Abstract

Objective

To analyze the association between the coverage by oral health teams in the Family Health Strategy (FHS-OH) and the use of dental services among 12-year-old adolescents in the state of Mato Grosso do Sul, Brazil, 2019.

Methods

This is a cross-sectional study involving school-based research, which adopted the use of dental services as its outcome. Structural equation modeling was used to test the association between covariates and the outcome.

Results

Of the 615 participants, 74.0% used dental services in the last three years. ESF-SB (oral health coverage by family health strategy, acronym in Portuguese) ≥50% was associated with a greater use of public dental services [standardized coefficient (SC) = 0.10 -95%CI 0.01;0.18], a lower use of these services for prevention (SC = -0.07 -95%CI -0.17;0.01) and higher unhealthy food consumption (SC = 0.19 -95%CI 0.11;0.26).

Conclusion

Higher ESF-SB coverage was associated with a lower use of dental services for prevention and higher unhealthy food consumption. Teams must organize the access to oral health service and qualify the work process.

Keywords:
Health Services Accessibility; Public Health; Family Health Strategy; Cross-sectional Studies; Oral Health

Introduction

The Family Health Strategy (FHS) is the central point of government actions and investments for reorientation of health care model. From the perspective of the integration model for health surveillance, the ESF incorporates light technologies for care in multi-professional actions of organized and programmatic offer, integrated to interventions that address social determinants and public policies, a privileged space for health promotion.¹1. Santos MLM, Zafalon EJ, Bomfim RA, Kodjaoglanian VL, Moraes SHM, Nascimento DDG, et al. Impact of distance education on primary health care indicators in central Brazil: an ecological study with time trend analysis. PLoS One. 2019 Mar 26;14(3):e0214485. doi: https://doi.org/10.1371/journal.pone.0214485.
https://doi.org/10.1371/journal.pone.021...

Between 1998 and 2018, there was a significant increase in the number of Family Health teams. National data show that in 1998, there were 2,000 teams to serve 7 million people, 4% of the Brazilian population,²2. Macinko J, Harris MJ. Brazil's family health strategy-delivering community-based primary care in a universal health system. N Engl J Med. 2015 Jun 4;372(23):2177-81. doi: https://doi.org/10.1056/NEJMp1501140.
https://doi.org/10.1056/NEJMp1501140... while twenty years later, in 2018, there were 43,000 teams responsible for primary health care for 134 million people, 64.7% of the population. With regard to oral health teams, there was also a significant growth, from 615 teams in 2003 to 25,905 in 2017, achieving coverage of 36.7% of the Brazilian population. This expansion had a positive effect on several health outcomes.³3. Chaves SCL, Almeida AMFL, Reis CS, Rossi TRA, Barros SG. Oral health policy in Brazil: transformations in the period 2015-2017. Saude Debate. 2018;42(Spec 2):76-91. doi: https://doi.org/10.1590/0103-11042018S206
https://doi.org/10.1590/0103-11042018S20...

4. Nascimento DDG, Moraes SHM, Santos CAST, Souza AS, Bomfim RA, De-Carli AD, et al. Impact of continuing education on maternal and child health indicators. PLoS One. 2020 Jun 26;15(6):e0235258. doi: https://doi.org/10.1371/journal.pone.0235258.
https://doi.org/10.1371/journal.pone.023...

5. Bastos ML, Menzies D, Hone T, Dehghani K, Trajman A. The impact of the Brazilian family health strategy on selected primary care sensitive conditions: A systematic review. PLoS One. 2017 Aug 7;12(8):e0182336. doi: https://doi.org/10.1371/journal.pone.0182336.
https://doi.org/10.1371/journal.pone.018... ^-66. Almeida Filho NM. Contextos, impasses e desafios na formação de trabalhadores em Saúde Coletiva no Brasil. Cien Saude Colet. 2013;18(6):1677-82. doi: https://doi.org/10.1590/s1413-81232013001400019.
https://doi.org/10.1590/s1413-8123201300...

