Analysis of the supply of specialized oral health care services in the Brazilian National Health System: Brazil, 2014**Article derived from the Master’s Degree thesis entitled 'Evaluation of Dental Specialty Centers in Brazil', submitted by Luiza Rahmeier Fietz Rios to the Postgraduate Program in Public Health of the Universidade Federal de Santa Catarina on 12 July 2018.

Luiza Rahmeier Fietz Rios Claudia Flemming Colussi About the authors

Abstract

Objective:

to analyze the availability of public specialized dental care services at Dental Specialties Centers (CEO) in Brazil in 2014.

Methods:

secondary data on the CEO ratio and dental surgeon ratio were analyzed by population as well as the adequacy of the quantity of complete dental consulting rooms per CEO type, the adequacy of the ratio between the working hours of dental auxiliaries /technicians and those of dental surgeons and the adequacy of the availability of recommended minimum specialties. Possible statistical differences between macro-regions were verified.

Results:

we found a ratio of one CEO per 217,797 inhabitants and one dental surgeon per 26,811 inhabitants; 97% of CEOs had the recommended number of dental consulting rooms; 26% had equivalent working hours between dental auxiliaries /technicians and dental surgeons; 60% offered the recommended minimum specialties.

Conclusion:

there were limitations in the provision of National Health System specialized oral health care services as well as regional differences.

Keywords:
Oral Health; Specialties, Dental; Health Services Accessibility; Public Health; Epidemiology, Descriptive

Introduction

The supply of health services can be understood as the availability of services to the population.11. Stopa SR, Malta DC, Monteiro CN, Szwarcwald CL, Goldbaum M, Cesar CLG. Use of and access to health services in Brazil, 2013 National Health Survey. Rev Saúde Pública [Internet]. 2017 Jun [cited 2019 Jan 18];51(Supp 1):3s. Available from: Available from: http://www.scielo.br/pdf/rsp/v51s1/pt_0034-8910-rsp-S1518-87872017051000074.pdf . Doi: 10.1590/s1518-8787.2017051000074
http://www.scielo.br/pdf/rsp/v51s1/pt_00...
Availability, in turn, is the existence of a given service within the reach of a service user at the right place and time.22. Esposti CDD, Cavaca AG, Côco LSA, Santos Neto ET, Oliveira AE. As dimensões do acesso aos serviços de saúde bucal na mídia impressa. Saúde Soc [Internet]. 2016 mar [citado 2019 jan 18]; 25(1):19-30. Disponível em: Disponível em: http://www.scielo.br/pdf/sausoc/v25n1/1984-0470-sausoc-25-01-00019.pdf . Doi: 10.1590/S0104-12902016141706
http://www.scielo.br/pdf/sausoc/v25n1/19...
Analysis of service supply can be useful for health planning, because important issues such as access, accessibility, use of health services, care continuity and comprehensiveness are influenced by it.33. Viacava F, Oliveira RAD, Carvalho CC, Laguardia J, Bellido JG. SUS: oferta, acesso e utilização de serviços de saúde nos últimos 30 anos. Ciênc Saúde Coletiva [Internet]. 2018 jun [citado 2019 jan 18];23(6):1751-62. Available from: Available from: http://www.scielo.br/pdf/csc/v23n6/1413-8123-csc-23-06-1751.pdf . Doi: 10.1590/1413-81232018236.06022018
http://www.scielo.br/pdf/csc/v23n6/1413-...

4. Fonseca EP, Fonseca SGO, Meneghim MC. Análise do acesso aos serviços odontológicos públicos no Brasil. ABCS Health Sci [Internet]. 2017 ago [citado 2019 jan 18];42(2):85-9217. Disponível em: Disponível em: https://www.portalnepas.org.br/abcshs/article/view/1008 . Doi: 10.7322/abcshs.v42i2.1008
https://www.portalnepas.org.br/abcshs/ar...

5. Albuquerque MSV, Lyra TM, Farias SF, Mendes MFM, Martelli PJL. Acessibilidade aos serviços de saúde: uma análise a partir da Atenção Básica em Pernambuco. Saúde Debate [Internet]. 2014 out [citado 2019 jan 18];38 (n esp):182-94. Disponível em: Disponível em: http://www.scielo.br/pdf/sdeb/v38nspe/0103-1104-sdeb-38-spe-0182.pdf . Doi: 10.5935/0103-1104.2014S014
http://www.scielo.br/pdf/sdeb/v38nspe/01...
-66. Silva HEC, Gottems LBD. Interface entre a atenção primária e a secundária em odontologia no Sistema Único de Saúde: uma revisão sistemática integrativa. Ciênc Saúde Coletiva [Internet]. 2017 ago [citado 2019 jan 18];22(8):2645-57. Disponível em: Disponível em: http://www.scielo.br/pdf/csc/v22n8/1413-8123-csc-22-08-2645.pdf . Doi: 10.1590/1413-81232017228.22432015
http://www.scielo.br/pdf/csc/v22n8/1413-...

