ABSTRACT:

Objective:

To describe the prevalence of use of dental services in Brazil according to states and the Federal District and its relationship with socioeconomic variables and types of services, based on the 2019 National Health Survey.

Methods:

This is a cross-sectional population-based study using data from the 2019 National Health Survey, which included 88,531 participants aged 18 or older. We assessed variables related to the use of dental health services according to sociodemographic and behavioral characteristics through multivariate analysis, using a Poisson regression model with robust variance.

Results:

The use of dental services in the year prior to the interview was higher among adults (53.2%, confidence interval — 95%CI 52.5–53.9) than older adults (34.3%, 95%CI 33.2–34.4). The multivariate analysis revealed that the use of dental services was greater in people with better schooling (prevalence ratio — PR=2.02, 95%CI 1.87–2.18) and higher income (PR=1.54, 95%CI 1.45–1.64). States from the Southeast, Midwest, and South regions presented the highest percentages of individuals who visited a dentist in the previous year — between 49.0 and 57.6% of the population.

Conclusion:

Inequalities were found in the use of dental health services among the adult and older adult population, with regional differences; the use was higher among women, younger individuals, those with better schooling, higher income, healthier behaviors, better self-perceived oral health status, and who paid for their last dental treatment.

Keywords:
Health surveys; Dental health services; Delivery of health care; Dental care; Health equity

INTRODUCTION

Providing access to dental care is a challenge for health systems. This challenge is a consequence of the high prevalence and incidence of oral diseases¹1. Hugo FN, Bailey JA, Stein C, Cunha AR, Iser BPM, Malta DC, et al. Prevalence, incidence, and years-lived with disability due to oral disorders in Brazil: an analysis of the Global Burden of Disease Study 2019. Revista da Sociedade Brasileira de Medicina Tropical 2021 (in press)., the size and distribution of the dental workforce, the financial resources available, and the low priority given to oral health in public health policies. The debate on access in Brazil is relevant because, although guaranteed by law, access to public health services remains selective, targeted, and exclusionary²2. Barros AJD, Bertoldi DA. Desigualdades na utilização e no acesso a serviços odontológicos: uma avaliação em nível nacional. Ciên Saúde Coletiva 2002; 7(4): 709-17. https://doi.org/10.1590/S1413-81232002000400008
https://doi.org/10.1590/S1413-8123200200... ,³3. Assis MMA, Jesus WLA. Acesso aos serviços de saúde: abordagens, conceitos, políticas e modelo de análise. Ciên Saúde Coletiva 2012; 17(11): 2865-75. https://doi.org/10.1590/S1413-81232012001100002
https://doi.org/10.1590/S1413-8123201200... ,⁴4. Stopa SR, Malta DC, Monteiro CN, Szwarcwald CL, Goldbaum M, Cesar CLG. Acesso e uso de serviços de saúde pela população brasileira, Pesquisa Nacional de Saúde 2013. Rev Saúde Pública 2017; 51(Supl 1): 3s. https://doi.org/10.1590/s1518-8787.2017051000074
https://doi.org/10.1590/s1518-8787.20170... .

In response to the low access to oral health services, in 2004, the Ministry of Health launched the National Oral Health Policy, which promoted an expressive advance in dental health coverage in Brazilian primary health care⁵5. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Coordenação Nacional de Saúde Bucal. Diretrizes da política nacional de saúde bucal [Internet]. Brasília: Ministério da Saúde. 2004 [accessed on May 14, 2021]. Available at:http://189.28.128.100/dab/docs/publicacoes/geral/diretrizes_da_politica_nacional_de_saude_bucal.pdf
http://189.28.128.100/dab/docs/publicaco... . In addition, water fluoridation⁶6. Narvai PC. Cárie dentária e flúor: uma relação do século XX. Ciênc Saúde Coletiva 2000; 5(2): 381-92. https://doi.org/10.1590/S1413-81232000000200011
https://doi.org/10.1590/S1413-8123200000... , the advance of primary care through the Family Health Program, and the implementation of specialized services through dental specialty centers⁷7. Scherer CI, Scherer MDA. Advances and challenges in oral health after a decade of the “Smiling Brazil” Program. Rev Saúde Pública 2015; 49: 98. https://doi.org/10.1590/S0034-8910.2015049005961
https://doi.org/10.1590/S0034-8910.20150... are part of the strategies to reduce social inequalities in oral health⁸8. Pucca Junior GA, Costa JFR, Chagas LD, Sivestre RM. Oral health policies in Brazil. Braz Oral Res 2009; 23(Suppl 1): 9-16. https://doi.org/10.1590/S1806-83242009000500003
https://doi.org/10.1590/S1806-8324200900... ,⁹9. Antunes JLF, Narvai PC. Políticas de saúde bucal no Brasil e seu impacto sobre as desigualdades em saúde. Rev Saúde Pública 2010; 44(2): 360-5. https://doi.org/10.1590/S0034-89102010005000002
https://doi.org/10.1590/S0034-8910201000... .