Childhood and adolescence are particularly relevant moments for the study on the use of oral health services. In some way, child development stages reflect their family context related to dental care-seeking behavior. Sociodemographic and psychosocial factors and factors related to lifestyle adopted by the individual/family may influence their health habits and behaviors, at all stages of life,⁷7. Davoglio RS, Aerts DRGC, Abegg C, Freddo SL, Monteiro L. Fatores associados a hábitos de saúde bucal e utilização de serviços odontológicos entre adolescentes. . Cad Saude Publica. 2009;25(3):655-67. doi: https://doi.org/10.1590/s0102-311x2009000300020.
https://doi.org/10.1590/s0102-311x200900... although preventive interventions for children and adolescents are not sufficient to make a positive impact on health and quality of life in adulthood. Several determining, structural (at the organizational level of services) and social factors should be taken into consideration in the health-disease process, reinforcing the importance of primary health care services (PHC) in the organization of access to dental care services and provision of comprehensive care for children and adolescents, highlighting the preventive and protective role of health services at these stages of life.⁸8. Menegaz AM, Silva AER, Cascaes AM. Educational interventions in health services and oral health: systematic review. Rev Saude Publica. 2018;52:52. doi: https://doi.org/10.11606/s1518-8787.2018052000109.
https://doi.org/10.11606/s1518-8787.2018... ^,99. Fonseca EPD, Frias AC, Mialhe FL, Pereira AC, Meneghim MC. Factors associated with last dental visit or not to visit the dentist by Brazilian adolescents: a population-based study. PLoS One. 2017 Aug 31;12(8):e0183310. doi: https://doi.org/10.1371/journal.pone.0183310.
https://doi.org/10.1371/journal.pone.018...

However, the need for dental treatment for dental caries and dental pain is one of the main reasons for the use of dental services among adolescents.⁹9. Fonseca EPD, Frias AC, Mialhe FL, Pereira AC, Meneghim MC. Factors associated with last dental visit or not to visit the dentist by Brazilian adolescents: a population-based study. PLoS One. 2017 Aug 31;12(8):e0183310. doi: https://doi.org/10.1371/journal.pone.0183310.
https://doi.org/10.1371/journal.pone.018... Seeking health service is a complex phenomenon, according to different contexts, and it needs to be better understood. The use of these services due to dental problems is associated with individual factors, such as non-satisfaction with their own oral health⁹9. Fonseca EPD, Frias AC, Mialhe FL, Pereira AC, Meneghim MC. Factors associated with last dental visit or not to visit the dentist by Brazilian adolescents: a population-based study. PLoS One. 2017 Aug 31;12(8):e0183310. doi: https://doi.org/10.1371/journal.pone.0183310.
https://doi.org/10.1371/journal.pone.018... and high consumption of sugars,⁷7. Davoglio RS, Aerts DRGC, Abegg C, Freddo SL, Monteiro L. Fatores associados a hábitos de saúde bucal e utilização de serviços odontológicos entre adolescentes. . Cad Saude Publica. 2009;25(3):655-67. doi: https://doi.org/10.1590/s0102-311x2009000300020.
https://doi.org/10.1590/s0102-311x200900... and contextual factors, such as greater population coverage by dentists.⁹9. Fonseca EPD, Frias AC, Mialhe FL, Pereira AC, Meneghim MC. Factors associated with last dental visit or not to visit the dentist by Brazilian adolescents: a population-based study. PLoS One. 2017 Aug 31;12(8):e0183310. doi: https://doi.org/10.1371/journal.pone.0183310.
https://doi.org/10.1371/journal.pone.018... The Ministry of Health recommends 50% of population coverage in primary health care of the Brazilian National Health System (SUS), as a potential indicator of provision of services.¹⁰10. França MASA, Freire MCM, Pereira EM, Marcelo VC. Indicadores de saúde bucal propostos pelo Ministério da Saúde para monitoramento e avaliação das ações no Sistema Único de Saúde: pesquisa documental, 2000-2017. Epidemiol Serv Saude. 2020 Feb 17;29(1):e2018406. doi: https://doi.org/10.5123/S1679-49742020000100002.
https://doi.org/10.5123/S1679-4974202000...

Inequities in oral health continue to represent a major challenge for Public Health.¹¹11. Bomfim RA, Frias AC, Panutti CM, Zilbovicius C, Pereira AC. Socio-economic factors associated with periodontal conditions among Brazilian elderly people: multilevel analysis of the SBSP-15 study. PloS One. 2018 Nov 7;13(11):e0206730. doi: https://doi.org/10.1371/journal.pone.0206730.
https://doi.org/10.1371/journal.pone.020...