In the field of oral health, in 2004, stronger financial incentives provided by the National Oral Health Policy (PNSB) both increased specialized dental services and implanted Dental Specialties Centers (CEO).77. Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Diretrizes da política nacional de saúde bucal [internet]. Brasília: Ministério da Saúde; 2004 [citado 2018 fev 15]. 4 p. Disponível em: Disponível em: 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...
Specialized dental care expansion in the public sector led to an increase of approximately 400% in specialized dental procedures.88. Magalhães BG, Oliveira RS, Góes PSA, Figueiredo N. Avaliação da qualidade dos serviços prestados pelos Centros de Especialidades Odontológicas: visão dos usuários. Cad Saúde Colet [Internet]. 2015 mar [citado 2019 jan 18];23(1):76-85. Disponível em: Disponível em: http://www.scielo.br/pdf/cadsc/v23n1/1414-462X-cadsc-23-01-00076.pdf . Doi: 10.1590/1414-462X201500010013
http://www.scielo.br/pdf/cadsc/v23n1/141...

Despite the progress made, CEOs are still unable to meet the needs of the population, due to several factors such as the demand for specialized services not previously offered by the Brazilian National Health System (SUS).99. Thomaz EBAF, Sousa GMC, Queiroz RCS, Coimbra LC. Avaliação do cumprimento das metas de produtividade em Centros de Especialidades Odontológicas no Maranhão, 2011. Epidemiol Serv Saúde [Internet]. 2016 out-dez [citado 2019 jan 18]; 25(4):807-18. Disponível em: Disponível em: http://www.scielo.br/pdf/ress/v25n4/2237-9622-ress-25-04-00807.pdf . Doi: 10.5123/s1679-49742016000400014
http://www.scielo.br/pdf/ress/v25n4/2237...
In addition, the effective functioning of the CEOs depends on an adequate interface between primary care and CEOs.1010. Machado FCA, Silva JV, Ferreira MAF. Fatores relacionados ao desempenho dos centros de especialidades odontológicas. Ciênc Saúde Coletiva [Internet]. 2015 abr [citado 2019 jan 18];20(4):371-87. Disponível em: Disponível em: http://www.scielo.br/pdf/csc/v20n4/pt_1413-8123-csc-20-04-01149.pdf . Doi: 10.1590/1413-81232015204.00532014
http://www.scielo.br/pdf/csc/v20n4/pt_14...

Analysis of the supply of specialized dental care services is essential for planning actions, in order to adapt their organizational and geographic aspects, so that they can ensure the continuity and comprehensiveness of oral health care.1111. Souza LF, Chavez SCL. Política nacional de saúde bucal: acessibilidade e utilização de serviços odontológicos especializados em um município de médio porte na Bahia. Rev Baiana Saúde Pública [Internet]. 2010 abr-jun [citado 2019 jan 18];34(2):371-87. Disponível em: Disponível em: http://files.bvs.br/upload/S/0100-0233/2010/v34n2/a1814.pdf
http://files.bvs.br/upload/S/0100-0233/2...
Based on this understanding, this study aimed to analyze the supply of public specialized dental care services in the CEO modality in Brazil in 2014.

Methods

This is a normative assessment of the supply of SUS specialized dental care services based on the norms provided within the legal-political framework of Ministry of Health (MoH) ordinances. We used data from the Brazilian Institute of Geography and Statistics (IBGE), from the database of the external evaluation of the National Program for Improving Access and Quality of Dental Specialty Centers (Pmaq-CEO) and the National Registry of Health Care Facilities (CNES), referring to the year 2014.

We included all CEOs that were implanted in Brazil in 2014.

Figure 1 describes the study variables, the measurement of the variables and the source of the data used. The following elements were analyzed: (i) the ratio between the resident population and the number of CEOs; (ii) the ratio between the resident population and the number of dental surgeons working in CEOs; (iii) the adequacy of the quantity of complete dental consulting rooms per CEO type; (iv) the adequacy of the ratio between the working hours of dental auxiliaries/technicians and those of dental surgeons; and (v) the adequacy of the supply of recommended minimum specialties.