At the same time, it is essential to assess to what extent the actions of the National Oral Health Policy have reduced inequalities in the use of and access to dental health services among the different social groups²2. Barros AJD, Bertoldi DA. Desigualdades na utilização e no acesso a serviços odontológicos: uma avaliação em nível nacional. Ciên Saúde Coletiva 2002; 7(4): 709-17. https://doi.org/10.1590/S1413-81232002000400008
https://doi.org/10.1590/S1413-8123200200... . Results of the 2003 National Household Sample Survey (Pesquisa Nacional por Amostra de Domicílios — PNAD) revealed that about 15.9% of the Brazilian population had never visited a dentist. In 1998, the proportion was 18.7%, representing a modest reduction in the five years evaluated. The 2003 PNAD also reported strong regional inequalities in the use of dental services, with significantly greater proportions of people who had never visited a dentist in the North and Northeast regions of Brazil¹⁰10. Pinheiro RS, Torres TZG. Uso de serviços odontológicos entre os Estados do Brasil. Ciênc Saúde Coletiva 2006; 11(4): 999-1010. https://doi.org/10.1590/S1413-81232006000400021
https://doi.org/10.1590/S1413-8123200600... . A comparison with 2008 PNAD data indicated an increased utilization of dental services in all ages between 1998 and 2008, especially among the poorest (first income quintile), pointing to a gradual decrease in access inequalities¹¹11. Peres KG, Peres MA, Boing AF, Bertoldi AD, Bastos JL, Barros AJD. Redução das desigualdades sociais na utilização de serviços odontológicos no Brasil entre 1998 e 2008. Rev Saúde Pública 2012; 46(2): 250-8. https://doi.org/10.1590/S0034-89102012000200007
https://doi.org/10.1590/S0034-8910201200... .

The 2013 National Health Survey (Pesquisa Nacional de Saúde — PNS) also described higher access to dental health services since the 1998 PNAD, even though socioeconomic disparities persisted. In the 2013 survey, 74.3% of participants who declared seeking a dentist within the 12 months prior to the research used private services¹²12. Pilotto LM, Celeste RK. The relationship between private health plans and use of medical and dental health services in the Brazilian health system. Ciên Saúde Coletiva 2019; 24(7): 2727-36. https://doi.org/10.1590/1413-81232018247.24112017
https://doi.org/10.1590/1413-81232018247... .