12. Sisson KL. Theoretical explanations for social inequalities in oral health. Community Dent Oral Epidemiol. 2007;35(2):81-8. doi: https://doi.org/10.1111/j.1600-0528.2007.00354.x.
https://doi.org/10.1111/j.1600-0528.2007... ^-1313. Dalazen CE, De-Carli AD, Bomfim RA. Fatores associados às necessidades de tratamento odontológico em idosos brasileiros: uma análise multinível. Cien Saude Colet. 2018;23(4):1119-1130. doi: https://doi.org/10.1590/1413-81232018234.27462015.
https://doi.org/10.1590/1413-81232018234... Sisson’s model¹²12. Sisson KL. Theoretical explanations for social inequalities in oral health. Community Dent Oral Epidemiol. 2007;35(2):81-8. doi: https://doi.org/10.1111/j.1600-0528.2007.00354.x.
https://doi.org/10.1111/j.1600-0528.2007... provides an overview of oral health inequities, explained by four main domain areas: (i) material, related to an individual’s position in the social structure, measured by socioeconomic status (SES), such as schooling and family income; (ii) cultural/behavioral (e.g., health-damaging choices, such as unhealthy food, the use of services for treatment rather than prevention); (iii) contextual (e.g., population coverage of dentists); and (iv) individual characteristics (e.g. sex and self-reported race/skin color).

The objective of this study was to analyze the association between the coverage by oral health teams in the Family Health Strategy (FHS) and the use of dental services by 12-year-old adolescents in the state of Mato Grosso do Sul, Brazil, in 2019.

Methods

This is a school-based and population-based study conducted in five cities with more than 80,000 inhabitants in the state of Mato Grosso do Sul: Campo Grande, Corumbá, Dourados, Ponta Porã and Três Lagoas. Conducted from April 2018 to February 2019, the study, known by the acronym SBMS 2018/2019, also included other age groups, such as 5-year-old children, adults and the elderly.

In 2018, the population of Campo Grande, the capital and largest city in the state of Mato Grosso do Sul, was estimated at 860,000 inhabitants. The population of Dourados, the second largest city in the state, was estimated at approximately 221,925 inhabitants. Together with Corumbá (119,465 inhabitants), Três Lagoas (119,464 inhabitants) and Ponta Porã (92,526 inhabitants), the five cities represented more than half of the 2,748,023 inhabitants of the state’s 79 municipalities.¹⁴14. Instituto Brasileiro de Geografia e Estatística. Conheça cidades e estados do Brasil [Internet]. [Brasília, DF]: IBGE; 2019 [acesso 10 set. 2019]. Disponível em: https://cidades.ibge.gov.br/
https://cidades.ibge.gov.br... Moreover, they are the most representative cities in the four territorial macro-regions of the state (Dourados and Ponta Porã are in the same macro-region) and its main affluent areas.

Participants

All enrolled students were considered eligible for the study. The exclusion criteria ruled out students circumstantially transferred to other schools or those who did not have regular attendance due to health reasons. A random sample of schoolchildren aged 12 years was obtained from a coordination list of the director/manager board. We selected up to ten students in this age group per classroom. When there was more than one classroom, students were randomly selected respecting equal proportion per classroom.

Variables analyzed

In structural equation modeling, the outcome variable was defined as ‘use of dental services in the last three years’, obtained through a question addressed to the adolescent’s parent/guardian - When did your child last visit the dentist? - and the following answer options: less than one year; between one and two years; between two and three years; more than three years ago; has never visited; don’t know. This variable was dichotomized between ‘Yes’ (used in the last three years) and ‘No’ (used more than three years ago, has never visited or don’t know). This was the cutoff point established because, among the reports on the use of dental services, no parent/guardian mentioned the use of dental services for a period longer than three years.