Figure 1
- The study variables, measurement of variables and data source used to analyze the supply of specialized oral health care services in the Brazilian National Health System, Brazil, 2014

The number of dental surgeons was obtained from the total working hours of dentists who work in minimum specialties, divided by 40. This procedure was performed for comparison purposes, since dentists can be hired for either 20 or 40 hours a week, and the Pmaq-CEO database does not hold this information.

We considered the number of dental consulting rooms in operation to be adequate when it was equal to or higher than expected for CEO type (Type I = 3 or more; Type II = 4 or more; Type III = at least 7).1212. Brasil. Ministério da Saúde. Portaria MS/GM nº 599, de 23 de março de 2006. Define a implantação de Especialidades Odontológicas (CEO) e de Laboratórios Regionais de Próteses Dentárias (LRPD) e estabelecer critérios, normas e requisitos para seu credenciamento. Diário Oficial da União, Brasília (DF), 2006 mar 24 [citado 2019 jan 18]. Seção 1:51. Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2006/prt0599_23_03_2006.html
http://bvsms.saude.gov.br/bvs/saudelegis...
We also considered the ratio between the weekly working hours of auxiliaries/technicians and those of dentists to be adequate when the calculated value was equal to or greater than 1, indicating that the dentist would not be working alone. The supply of specialties was considered to be adequate in relation to the norms established by the MoH ordinance when the CEO offered the five minimum specialities,1212. Brasil. Ministério da Saúde. Portaria MS/GM nº 599, de 23 de março de 2006. Define a implantação de Especialidades Odontológicas (CEO) e de Laboratórios Regionais de Próteses Dentárias (LRPD) e estabelecer critérios, normas e requisitos para seu credenciamento. Diário Oficial da União, Brasília (DF), 2006 mar 24 [citado 2019 jan 18]. Seção 1:51. Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2006/prt0599_23_03_2006.html
http://bvsms.saude.gov.br/bvs/saudelegis...
with at least one professional working in each one of them.

The collected data were tabulated and analyzed on a Microsoft Excel Office spreadsheet (version 2013), by calculating the absolute and relative frequencies of the variables. The variables were analyzed for the country’s five macro-regions, and differences in the distributions were tested using Pearson’s chi-square test, with the aid of R statistical software (https://www.R-project.org/), taking a 5% significance level.

As we used secondary data from public domain databases, the project did not need to be submitted to a Research Ethics Committee, as per Brazilian National Health Council Resolution No. 510, dated 7 April 2016.

Results

In 2014, Brazil had 931 CEOs, distributed over 780 of the country’s 5,570 municipalities. Of these CEOs, 349 (37%) were Type I, 474 (51%) were Type II and 109 (12%) were Type III. Table 1 presents the distribution of CEOs and the number of dental surgeons working in CEOs in the Brazilian macro-regions, as well as the respective ratios between CEOs and population.

Table 1
- Number and percentage of Dental Specialties Centers (CEOs) and dental surgeons working in CEOs, by macro-region, and their ratio to the resident population, Brazil, 2014 (N=931)

The Northeastern region had the greatest number of CEOs in Brazil with 357 (38%), followed by the Southeastern region with 337 (36%). The Northern region had the lowest number of CEOs with 60 (6%). The ratio between CEO and population was 217,797 inhabitants per CEO. The best ratio was found in the Northeastern macro, with 157,384 inhabitants per CEO, while the worst was found in the Northern region, with 287,184 inhabitants per CEO.

There was an overall ratio of one CEO dental surgeon per 57,640 inhabitants. The best ratio between inhabitants and CEO dental surgeons was found in the Northeastern region (one dentist per 46,670 inhabitants), followed by the Midwest, Southern and Southeastern regions; while the worst ratio was found in the Northern macro-region (one dentist per 72,982 inhabitants).

Ninety-seven percent of CEOs had an adequate number of complete dental consulting rooms per CEO type ; 26% had an adequate ratio between the working hours of nursing auxiliaries/technicians and those of dental surgeons; and 60% had adequate supply of recommended minimum specialties (Table 2).

Table 2
- Adequate Dental Specialty Centers (CEOs) in relation to the analyzed variables (%), per macro-region, Brazil, 2014 (n=931)

CEOs located in the Southeast region had the lowest percentage for adequate ratio between the working hours of nursing auxiliaries/technicians and those of dental surgeons, while proportionally the Northern region had the lowest percentage of adequate supply of recommended minimum specialties. The proportional difference between the regions was statistically significant (Table 2).

Discussion

The Northeastern region had the best ratio between CEO and dental surgeons per inhabitant, while the Northern region had the worst. The quantity of complete dental consulting rooms was adequate in most CEOs. The majority of CEOs were not adequate with regard to the working hours of nursing auxiliaries/technicians in relation to those of dental surgeons. In addition, some CEOs did not offer the minimum number of specialties recommended by the Ministry of Health.