Different studies indicate that the access to and use of health services in Brazil reflect the inequalities between distinct social groups¹³13. Travassos C, Oliveira EXG, Viacava F. Desigualdades geográficas e sociais no acesso aos serviços de saúde no Brasil: 1998 e 2003. Ciên Saúde Coletiva 2006; 11(4): 975-86. https://doi.org/10.1590/S1413-81232006000400019
https://doi.org/10.1590/S1413-8123200600... ,¹⁴14. Cesar CLG, Tanaka OY. Inquérito domiciliar como instrumento de avaliação de serviços de saúde: um estudo de caso na região sudoeste da área metropolitana de São Paulo, 1989-1990. Cad Saúde Pública. 1996; 12(Suppl 2): 59-70. https://doi.org/10.1590/S0102-311X1996000600007
https://doi.org/10.1590/S0102-311X199600... ,¹⁵15. Lima-Costa MF, Barreto S, Giatti L. A situação socioeconômica afeta igualmente a saúde de idosos e adultos mais jovens no Brasil? Um estudo utilizando dados da Pesquisa Nacional por Amostra de Domicílios PNAD/98. Ciên Saúde Coletiva 2002; 7(4): 813-24. https://doi.org/10.1590/S1413-81232002000400015
https://doi.org/10.1590/S1413-8123200200... . Inequalities in the use of dental services have been associated with determinants such as gender and age, but also with variables that reflect inequities, such as income, schooling, having private insurance, and region of the country¹⁰10. Pinheiro RS, Torres TZG. Uso de serviços odontológicos entre os Estados do Brasil. Ciênc Saúde Coletiva 2006; 11(4): 999-1010. https://doi.org/10.1590/S1413-81232006000400021
https://doi.org/10.1590/S1413-8123200600... ,¹²12. Pilotto LM, Celeste RK. The relationship between private health plans and use of medical and dental health services in the Brazilian health system. Ciên Saúde Coletiva 2019; 24(7): 2727-36. https://doi.org/10.1590/1413-81232018247.24112017
https://doi.org/10.1590/1413-81232018247... . In addition, the universalization of public policy benefits and the distribution of resources to groups with greater needs are still scarce. This scenario creates a situation of inverse equity, in which low-income families and marginalized groups have difficulties in accessing services, while groups with better socioeconomic conditions are favored with greater public policy advantages¹⁶16. Batista MJ, Rihs LB, Sousa MLR. Risk indicators for tooth loss in adult workers. Braz Oral Res 2012; 26(5): 390-6. https://doi.org/10.1590/S1806-83242012000500003.
https://doi.org/10.1590/S1806-8324201200... ,¹⁷17. Fernandes LS, Peres MA. Associação entre atenção básica em saúde bucal e indicadores socioeconômicos municipais. Rev Saúde Pública 2005; 39(6): 930-6. https://doi.org/10.1590/S0034-89102005000600010
https://doi.org/10.1590/S0034-8910200500... ,¹⁸18. Soares FF, Chaves SCL, Cangussu MCT. Desigualdade na utilização de serviços de saúde bucal na atenção básica e fatores associados em dois municípios brasileiros. Rev Panam Salud Pública 2013; (34): 401-6..

Therefore, analyzing whether the use pattern of dental services is changing in the country is crucial. This analysis is particularly relevant given the transformations that occurred in recent years in Brazil, with fiscal austerity measures¹⁹19. Malta DC, Duncan BB, Barros MBA, Katikireddi SV, Souza FM, Silva AG, et al. Medidas de austeridade fiscal comprometem metas de controle de doenças não transmissíveis no Brasil. Ciênc Saúde Coletiva 2018; 23(10): 3115-22. http://doi.org/10.1590/1413-812320182310.25222018
http://doi.org/10.1590/1413-812320182310... , and in the National Oral Health Policy after 2015, when a restrictive scenario was identified due to the lower implementation of new public dental health services and the significant reduction in important indicators, such as the initial dental examination²⁰20. Chaves SCL, Almeida AMFL, Reis CS, Rossi TRA, Barros SG. Política de Saúde Bucal no Brasil: as transformações no período 2015-2017. Saúde Debate 2018; 42(2): 76-91. https://doi.org/10.1590/0103-11042018s206
https://doi.org/10.1590/0103-11042018s20... . In contrast, the private dental insurance market exploded, escalating from 2.6 million users in 2000 to 24.3 million in 2018, representing approximately a ten-fold increase²¹21. Rossi TRA, Lorena Sobrinho JE, Chaves SCL, Martelli PJL. Crise econômica, austeridade e seus efeitos sobre o financiamento e acesso a serviços públicos e privados de saúde bucal. Ciênc Saúde Coletiva 2019; 24(12): 4427-36. https://doi.org/10.1590/1413-812320182412.25582019
https://doi.org/10.1590/1413-81232018241... . Considering this scenario, the current study aimed to describe the prevalence of use of dental services in Brazil, evaluating its distribution across 26 states and the Federal District and its relationship with socioeconomic variables and types of service in the 2019 PNS.

METHODS

This is a cross-sectional study using data from the 2019 PNS, a household survey with national representation. We adopted a three-stage cluster sampling, in which: the primary sampling units were census tracts or sets of tracts; the secondary sampling units were private households selected by simple random sampling; and the tertiary sampling units were selected residents aged 15 years or older. The interviews were conducted between August 2019 and March 2020, using mobile devices for data collection.

The 2019 edition of PNS held interviews in 94,114 households, from which individuals aged 15 years or older were randomly selected to answer the individual questionnaire. Specific publications provide more details on the methodology²²22. Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, et al. Pesquisa Nacional de Saúde 2019: histórico, métodos e perspectivas. Epidemiol Serv Saúde 2020; 29(5): e2020315. https://doi.org/10.1590/s1679-49742020000500004
https://doi.org/10.1590/s1679-4974202000... . This study included data from adults aged 18 or older (n=88,531).

