Paulo: Edições 70, 2011. 229 p.) in three stages: 1) Pre-analysis and exploration of the material; 2) Data processing with the construction of thematic categories; and 3) Inference and interpretation of the categories. The data were interpreted and associated with existing studies and the National Oral Health Policy (Brazil, 2004).

The study was approved by the Ethics Committee of the University of São Paulo at Ribeirão Preto School of Dentistry under opinion number 3,150,556.

Results and Discussion

The participants of the research were 20 women, aged between 60 and 84 years (mean of 74 years), 90% white, 35% married and 65% widowed, single or divorced and 20% living alone. They had an average of 6 years of schooling and reported having chronic diseases, 80% hypertension, 60% diabetes mellitus and 11% cancer. All of those who declared family income (50%), had an income of at least two minimum wages. Regarding access to oral health care, 65% of them visited the dentist less than a year ago and, of these, 60% used the public service and 40% the private service.

Some elderly women reported using the oral health services offered by the FHU, such as dental care, while others preferred to attend private oral health services, even though they were registered in the FHU, and used other health services offered, such as medical care, care by a multidisciplinary team, and participation in health promotion groups. They use private services due to the delay in access to public secondary care service, such as prosthetic rehabilitation, or because they had a bond with professionals in private care services throughout their lives.

Based on the analysis of the interviews, the results were organized into four thematic categories presented below: Access yesterday and today; The construction of popular knowledge in oral health care; Meanings of the Experiences of the Health-Disease Process; and Food: synonymous of happiness.

Access yesterday and today

The first category is mainly related to the barriers to accessing oral health care. In the following excerpt, the elderly woman talks about her experience of tooth loss when she lived in a rural area.

In addition to geographical barriers, the consultation with the oral health professional (dentist) was influenced by financial aspects and by the experience of a curative model of oral health.

Based on the participants' experience and their life context, it was possible to identify different barriers to access to services, such as the lack of human resources and the fact that they lived in a rural area. This reality is mainly present in rural populations, where the elderly have difficulties accessing health services due to the need to move, lack of transportation, or long distances to health facilities (Costa ., 2019COSTA, M. J. F. et al. Clinical and self-perceived oral health assessment of elderly residents in urban, rural, and institutionalized communities. Clinics, v. 74, p. e972, 2019. doi: http://dx.doi.org/10.6061/clinics/2019/e972
http://dx.doi.org/10.6061/clinics/2019/e... ).

Before the creation of SUS (Sistema Único de Saúde, Brazilian Public Health System) and the implementation of actions proposed in the PNSB (Política Nacional de Saúde Bucal, Oral Health National Policy), universal access to oral health was considered precarious with few resources allocated to supplies and training of professionals (Brazil, 2004), therefore, it is understood that there is a need for a transition care model for the elderly, people-centered and involving different actors such as caregivers, family members and managers (Nitschke ., 2022NITSCHKE, I. et al. On the Necessity of a Geriatric Oral Health Care Transition Model: Towards an Inclusive and Resource-Oriented Transition Process. Int J Environ Res Public Health, v. 19, n. 10, p. 6148, 2022. doi: 10.3390/ijerph19106148. PMID: 35627684; PMCID: PMC9141301.
https://doi.org/10.3390/ijerph19106148... ). The implementation of the PNSB should, therefore, reorient the oral health care model, developing network, decentralized and priority actions regarding pain, infection, and suffering, to qualify for comprehensive care (Brazil, 2004).

For these elderly women, the unusual toothbrushing culture and difficulties in accessing water were considered barriers to oral health care, especially for those who spend their childhood in rural areas.

Besides cultural aspects, financial difficulties to access restorative treatments and the hegemony of the mutilating curative model were reported as factors that influenced their choices and that may have repercussions in suffering due to tooth loss.