To estimate the population covered by the ESF-SB, the parameter of 3,450 individuals covered by oral health team was considered. The sample size calculation estimated the percentage of the population covered by the ESF-SB¹⁸18. Ministério da Saúde (BR). SB Brasil 2010: pesquisa nacional de saúde bucal: resultados principais [Internet]. Brasília, DF: MS; 2012 [acesso 10 set. 2019]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/pesquisa_nacional_saude_bucal.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... in December 2018, chosen as the reference month, for each participating city. The data were obtained from the E-manager platform of the Ministry of Health.¹⁸18. Ministério da Saúde (BR). SB Brasil 2010: pesquisa nacional de saúde bucal: resultados principais [Internet]. Brasília, DF: MS; 2012 [acesso 10 set. 2019]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/pesquisa_nacional_saude_bucal.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... The variable ‘coverage by the ESF-SB’ was dichotomized - less than 50%; equal to or greater than 50% - and estimated by municipality.¹⁰10. França MASA, Freire MCM, Pereira EM, Marcelo VC. Indicadores de saúde bucal propostos pelo Ministério da Saúde para monitoramento e avaliação das ações no Sistema Único de Saúde: pesquisa documental, 2000-2017. Epidemiol Serv Saude. 2020 Feb 17;29(1):e2018406. doi: https://doi.org/10.5123/S1679-49742020000100002.
https://doi.org/10.5123/S1679-4974202000...

The weekly frequency of unhealthy food consumption was investigated using an instrument recommended by the Brazilian Ministry of Health,¹⁹19. Bomfim RA, Frias AC, Cascaes AM, Mazzilli LEN, Souza LB, Carrer FCA, et al. Sedentary behavior, unhealthy foods consumption and dental caries in 12 year-olds: a population-based study. Braz Oral Res; 2021 Apr 26;35:e041. doi: https://doi.org/10.1590/1807-3107bor-2021.vol35.0041.
https://doi.org/10.1590/1807-3107bor-202... contemplating five food groups that adolescents reported having consumed: (1) French fries, packaged potato chips and fried snacks (chicken drumstick, kibbeh, fried pastry, and so on.); (2) hamburger and sausage (hotdog sausage, mortadella, salami, ham, sausage and so on); (3) cracker/salted biscuits or packet snacks; (4) cracker/filled sweet biscuits, sweets, candies and chocolate (bars or chocolate candies); and (5) regular soft drink consumption. The weekly unhealthy food intake was obtained from the sum of the frequencies of the five food groups, divided by five. Thus, the weekly consumption of unhealthy foods was stratified as follows: low, up to 2 times/week; moderate, 2 to 4 times/week; and high, 4 or more times/week.

Sex and race/skin color [white; non-white (black, brown, yellow or indigenous)] were self-reported. Household income per capita was categorized as follows: below the poverty line; equal to or above the poverty line. In the Brazilian context, the poverty threshold was established according to the household monthly income of up to R$ 466.00 in 2018.¹⁴14. Instituto Brasileiro de Geografia e Estatística. Conheça cidades e estados do Brasil [Internet]. [Brasília, DF]: IBGE; 2019 [acesso 10 set. 2019]. Disponível em: https://cidades.ibge.gov.br/
https://cidades.ibge.gov.br... Mother’s education level (in years of study) was dichotomized between: 1 to 4 years; above 4 years. A latent variable was created based on the household income and mother’s education level and it was applied to the structural equation modeling. The type of dental service used by the adolescent the last time he or she visited the dentist was characterized as private or public, and the reason for the use of the dental service when he/she attended his/her last appointment, dichotomized between use for treatment and use for prevention.

Sample size

For the sample size calculation, the formula proposed by Silva¹⁶16. Silvani J, Buss C, Pena GDP, Recchi AF, Wendland EM. Food consumption of users of the Brazilian unified health system by type of assistance and participation in the "Bolsa Familia". Cien Saude Colet. 2018;23(8):2599-2608. doi: https://doi.org/10.1590/1413-81232018238.06472016.
https://doi.org/10.1590/1413-81232018238... was used to estimate the prevalence of the use of services by Brazilian adolescents. Data on the use of oral health services by 12-year-old adolescents from the Midwest region who took part in the Brazilian Oral Health Survey (SBBrasil 2010),¹⁵15. Ministério da Saúde (BR). Nota técnica: relatório de cobertura de saúde bucal na atenção básica [Internet]. Brasília, DF: MS; 2018 [acesso 20 fev. 2020]. Disponível em: https://egestorab.saude.gov.br/paginas/acessoPublico/relatorios/nota_tecnica/nota_tecnica_relatorio_de_cobertura_SB.pdf
https://egestorab.saude.gov.br/paginas/a... were used as a parameter.