The questionnaire was divided into three sections:

1. a)

   household questionnaire;

2. b)

   questionnaire related to all household members, answered by a resident aged 18 or older;

3. c)

   individual questionnaire, answered by a resident aged 15 or older, selected by draw.

The 2019 PNS had 26 specific modules. Module U, corresponding to oral health, involves 19 specific questions. This study also considered questions from modules C – general characteristics of residents; I – health insurance coverage; J – use of health services; and P – lifestyles, related to adults aged 18 and older, and only those who answered the individual questionnaire were selected.

The outcome of interest of this study was the use of dental services in the previous year, assessed by the question: “When did you last visit a dentist?” Answers were categorized according to the use or not of dental services in the year prior to the interview (up to one year ago; over one year and up to two years ago; over two years and up to three years ago; over three years ago; never visited a dentist). The descriptive analysis also considered the type of dental service used, whether the participant directly paid for the dental appointment, and if they had dental insurance. Chart 1 (supplementary material) describes the baseline questions for the construction of the indicators employed.

Statistical Analysis

Data analysis adopted sample weights for primary sampling units, households, and the selected resident, following the complex survey sampling²²22. Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, et al. Pesquisa Nacional de Saúde 2019: histórico, métodos e perspectivas. Epidemiol Serv Saúde 2020; 29(5): e2020315. https://doi.org/10.1590/s1679-49742020000500004
https://doi.org/10.1590/s1679-4974202000... . Analyses were performed in the Stata software, version 14.0 (College Station, TX), using the survey module.

The descriptive analysis presented the general prevalence of sample characteristics, use of dental services in the previous year, last dentist appointment in the public service, direct payment for the last dentist appointment, and having dental insurance, according to exposure variables. Descriptive data are presented for the general sample of individuals aged 18 or older and also stratified by age (18–59 and ≥60).

For the distribution evaluation among the 26 states and the Federal District, we elaborated maps with the outcome prevalence in quartiles per state/Federal District. The cartographic basis was built with shapefiles, available at the website of the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística — IBGE)²³23. Brasil. Instituto Brasileiro de Geografia e Estatística. Bases cartográficas contínuas [Internet]. 2010 [accessed on May 13, 2021]. Available at:https://www.ibge.gov.br/geociencias/downloads-geociencias.html
https://www.ibge.gov.br/geociencias/down... .

Subsequently, a multivariate analysis was performed using the Poisson regression model and robust variance to estimate crude and adjusted prevalence ratios (PR), their respective 95% confidence intervals (95%CI), and a 5% significance level, adopting the variable use of dental services in the previous year as the outcome.

The selection of covariates was based on Andersen’s behavioral model²⁴24. Babitsch B, Gohl D, von Lengerke T. Re-revisiting Andersen’s Behavioral Model of Health Services Use: a systematic review of studies from 1998-2011. GMS Psychosoc Med 2012; 9: Doc11. https://doi.org/10.3205/psm000089
https://doi.org/10.3205/psm000089... , which seeks to identify the determinants of health service use. According to this model, predisposing factors, facilitators, and health behaviors, as well as perceived and normative needs, act as determinants of health service use. Initially, we selected predisposing variables for the use of services, including demographic characteristics (gender and age), socioeconomic aspects (education and ethnicity), and health behaviors (smoking and use of toothbrush); followed by enabling variables, characterized as economic and organizational factors that allow the use of services (area and per capita household income); and, lastly, variables related to health care needs, divided into perceived (self-perceived oral health) and normative (dental loss)²⁴24. Babitsch B, Gohl D, von Lengerke T. Re-revisiting Andersen’s Behavioral Model of Health Services Use: a systematic review of studies from 1998-2011. GMS Psychosoc Med 2012; 9: Doc11. https://doi.org/10.3205/psm000089
https://doi.org/10.3205/psm000089... .

Regarding predisposing factors, the variable gender was classified as male or female; age as adults (18 to 59 years) or older adults (60 years or older); schooling as illiterate, incomplete elementary school, complete elementary school, incomplete high school, complete high school, incomplete higher education, or complete higher education; ethnicity/skin color as white, black, multiracial/brown, Asian/yellow, or indigenous. Health behavior variables included: smoking, divided into yes (yes, daily; yes, less than daily) or no; and use of the toothbrush, with the options yes or no.