In Brazil, despite advances in dentistry, edentulism is still quite prevalent among the elderly, with an average of 29.4 missing teeth in the age group of 65 to 74 years, evidenced by the need and/or use of prostheses for oral rehabilitation in most of the population in this age group (Brazil, 2012). Reports of invasive procedures in services such as dental extraction explain the predominance of the curative care model, in which tooth loss results in psychological discomfort, an important factor that impacts the quality of life of elderly people (Echeverria ., 2019ECHEVERRIA, M. et al. Oral health-related quality of life in older adults-Longitudinal study. Gerodontology, v. 36, n. 2, p. 118-124, 2019. doi: 10.1111/ger. PMID: 30565315.
https://doi.org/10.1111/ger... ).

Another point raised was the desire to have information about their oral health condition and treatment needs, before the prognosis of the disease “was the worst” and demanded more invasive procedures.

The literature shows that social factors such as housing conditions, geographic location, social interaction, access to basic sanitation, and health information are important for oral health (Costa ., 2019COSTA, M. J. F. et al. Clinical and self-perceived oral health assessment of elderly residents in urban, rural, and institutionalized communities. Clinics, v. 74, p. e972, 2019. doi: http://dx.doi.org/10.6061/clinics/2019/e972
http://dx.doi.org/10.6061/clinics/2019/e... ). Travassos and Castro (2009TRAVASSOS, C.; CASTRO, M. S. M. Determinantes e desigualdades sociais no acesso e na utilização de serviços de saúde. In: GIOVANELLA, L. et al. (Orgs). Políticas e Sistemas de Saúde no Brasil. Rio de Janeiro: Fiocruz, 2009. p. 219-21.) explain that access barriers mark social inequalities both in the access and the use of health services. For these authors, the absence of health professionals is one of the main barriers to access, but they also highlight other obstacles, such as geographical, related to home location; financial, linked to access to goods and services; organizational; informational, regarding access to information; and cultural, referring to values and beliefs. In addition, barriers related to the type of health services offered also contribute to or hinder the access to services.

It is also possible to observe that the relationship with the professional who provided the healthcare was based on the service provided and not on the relationship between patient and professional or on the exchange of knowledge in the health-disease process. Thus, acknowledging access barriers, including communication and bonding between professional and patient, are important aspects the intention is to expand the clinic beyond oral health, and rescue biopsychosocial needs.

The construction of popular knowledge in oral health care

The second theme concerns the use of home remedies and oral hygiene habits, built from popular knowledge. For Holanda et al. (2020), the work of the multidisciplinary team in the FHU consists of redirecting health practices when it is guided by the valorization of popular health education. This position enhances movements of autonomy to construct knowledge collectively in the community. In view of the difficult access to oral health services, the use of medicinal plants, teas and herbs as home remedies for pain relief is observed among the elderly women.

Based on these reports, it can be thought that clinical-restorative procedures in dental treatment are not the only alternative to deal with the health-disease process. Popular knowledge, i.e., beliefs and values passed down between generations in families, show the strength of the user's autonomy and the appreciation of their knowledge in health care. In Brazil, due to the influence of indigenous, African and European cultures, the use of medicinal plants is a common primary care practice in populations and is characterized by coming from popular knowledge and tradition (Zeni ., 2017ZENI, A. L. B. et al. Utilização de plantas medicinais como remédio caseiro na Atenção Primária em Blumenau, Santa Catarina, Brasil. Ciência & Saúde Coletiva, Rio de Janeiro, v. 22, n. 8, p. 2703-2712, 2017. http://dx.doi.org/10.1590/1413-81232017228.18892015.
http://dx.doi.org/10.1590/1413-812320172... ).

To expand the articulation with the community and its knowledge, the National Health Promotion Policy (Brazil, 2010) proposes networking, so that health actions planning is more linked to the perceived needs and experiences of the population in the different territories, promoting quality of life and reducing vulnerabilities and risks to health, increasing the autonomy and co-responsibility of the subjects.

The construction of health habits, with reference to family tradition, were reported by the interviewees, such as the participation and vigilance of parents in oral health care.

The perception of the elderly women reveals the family and cultural values built since childhood, which make up factors that can influence hygiene habits, the cariogenic diet, or the development of caries in childhood, with consequences for the oral health of their children (Carmo ., 2023CARMO, S. M. A. et al. Influência do ambiente familiar na saúde bucal: uma revisão integrativa. Revista Faipe, v. 13, n. 2, p. 110-119, jul./dez. 2023.). According to the participants, the oral health experience reported had repercussions on the habits and parenting and shows differences in access between the generations.