Probability cluster sampling was adopted. The five participating cities were pre-selected and considered the primary sampling units (PSU). The municipal public elementary schools were defined as secondary sampling units (SSU). The largest Brazilian Oral Health Survey, SBBrasil 2010,¹⁵15. Ministério da Saúde (BR). Nota técnica: relatório de cobertura de saúde bucal na atenção básica [Internet]. Brasília, DF: MS; 2018 [acesso 20 fev. 2020]. Disponível em: https://egestorab.saude.gov.br/paginas/acessoPublico/relatorios/nota_tecnica/nota_tecnica_relatorio_de_cobertura_SB.pdf
https://egestorab.saude.gov.br/paginas/a... selected 32 secondary sampling units per city. Thus, we randomly selected 32 schools in the two largest cities (both have more than 32 schools) and all schools in the other three cities.

The national survey showed that 79.8% of adolescents reported using dental services. The design effect (deff) of 2.0, the 95%confidence interval and the 20% loss rate were considered. Sample size calculation for analysis of the use of the services was comprised of 536 adolescents.

Calibration of oral health teams

Five oral health teams, per municipality, comprised of a dentist and an annotator, had 32 hours of practical and theoretical training to join the research.¹⁷17. Silva NN. Amostragem probabilística. 2a ed. São Paulo: Edusp; 1998. The intra- and inter-examiner calibration showed a Kappa coefficient of 0.73.¹⁷17. Silva NN. Amostragem probabilística. 2a ed. São Paulo: Edusp; 1998.

Data collection

Data were collected through a questionnaire, the same applied in SBBrasil 2010,¹⁶16. Silvani J, Buss C, Pena GDP, Recchi AF, Wendland EM. Food consumption of users of the Brazilian unified health system by type of assistance and participation in the "Bolsa Familia". Cien Saude Colet. 2018;23(8):2599-2608. doi: https://doi.org/10.1590/1413-81232018238.06472016.
https://doi.org/10.1590/1413-81232018238... distributed to adolescent’s parents/guardians. Sociodemographic questions were answered, being gender and race/skin color self-reported. The adolescent returned the completed questionnaire and, in the school setting, answered another questionnaire about their eating habits. Then, each participating adolescent got a dental exam.¹⁷17. Silva NN. Amostragem probabilística. 2a ed. São Paulo: Edusp; 1998.

Statistical analysis

We performed a descriptive analysis of proportion, taking into consideration the sample weights, and analyses of structural equation modeling. These analyses allowed the development of association relationships between independent variables and their outcomes, with the advantage of using only one confirmatory factor model.¹⁹19. Bomfim RA, Frias AC, Cascaes AM, Mazzilli LEN, Souza LB, Carrer FCA, et al. Sedentary behavior, unhealthy foods consumption and dental caries in 12 year-olds: a population-based study. Braz Oral Res; 2021 Apr 26;35:e041. doi: https://doi.org/10.1590/1807-3107bor-2021.vol35.0041.
https://doi.org/10.1590/1807-3107bor-202... ^,2020. Keith N, Hodapp V, Schermelleh-Engel K, Moosbrugger H. Cross-sectional and longitudinal confirmatory factor models for the German test anxiety inventory: a construct validation. Anxiety Stress Coping. 2003;16(3):251-70. doi: https://doi.org/10.1080/1061580031000095416
https://doi.org/10.1080/1061580031000095... The structural equation modeling was used to estimate possible association between material explanation, contextual, behavioral health and sociodemographic variables, and the use of dental services. In the performed model, we used robust regression coefficients for interpretation, estimating direct and indirect effects, and the potential paths to the associations, taking into consideration sample complexity. Sisson’s interpretative model,¹²12. Sisson KL. Theoretical explanations for social inequalities in oral health. Community Dent Oral Epidemiol. 2007;35(2):81-8. doi: https://doi.org/10.1111/j.1600-0528.2007.00354.x.
https://doi.org/10.1111/j.1600-0528.2007... designed to explain inequities in oral health, was adopted as a reference for the analysis. Variables that support (i) the material explanation, related to the position of an individual in the social structure, measured by socioeconomic status, (ii) cultural/behavioral explanations, measured by unhealthy food consumption and use of services for the treatment of dental caries and dental pain rather than prevention, and (iii) the contextual perspective, measured by Family Health Strategy coverage and type of dental service (public or private), were used. Figure 1 shows the graphical representation of the model-based testing. Variables drawn as rectangle are observable. The ellipse, a variable constructed from observable variables (income and schooling), is a variable that best represents family socioeconomic status. The arrows indicate potential association paths between variables.