As for facilitators, area was categorized into urban or rural; and per capita household income into up to ¼ minimum wage, over ¼ and up to ½ minimum wage, over ½ and up to a minimum wage, over one and up to two minimum wages, over two and up to three minimum wages, over three and up to five minimum wages, or over five minimum wages.

Concerning necessity factors, self-reported dental loss considered the total number of teeth lost and was classified as no dental loss, loss of one to nine, ten to 19, or 20 or more teeth; and self-perceived oral health was divided into good (incredibly good or good) or poor (regular, poor, or very poor).

PNS data are available for public access and use at the official IBGE website (https://www.ibge.gov.br/estatisticas/sociais/saude.html). The National Research Ethics Committee (Comissão Nacional de Ética em Pesquisa — CONEP) approved PNS (3,529,376). The Informed Consent Form (ICF) was obtained at the interview.

RESULTS

The final sample of this study comprised 88,531 participants aged 18 years or older who answered questions regarding dental care in the year before the interview. For specific questions, the loss rate was 16.2%, below the maximum expected (27.0%). Table 1 presents the sample characteristics and the prevalence of use of dental services. The rate was 78.4% among individuals aged 18 to 59 years, 43.8% among brown participants, and 86.2% among urban residents. A total of 48.2% of the sample used dental services in the previous year, among which 24.4% used public services and 60.1% paid for the appointment. Women and white people used dental services more often. The frequency of payment for dental appointments was higher among white and yellow/Asian individuals. Regarding socioeconomic characteristics, 29.8% of the sample had completed high school, and most (51.1%) had a per capita household income of up to a minimum wage (Table 1).

Dental insurance was higher among white individuals (15.2%, 95%CI 14.5–15.9), those who lived in the urban area (14.5%, 95%CI 13.9–15.0), and with better schooling and income. Most participants declared not smoking and using a toothbrush. A total of 50.9% had lost less than ten teeth, and 69.7% perceived their oral health as good; these individuals also visited the dentist more often, used fewer public services, and were less inclined to have dental insurance (Table 1).

The crude prevalence of dental care was higher among adults (53.2%) than older adults (34.3%), similarly to having dental insurance. The use of public dental services was greater in individuals who reported losing a higher number of teeth and considered their oral health poor, regardless of age, but with lower prevalence rates in the older population. The prevalence of direct payment for dental services was higher in the older population (Supplementary Tables 1 and 2).

After adjusting the estimates, women had an 18% higher prevalence (PR=1.18; 95%CI 1.15–1.20) of demand for dental services in the previous year. Prevalence of service use was greater in people with better educational levels and income, with no differences as to skin color (Table 2). Non-smokers presented a higher prevalence (PR=1.10; 95%CI 1.06–1.14) of dental service utilization in the previous year compared to smokers (Supplementary Table 3). Individuals who reported using a toothbrush had a greater prevalence (PR=1.34; 95%CI 1.12–1.61) of dentist visits than those who did not use it. Compared to those who lost 20 or more teeth, participants who lost 10 to 19 teeth showed an 85% higher prevalence (PR=1.85; 95%CI 1.73–1.99) of using dental services, while for individuals who lost one to nine teeth, the rate was twice as high (PR=2.03; 95%CI 1.91–2.17). Individuals with good self-perceived oral health used dental services more often in the previous year (PR=1.15; 95%CI 1.16–1.19) (Supplementary Table 3).

The analysis of outcome distribution per state/Federal District indicated significant regional differences. States from the Southeast, Midwest, and — especially — South regions had the highest frequencies of dentist visits in the previous year — between 49.0 and 57.6% of the population. Amapá, Pará, and Rondônia (North region), as well as Maranhão, Piauí, and Ceará (Northeast region), had no more than 41.3% of the population receiving this type of care. The use of public services was higher (above 30%) in the North and Northeast regions, while it ranged from 10.1 to 22.2% in the Southeast region. Greater percentages of payment for dentist appointments and coverage by private dental insurance were identified in the Midwest, Southeast, and South regions, while in Northern and Northeastern states, this coverage reached less than 8% of the population (Figure 1).

DISCUSSION

This study presents the prevalence and characteristics of the use of dental health services in Brazil, in the different states/Federal District/regions, according to more recent data from the 2019 PNS. We identified a clear social gradient in the prevalence of dental care in the year before the interview and of payment for this care, which increased with socioeconomic strata, while the treatment in public services decreased in inverse proportion to having dental insurance.