The health promotion actions proposed in the PNSB, in this sense, should contribute to the autonomy of citizens through approaches to risk factors, or simultaneous protection, both for diseases of the oral cavity and for other diseases (Brazil, 2004). The studies by Quintela . (2019QUINTELA, S. H. C. et al. The perceptions of vascular dysfunction bearing patients with regards to health education as an autonomy instrument. Revista de Pesquisa: Cuidado é Fundamental, [S.l.], v. 11, n. 1, p. 25-30, 2019. http://dx.doi.org/10.9789/2175-5361.2019.v11i1.25-30.
http://dx.doi.org/10.9789/2175-5361.2019... ) and Dutra, Bossato and Oliveira (2017DUTRA, V. F. D.; BOSSATO, H. R.; OLIVEIRA, R. M. P. de. Mediating autonomy: an essential care practice in mental health. Escola Anna Nery. Rio de Janeiro, v. 21, n. 3, e20160284, 2017. https://doi.org/10.1590/2177-9465-ean-2016-0284.
https://doi.org/10.1590/2177-9465-ean-20... ) point to the importance of valuing autonomy, valuing the individual's potential, and empowering the user by sharing knowledge between professional and patient, so that neither party is seen as holding knowledge.

As a result of early tooth loss, many elderly women reported having removable dental prostheses, as well as how the take care of them in their daily routine. As found in the literature, the participants reported the habit of performing oral and prosthesis hygiene mechanically, that is, with the use of a toothbrush, and knowledge about the importance of removing them to sleep (Oliveira ., 2018OLIVEIRA, M. B. et al. Associação entre fatores socioeconômicos, comportamentais, saúde geral e condição da mucosa bucal em idosos. Ciência & Saúde Coletiva, v. 23, n. 11, p. 3663-3674, 2018. https://doi.org/10.1590/1413-812320182311.26182016.
https://doi.org/10.1590/1413-81232018231... ; Falcão ., 2019FALCÃO, T. N. et al. Qualidade de vida e condições de higiene de próteses dentárias de idosos institucionalizados. Revista Brasileira de Ciências da Saúde, v. 23, n. 1, p. 73-80, 2019 https://doi.org/10.22478/ufpb.2317-6032.2019v23n1.34935.
https://doi.org/10.22478/ufpb.2317-6032.... ).

Thus, it is possible to observe suffering pain, and anguish in the past led them to search for alternatives for care, such as home remedies, and to protect their children, constructing their popular knowledge in oral health care, which contributed to changes in habits between generations.

Meaning of health-disease experiences

In the third category, self-perception of oral health led the participants to express various feelings, representing their experiences and emotions concerning what they experienced in the health-disease process. In addition to the dissatisfaction with the losses suffered, the elderly women expressed anguish and dissatisfaction with their history and desires for changes, such as, for example, a woman who regretted that she no longer had her natural teeth.

In this context, their experiences of health and disease were marked by insecurities and fear in the face of the curative oral health model. And the fear of these elderly women is shown to be something real that interferes with self-care in oral health. These aspects are confirmed in the literature, as fear of the dentist is more prevalent among women and fear affects choices about dental care (Silveira ., 2021SILVEIRA, E. R. et al. Estimated prevalence of dental fear in adults: A systematic review and meta-analysis. J Dent, v.108, p. 103632, 2021. doi: 10.1016/j.jdent.2021.103632.
https://doi.org/10.1016/j.jdent.2021.103... ; Alenezi; Aldokhayel, 2022ALENEZI, A. A.; ALDOKHAYEL, H. S. The impact of dental fear on the dental attendance behaviors: A retrospective study. Journal of Family Medicine and Primary Care, v. 11, n. 10, p. 6444, 2022. doi: 10.4103/jfmpc.jfmpc_1030_22
https://doi.org/10.4103/jfmpc.jfmpc_1030... ). Thus, their anxieties once again pointed that access to information barriers are essential for safe decision-making about their own health, in addition to the expectation about access to specialized treatment.