The quality of the adjustment of the models was evaluated by the coefficient of determination (CD) and supplemented through applying the Root Mean Square Error of Approximation (RMSEA), in which values less than or equal to 0.08 are considered adequate. The comparative fit index (CFI) and the Tucker-Lewis index (TLI) provided additional reliability; and values greater than 0.80 were considered adequate.²⁰20. Keith N, Hodapp V, Schermelleh-Engel K, Moosbrugger H. Cross-sectional and longitudinal confirmatory factor models for the German test anxiety inventory: a construct validation. Anxiety Stress Coping. 2003;16(3):251-70. doi: https://doi.org/10.1080/1061580031000095416
https://doi.org/10.1080/1061580031000095... ^,2121. Bomfim RA, Souza LB, Corrente JE. Tooth loss and its relationship with protein intake by elderly Brazilians: a structural equation modelling approach. Gerodontology. 2018;35(1):51-8. doi: https://doi.org/10.1111/ger.12317.
https://doi.org/10.1111/ger.12317... All analyses were performed using Stata software version 14.2 (College Station, TX, USA).

Ethical aspects

The research project was submitted to the Human Research Ethics Committee of the Federal University of Mato Grosso do Sul (CEP/UFMS) and was approved. Opinion No. 2,596,211, issued on April 12, 2018 (Certificate of Submission for Ethical Appreciation (CAAE) No. 85647518.4.0000.0021), based on the ethical guidelines established in the Resolution of the National Health Council (CNS) No. 466 of December 12, 2012. All participants signed the Free and Informed Consent Form; and their Parents/guardians, the Free and Informed Assent Form.

Results

The study included 615 12-year-old adolescents. Table 1, taking into consideration the sample weights, it could be seen that 43.9% of them self-reported being white, 51.2% were female and 61.1% had household income per capita above the poverty line; 62.0% of their mothers had up to four years of schooling. Regarding the coverage of the ESF-SB, 55.3% were in a context of coverage of less than 50% and of these, 56.8% used dental services in the last three years. Of the 44.7% who had ESF-SB coverage equal to or greater than 50%, 90.8% reported having used dental services in the last three years. Regarding food, 35.3% of the participants reported high unhealthy food consumption (four to seven times a week) and of these, 85.4% used the dental service in the last three years.

Table 2 shows that 74.0% of the participants used dental services in the last three years. Regarding the type of service used, 56.7% reported having used the public dental service and 43.3% private service. With regard to the use, 46.2% sought dental service for prevention and 53.8% for treatment.

Table 3 shows the results of the structural equation modeling, according to Sisson’s theoretical framework, with the individual variables (sex; race/skin color), health behaviors (unhealthy eating; use of dental services for prevention), material explanation (family income; maternal education) and contextual variables (ESF-SB coverage ≥50%). It could be seen that the use of dental services in the last three years was associated with higher socioeconomic status (CP = 0.79; p<0.001), self-declared race/skin color as being white (CP = 0.14; p<0.001) and higher unhealthy food consumption (CP = 0.30; p<0.001). White adolescents used dental services mostly for prevention, and they used public services less than non-white adolescents. The higher ESF-SB coverage was positively related to higher unhealthy food consumption (CP = 0.19; p<0.001), use of public dental services (CP = 0.10 - p=0.045) and lower use of services for prevention (CP = -0.07; p=0.067). An indirect association was identified, through unhealthy food consumption, which measured the association of greater coverage of the ESF-SB with the greater use of dental services in the last three years.

Discussion

The study, conducted with school adolescents from the five cities in Mato Grasso do Sul with more than 80,000 inhabitants, showed three important findings. The first one was the association among the greater ESF-SB coverage, the greater use of dental services in the public network and the use of services for treatment. The second important finding was the association between the higher frequency of weekly consumption of unhealthy foods and the higher use of dental services for treatment rather than for prevention, partially mediating the relationship between greater coverage of ESF-SB and greater use of dental services. The third finding of considerable importance was a higher frequency of the use of private dental services for preventive care, by self-declared white adolescents when compared to non-white adolescents.

In the places where ESF-SB coverage was equal to or greater than 50%, a higher percentage of the use of public dental services was observed, showing how contextual factors can influence individual choices. Thus, it should be taken into consideration that greater ESF-SB coverage occurs in municipalities with a smaller population size, where the provision of private dental services is lower, and public service is the main access to oral health care. This result, particularly, reinforces the importance of public dental services to reduce inequalities in access to oral health care.