The use of dental services in the year prior to the interview was 53.2% in adults and 34.3% among older adults, slightly higher than the rates found in a study using data from the 2013 PNS, whose prevalence of dentist appointments in the previous 12 months was 47.7% among adults and 29.4% in older adults. Regarding income, the prevalence of adults who paid for dentist appointments or had dental insurance increased with socioeconomic strata, just as in the 2013 survey results²⁵25. Bastos TF, Medina LPB, Sousa NFS, Lima MG, Malta DC, Barros MBA. Income inequalities in oral health and access to dental services in the Brazilian population: National Health Survey, 2013. Rev Bras Epidemiol 2019; 22(Suppl 2): E190015. http://doi.org/10.1590/1980-549720190015.supl.2
http://doi.org/10.1590/1980-549720190015... .

Universal and equal access to actions and services for health promotion, protection, and recovery, at all levels of complexity, is a fundamental right guaranteed to every Brazilian citizen²⁶26. Brasil. Presidência da República. Casa Civil. Subchefia para Assuntos Jurídicos. Constituição da República Federativa do Brasil de 1988 [Internet]. 1988 [accessed on May 14, 2021]. Available at:http://www.planalto.gov.br/ccivil_03/constituicao/constituicao.htm
http://www.planalto.gov.br/ccivil_03/con... . The implementation of the National Oral Health Policy in Brazil, in 2004 led to increased access to dental services and the strengthening of Oral Health Teams in the Family Health Strategy²⁷27. Narvai PC. O caso do ‘Brasil sorridente’ e perspectivas da Política Nacional de Saúde Bucal em meados do século XXI. Tempus – Actas de Saúde Coletiva 2020; 14(1): 175-87. http://doi.org/10.18569/tempus.v14i1.2622
http://doi.org/10.18569/tempus.v14i1.262... . Despite this progress, a recent study identified an upward trend in the funding of public oral health services in Brazil between 2003 and 2010 and stability from 2011 to 2018²¹. In contrast to the public financial crisis, the study shows that the coverage of dental-only insurance increased significantly between 2000 and 2018. The decreased financial transfer to public oral health services affected the use of this service in Brazil, reducing oral health indicators, such as the number of initial dental examinations²⁰20. Chaves SCL, Almeida AMFL, Reis CS, Rossi TRA, Barros SG. Política de Saúde Bucal no Brasil: as transformações no período 2015-2017. Saúde Debate 2018; 42(2): 76-91. https://doi.org/10.1590/0103-11042018s206
https://doi.org/10.1590/0103-11042018s20... ,²¹21. Rossi TRA, Lorena Sobrinho JE, Chaves SCL, Martelli PJL. Crise econômica, austeridade e seus efeitos sobre o financiamento e acesso a serviços públicos e privados de saúde bucal. Ciênc Saúde Coletiva 2019; 24(12): 4427-36. https://doi.org/10.1590/1413-812320182412.25582019
https://doi.org/10.1590/1413-81232018241... . In this scenario, social inequality also persists in oral health, perpetuating an exclusionary model that reproduces inequities in our country.

According to IBGE’s Household Budget Survey from 2008 and 2009, the profile of Brazilians who had dental-only insurance was individuals with higher income and schooling. Among regional differences, São Paulo State had the highest expenditures, and Northern states, such as Amazonas and Tocantins, spent less on dental care²⁸28. Cascaes AM, Camargo MBJ, Castilhos ED, Silva AER, Barros AJD. Gastos privados com saúde bucal no Brasil: análise dos dados da Pesquisa de Orçamentos Familiares, 2008-2009. Cad Saúde Pública 2017; 32(1): e00148915. https://doi.org/10.1590/0102-311X00148915
https://doi.org/10.1590/0102-311X0014891... . With respect to the use of services in the 2013 PNS, differences were found in the proportion of dentist visits in the previous 12 months according to Brazilian regions — higher in the South region (51.9%) than the North region (34.4%). This study, based on 2019 data, identified similar results, indicating that the country’s health inequities changed little during this period. The increased use of dental health services in the most developed regions of the country coincides with the highest percentage of expenditures with dentist appointments in these regions, demonstrating that oral care in Brazil still depends on private payment, thus suggesting the limits of the public health system (Sistema Único de Saúde — SUS) in reducing health-related social inequalities, especially regarding access.