Lack of available information about the working hours of each CEO dental surgeon is the main limitation of this study. Moreover, there is no ideal standard for the ratios analyzed that could have allowed opinions to be given as to the ratios found. A further limitation is that the data could not be compared over time as there was only one Pmaq-CEO evaluation cycle for the period analyzed.

The best ratio found between the population and the quantity of CEOs reinforces the pioneering nature of the Northeast region in implementing public health policies.1313. Saliba NA, Moimaz SAS, Fadel CB, Bino LS. Saúde bucal no Brasil: uma nova política de enfrentamento para a realidade nacional. Rev Odontol Bras Central [Internet]. 2010 [citado 2019 jan 18];18(48):62-6. Disponível em: Disponível em: http://files.bvs.br/upload/S/0104-7914/2010/v19n48/a0013.pdf
http://files.bvs.br/upload/S/0104-7914/2...
In 2001, 59.2% of all SUS oral health care teams (ESBs) were located in the Northeast, compared to 4.9% in the North. In 2013, these proportions were 48.5% and 7.8%, respectively.14 In 2012, the proportion of the population covered by ESBs was highest in the Northeast (37.89%) and lowest in the North (6.15%).1515. Martins PHS, Amaral Júnior OL, Faustino-Silva DD, Torres LHN, Giordani JMA, Unfer B. Desigualdades na distribuição das equipes de saúde bucal no Brasil. Stomatos [Internet]. 2017 jul-dez [citado 2019 jan 18];23(45):4-13. Disponível em: Disponível em: http://www.periodicos.ulbra.br/index.php/stomatos/article/view/3130/2830
http://www.periodicos.ulbra.br/index.php...

Labor force availability is an essential factor in the supply of secondary oral health care services. In this study, there was difference in the ratio between the number of dental surgeons and inhabitants in some macro-regions, especially in the North. This fact is explained by the tendency of professionals to take up residence close to the place where they graduated or in large urban centers and in places where it is easier to take refresher and postgraduate courses.1616. Martin ASS, Chinisi LA, Martelli S, Sartori LRM, Ramos EC, Demarco FF. Distribuição dos cursos de odontologia e de cirurgiões-dentistas no Brasil: uma visão do mercado de trabalho. Rev Abeno [Internet]. 2018 mar [citado 2019 jan 18];18(1):63-73. Disponível em: Disponível em: https://revabeno.emnuvens.com.br/revabeno/article/view/399 . Doi: 10.30979/rev.abeno.v18i1.399
https://revabeno.emnuvens.com.br/revaben...
,1717. Cascaes AM, Dotto L, Bomfim RA. Tendências da força de trabalho de cirurgiões-dentistas no Brasil, no período de 2007 a 2014: estudo de séries temporais com dados do Cadastro Nacional de Estabelecimentos de Saúde. Epidemiol Serv Saúde [Internet]. 2018 [citado 2019 jan 18];27(1): e201723615. Disponível em: Disponível em: http://www.scielo.br/pdf/ress/v27n1/2237-9622-ress-27-01-e201723615.pdf . Doi: 10.5123/S1679-49742018000100015
http://www.scielo.br/pdf/ress/v27n1/2237...
According to Federal Council of Dentistry data for 2014, the majority of dentistry degree courses were concentrated in the Southeastern (43%), Northeastern (19%) and Southern (18%) macro-regions.1616. Martin ASS, Chinisi LA, Martelli S, Sartori LRM, Ramos EC, Demarco FF. Distribuição dos cursos de odontologia e de cirurgiões-dentistas no Brasil: uma visão do mercado de trabalho. Rev Abeno [Internet]. 2018 mar [citado 2019 jan 18];18(1):63-73. Disponível em: Disponível em: https://revabeno.emnuvens.com.br/revabeno/article/view/399 . Doi: 10.30979/rev.abeno.v18i1.399
https://revabeno.emnuvens.com.br/revaben...