After the reorientation of the care model for health promotion in the Brazilian National Health System (SUS),²2. Macinko J, Harris MJ. Brazil's family health strategy-delivering community-based primary care in a universal health system. N Engl J Med. 2015 Jun 4;372(23):2177-81. doi: https://doi.org/10.1056/NEJMp1501140.
https://doi.org/10.1056/NEJMp1501140... PHC has provided services aimed at comprehensive care to the population. Generally, associated with the significant increase in population coverage by the ESF, there is evidence of the positive impact of Family Health Strategy on important health indicators,⁴4. Nascimento DDG, Moraes SHM, Santos CAST, Souza AS, Bomfim RA, De-Carli AD, et al. Impact of continuing education on maternal and child health indicators. PLoS One. 2020 Jun 26;15(6):e0235258. doi: https://doi.org/10.1371/journal.pone.0235258.
https://doi.org/10.1371/journal.pone.023... especially in reducing hospitalizations due to primary health care-sensitive conditions.⁵5. Bastos ML, Menzies D, Hone T, Dehghani K, Trajman A. The impact of the Brazilian family health strategy on selected primary care sensitive conditions: A systematic review. PLoS One. 2017 Aug 7;12(8):e0182336. doi: https://doi.org/10.1371/journal.pone.0182336.
https://doi.org/10.1371/journal.pone.018...

The results presented showed that a greater ESF-SB coverage was associated with a greater use of services for treatment than for prevention, contrary to authors’ hypothesis. The pent-up demand for dental treatments is high in Brazil,⁹9. Fonseca EPD, Frias AC, Mialhe FL, Pereira AC, Meneghim MC. Factors associated with last dental visit or not to visit the dentist by Brazilian adolescents: a population-based study. PLoS One. 2017 Aug 31;12(8):e0183310. doi: https://doi.org/10.1371/journal.pone.0183310.
https://doi.org/10.1371/journal.pone.018... imposing the challenge of balancing prevention and curative care actions on public dental services. Although no causality was analyzed, since we kept focused on associated factors, this finding contributed to the discussion on the need for the ESF-SB to qualify the work process, especially with regard to the expansion of prevention and health education, through a model of comprehensive health care for adolescents.

ESF-SB coverage equal to or greater than 50% was also associated with a higher frequency of weekly consumption of unhealthy foods, which in turn, partially measured the relationship between ESF-SB coverage and the use of dental services for treatment. A study conducted with adolescents in Rio Grande do Sul, in 2009, showed that sugar consumption was the highest predictor for the use of curative dental services.⁷7. Davoglio RS, Aerts DRGC, Abegg C, Freddo SL, Monteiro L. Fatores associados a hábitos de saúde bucal e utilização de serviços odontológicos entre adolescentes. . Cad Saude Publica. 2009;25(3):655-67. doi: https://doi.org/10.1590/s0102-311x2009000300020.
https://doi.org/10.1590/s0102-311x200900... The causal relationship between sugar consumption and dental caries is well established in the literature⁷7. Davoglio RS, Aerts DRGC, Abegg C, Freddo SL, Monteiro L. Fatores associados a hábitos de saúde bucal e utilização de serviços odontológicos entre adolescentes. . Cad Saude Publica. 2009;25(3):655-67. doi: https://doi.org/10.1590/s0102-311x2009000300020.
https://doi.org/10.1590/s0102-311x200900... the higher the frequency of consumption, the greater the probability of occurrence of the disease. Tooth decay is the main reason for seeking dental treatment by adolescents⁹9. Fonseca EPD, Frias AC, Mialhe FL, Pereira AC, Meneghim MC. Factors associated with last dental visit or not to visit the dentist by Brazilian adolescents: a population-based study. PLoS One. 2017 Aug 31;12(8):e0183310. doi: https://doi.org/10.1371/journal.pone.0183310.
https://doi.org/10.1371/journal.pone.018... and possibly explains the relationship between unhealthy food consumption (with large amounts of sugars) and the use of dental services for treatment. The result shows the importance of public policies in promoting healthy eating, family strategies for preventing oral health problems, through the use of oral care technologies and interdisciplinary work at PHC aimed at changes in eating behaviors of the population.