We emphasize that the perceived need for treatment can also influence the demand for health services. The evaluation of access to and use of dental health services in Brazilian state capitals, based on data from the 2009 Vigitel telephone survey, revealed that 45% of interviewees reported needing treatment and that 15% of them were unable to receive care, with a greater proportion of need and non-treatment in Northern and Northeastern capitals. These results can be attributed to the lower professional activity in these regions, the high demand for treatment, and the larger portion of the population that depends on SUS, reflecting the structure and organization of dental care in Brazil, with lower availability of public dental services in certain regions²⁹29. Peres MA, Iser BPM, Peres KG, Malta DC, Antunes JLF. Desigualdades contextuais e individuais da prevalência de dor dentária em adultos e idosos no Brasil. Cad Saúde Pública 2012; 28(suppl): S114-S123. http://doi.org/10.1590/S0102-311X2012001300012
http://doi.org/10.1590/S0102-311X2012001... , suggesting the need to expand the services in these locations.

In the same study²⁹29. Peres MA, Iser BPM, Peres KG, Malta DC, Antunes JLF. Desigualdades contextuais e individuais da prevalência de dor dentária em adultos e idosos no Brasil. Cad Saúde Pública 2012; 28(suppl): S114-S123. http://doi.org/10.1590/S0102-311X2012001300012
http://doi.org/10.1590/S0102-311X2012001... , the lowest proportion of need for treatment was reported among older adults and those with less schooling. This fact could explain, at least in part, the lower access of the older population to oral health services since dental loss is still understood as a natural result of the aging process³⁰30. De Marchi RJ, Leal AF, Padilha DM, Brondani MA. Vulnerability and the psychosocial aspects of tooth loss in old age: a Southern Brazilian study. J Cross Cult Gerontol 2012; 27(3): 239-58. https://doi.org/10.1007/s10823-012-9170-5
https://doi.org/10.1007/s10823-012-9170-... , discouraging the older individual from seeking these services.

Regarding health costs, older adults usually had to pay for care, possibly given the type of treatment performed, which in many cases involved oral rehabilitation and procedures not covered by SUS. Another research, which evaluated the private spending of Brazilians on dental care and oral hygiene products and used data from the 2008–2009 Household Budget Survey, found higher per capita expenditure on dental care in households with greater income, whose head of the family was aged 60 years or older and better educated²⁸28. Cascaes AM, Camargo MBJ, Castilhos ED, Silva AER, Barros AJD. Gastos privados com saúde bucal no Brasil: análise dos dados da Pesquisa de Orçamentos Familiares, 2008-2009. Cad Saúde Pública 2017; 32(1): e00148915. https://doi.org/10.1590/0102-311X00148915
https://doi.org/10.1590/0102-311X0014891... . We underline the importance of SUS in the care of populations with lower schooling and income, aiming at reducing health inequities⁸8. Pucca Junior GA, Costa JFR, Chagas LD, Sivestre RM. Oral health policies in Brazil. Braz Oral Res 2009; 23(Suppl 1): 9-16. https://doi.org/10.1590/S1806-83242009000500003
https://doi.org/10.1590/S1806-8324200900... .

The limitations of the present study involve the data collected by the 2019 PNS. The survey excluded the homeless population and individuals living in nursing homes, groups with possibly low or no access to dental health services, which may indicate a scenario of even greater vulnerability than that presented in this study, especially among older populations. Data from geographical areas smaller than the state capitals were not estimated, and interviews were conducted with only one household resident. Moreover, the cross-sectional design of this study precluded us from making causal inferences.

In any case, we highlight that the work, performed with PNS data, allowed us to offer an overview of access to dental health services in Brazil, evidencing health inequities in the adult and older adult population, as well as according to states and regions of the country. Estimates show that approximately half of the Brazilian adults reported using some dental service in the year before the interview, with greater access among women, younger individuals, those better educated, and with higher income. Inequalities were also revealed by the greater use of services among the population with better health behaviors and perceived health status, as well as among those who can pay for treatment. These findings indicate that SUS still needs to advance in promoting access to dental care, especially in more vulnerable population groups and regions.

Analyzing and monitoring indicators of access to and use of health services through population-based surveys is crucial for elaborating effective public policies, contributing to the construction and improvement of SUS. The results of this study reinforce the importance of analyzing the information collected in population health surveys to guide policies or actions and promote greater equity in health access in Brazil.

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