The number of complete dental consulting rooms per CEO type was adequate in relation to MoH ordinance norms, indicating that the supply of secondary dental care is in accordance with the recommended procedure.1212. Brasil. Ministério da Saúde. Portaria MS/GM nº 599, de 23 de março de 2006. Define a implantação de Especialidades Odontológicas (CEO) e de Laboratórios Regionais de Próteses Dentárias (LRPD) e estabelecer critérios, normas e requisitos para seu credenciamento. Diário Oficial da União, Brasília (DF), 2006 mar 24 [citado 2019 jan 18]. Seção 1:51. Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2006/prt0599_23_03_2006.html
http://bvsms.saude.gov.br/bvs/saudelegis...
Supply of minimum specialties oscillated in the Brazilian regions. The lack of these specialties compromises referral of primary care service users to secondary care and restricts treatment options,1717. Cascaes AM, Dotto L, Bomfim RA. Tendências da força de trabalho de cirurgiões-dentistas no Brasil, no período de 2007 a 2014: estudo de séries temporais com dados do Cadastro Nacional de Estabelecimentos de Saúde. Epidemiol Serv Saúde [Internet]. 2018 [citado 2019 jan 18];27(1): e201723615. Disponível em: Disponível em: http://www.scielo.br/pdf/ress/v27n1/2237-9622-ress-27-01-e201723615.pdf . Doi: 10.5123/S1679-49742018000100015
http://www.scielo.br/pdf/ress/v27n1/2237...
thus interfering with care comprehensiveness. Furthermore, in cases in which more conservative dental procedures could be carried out, more complex treatment ends up being provided, leading to future demands for costly rehabilitation for the patient or the public health system.1818. Herkrath FJ, Herkrath APCQ, Costa LNBS, Silva LNB, Gonçalves MJF. Desempenho dos Centros de Especialidades Odontológicas frente ao quadro sociodemográfico dos municípios do Amazonas, Brasil, 2009. Saúde Debate [Internet]. 2013 jan-mar [citado 2019 jan 18];37(96):148-58. Disponível em: Disponível em: http://www.scielo.br/pdf/sdeb/v37n96/17.pdf . Doi: 10.1590/S0103-11042013000100017
http://www.scielo.br/pdf/sdeb/v37n96/17....
Moreover, the greater the ESB coverage, the worse the performance of specialized oral health care.1818. Herkrath FJ, Herkrath APCQ, Costa LNBS, Silva LNB, Gonçalves MJF. Desempenho dos Centros de Especialidades Odontológicas frente ao quadro sociodemográfico dos municípios do Amazonas, Brasil, 2009. Saúde Debate [Internet]. 2013 jan-mar [citado 2019 jan 18];37(96):148-58. Disponível em: Disponível em: http://www.scielo.br/pdf/sdeb/v37n96/17.pdf . Doi: 10.1590/S0103-11042013000100017
http://www.scielo.br/pdf/sdeb/v37n96/17....

The standard collective oral health team is comprised of a dental surgeon and dental auxiliaries/technicians.1919. Warmling CM, Cipriani CR, Pires FS. Perfil de auxiliares e técnicos em saúde bucal que atuam no Sistema Único de Saúde. Rev APS [Internet]. 2016 out-dez [citado 2019 jan 18];19(4):592-601. Disponível em: Disponível em: https://www.lume.ufrgs.br/bitstream/handle/10183/169002/001020144.pdf?sequence=1
https://www.lume.ufrgs.br/bitstream/hand...
The lack of dental auxiliaries/technicians working together with dental surgeons can negatively influence the efficiency and duration of their work, as well as productivity.2020. Costa AO, Silva LP, Saliba O, Garbin AJI, Moimaz SAS. A participação do auxiliar em saúde bucal na equipe de saúde e o ambiente odontológico. Rev Odontol UNESP [Internet]. 2010 nov-dez [citado 2019 jan 18];41(6):371-76. Disponível em: Disponível em: http://www.scielo.br/pdf/rounesp/v41n6/a01v41n6.pdf . Doi: 10.1590/S1807-25772012000600001
http://www.scielo.br/pdf/rounesp/v41n6/a...
In this study, discrepancy between the working hours of nursing auxiliaries/technicians and those of dental surgeons and the MoH ordinance norm was found in most CEOs, which suggests that dentists are often working alone.

In conclusion, there were limitations in the supply of SUS specialized dental care services, with regional differences. This study suggests the creation of an ideal standard ratio for CEO and dental surgeon per inhabitant for each Brazilian region, considering the local particularities and the epidemiological picture of each location. Such a standard would allow evaluation of health professional availability in each location, helping health planning processes in relation to the allocation of human resources.

References

  • *
    Article derived from the Master’s Degree thesis entitled 'Evaluation of Dental Specialty Centers in Brazil', submitted by Luiza Rahmeier Fietz Rios to the Postgraduate Program in Public Health of the Universidade Federal de Santa Catarina on 12 July 2018.

History

  • Received
    14 Oct 2018
  • Accepted
    07 Jan 2019
  • Online publication
    08 Apr 2019
  • Issue publication
    2019
Secretaria de Vigilância em Saúde - Ministério da Saúde do Brasil Brasília - Distrito Federal - Brazil
E-mail: leilapgarcia@gmail.com