The oral health care model provided by the PNSB focuses on comprehensive care, so that there is the progressive incorporation of actions to promote, protect and recover oral health, at all levels of care, and these elderly women aim for and expect all complete actions to improve their quality of life.

Food: synonym of happiness

In the fourth category, the participants indicated that they believe in the direct relationship between the health of the gastrointestinal tract and chewing functionality and pointed to the relationship between food and quality of life.

Most of the participants reported some alteration in oral health functionalities, mainly related to chewing difficulty and aesthetic loss.

When reflecting on the meaning of quality of life, the participants reported on financial conditions and the relationship with food and the feeling of happiness.

It is possible to notice a strong relationship between good nutrition and happiness, from access to food to the possibility of chewing and smiling, being happy. The mouth is then understood as a fundamental part of being in the world. Based on the functional aspect of the mouth as a key component, these elderly women were able to recover the idea of the oral area (Botazzo, 2006BOTAZZO, C. Sobre a bucalidade: notas para a pesquisa e contribuição ao debate. Ciência & Saúde Coletiva, Rio de Janeiro, v. 11, n. 1, p. 7-17, 2006. https://doi.org/10.1590/S1413-81232006000100002.
https://doi.org/10.1590/S1413-8123200600... ), that is, the dimension of oral health and the relationship between the mouth and its social function to survive, live and coexist. According to Botazzo (2006), this concept refers to the mouth relating to the world in its different sociological and psychological aspects and producing subjectivities. In this sense, oral health professionals should connect with this dimension to recognize their co-responsibility in restoring the lost dignity of these elderly women who want to eat and smile again.

Silva . (2019SILVA, A. E. R. et al. A Saúde bucal está associada à presença de sintomas depressivos em idosos? Ciência & Saúde Coletiva, Rio de Janeiro, v. 24, n. 1, p. 181-188, jan. 2019. https://doi.org/10.1590/1413-81232018241.12662017.
https://doi.org/10.1590/1413-81232018241... ) pointed out an important association between oral health variables and depressive symptoms in the elderly population, in which a strong prevalence of depressive symptoms was observed with the need for oral rehabilitation, aiming precisely to bring back the chewing function and pleasure in eating. Thus, the lack of teeth, or even the changes perceived in the oral health functionalities of the participants, directly reflects on the feelings of self-care and social interaction, an important point for self-esteem and quality of life of the elderly.

Given oral health self-perception, we suggest that dental treatment of the oral health team, especially in oral rehabilitation, should consider not only technical aspects but also the patient's perception of their image and the need to work as a team with a focus on the expanded clinic, to promote full individual-centered care.

Conclusion

This study shows an important relationship between self-perception of oral health and its relationship with quality of life, emphasizing that individuals bring with them the consequences of both their previous and recent experiences. In the population studied, we can observe barriers that prevent access to healthcare, the importance of popular knowledge, self-perception of the mouth as part of their general health, feelings of dissatisfaction and insecurity in the face of the lack of information and access to specialties, associated with the experience of a mutilating curative model in oral health.

The oral health care offered to these elderly women presented aesthetic and functional aspects that influenced their social life, and they reported having sequelae in their self-esteem and in the relationship with their health and the oral health professional. It is emphasized that the construction of the professional-patient bond and relationship should be based on dialogue and the joint construction of solutions according to each social context, favoring the patient's autonomy in making choices about their health condition. Based on the perceptions of these elderly women, we expect to contribute to the development of promotion, prevention, and recovery health actions with an expanded approach, and in a multidisciplinary team, focusing on elderly women’s comprehensive care and quality of life¹1 M. de Matos and S. F. Mestriner: study conception and design, data analysis and interpretation; writing of the article, relevant critical review of the intellectual content, final approval of the version to be published, responsible for all aspects of the work ensuring the accuracy and integrity of any part of the work. L. P. de M. Lago and A. F. Bulgarelli: data analysis and interpretation; writing of the article, relevant critical review of the intellectual content, final approval of the version to be published, responsible for all aspects of the work ensuring the accuracy and integrity of any part of the work..

References

Publication Dates

History