Using Sisson’s reference,¹²12. Sisson KL. Theoretical explanations for social inequalities in oral health. Community Dent Oral Epidemiol. 2007;35(2):81-8. doi: https://doi.org/10.1111/j.1600-0528.2007.00354.x.
https://doi.org/10.1111/j.1600-0528.2007... it was possible to understand these findings through the material explanation, related to socioeconomic status. Differences in socioeconomic status can influence the access to food resources, making the socioeconomic status one of the main determinants of health inequalities.¹² In Brazil, between 2003 and 2010, there were unequal improvements in oral health, especially related to dental caries,²²22. Roncalli AG, Sheiham A, Tsakos G, Watt RG. Socially unequal improvements in dental caries levels in Brazilian adolescents between 2003 and 2010. Community Dent Oral Epidemiol. 2015;43(4):317-24. doi: https://doi.org/10.1111/cdoe.12156.
https://doi.org/10.1111/cdoe.12156... ^,2323. Roncalli AG, Sheiham A, Tsakos G, Araújo-Souza GC, Watt RG. Social factors associated with the decline in caries in Brazilian children between 1996 and 2010. Caries Res. 2016;50(6):551-9. doi: https://doi.org/10.1159/000442899.
https://doi.org/10.1159/000442899... favoring higher-income individuals. The results showed that the highest use of private dental services was associated with the highest socioeconomic level and adolescents who self-reported being white, factors which in turn, are related to better health behaviors and lower prevalence of diseases.²⁴24. Bastos TF, Medina LPB, Sousa NFDS, 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 Oct 7;22 (Suppl 2):E190015.SUPL. 2. doi: https://doi.org/10.1590/1980-549720190015.supl.2.
https://doi.org/10.1590/1980-54972019001... One of the explanations for the association between whites and a higher use of private dental services for prevention is the fact that these adolescents are from higher-income families and also have higher schooling, which expands their access to preventive resources and the purchase of services, therefore they tend to seek private health services for routine checkup/prevention.²⁴24. Bastos TF, Medina LPB, Sousa NFDS, 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 Oct 7;22 (Suppl 2):E190015.SUPL. 2. doi: https://doi.org/10.1590/1980-549720190015.supl.2.
https://doi.org/10.1590/1980-54972019001...

However, inequalities in the availability of dental care may favor the use of these services among certain groups, in places with higher concentrations of individuals of white race/skin color.²⁵25. Yoon H, Jang Y, Choi K, Kim H. Preventive dental care utilization in Asian Americans in Austin, Texas: does neighborhood matter? Int J Environ Res Public Health. 2018 Oct 16;15(10):2261. doi: https://doi.org/10.3390/ijerph15102261.
https://doi.org/10.3390/ijerph15102261... ^,2626. Bastos JL, Celeste RK, Paradies YC. Racial inequalities in oral health. J Dent Res. 2018;97(8):878-86. doi: 10.1177/0022034518768536.
https://doi.org/10.1177/0022034518768536... Although it is essential to focus on social inequalities in oral health, racial inequalities cannot be eliminated simply by addressing only the mechanisms that link socioeconomic status to health.²⁷27. Phelan JC, Link BG. Is racism a fundamental cause of inequalities in health? Annu Rev Sociol. 2015;41:311-30. doi: https://doi.org/10.1146/annurev-soc-073014-112305.
https://doi.org/10.1146/annurev-soc-0730... This is one of the greatest challenges of the ESF-SB and public health services. Positive discrimination in health care in neighborhoods with racial groups at higher risk could be one of the solutions to minimize racial inequalities in the use of preventive services.²⁷27. Phelan JC, Link BG. Is racism a fundamental cause of inequalities in health? Annu Rev Sociol. 2015;41:311-30. doi: https://doi.org/10.1146/annurev-soc-073014-112305.
https://doi.org/10.1146/annurev-soc-0730... Racial inequities in tooth loss among Brazilian elderly population, through decomposition analysis, were 50% explained by the reasons and frequency of use of dental services,²⁸28. Bomfim RA, Schneider IJC, Andrade FB, Lima-Costa MF, Corrêa VP, Frazão P, et al. Racial inequities in tooth loss among older Brazilian adults: a decomposition analysis. Community Dent Oral Epidemiol. 2021;49(2):119-27. Epub 2020 Oct 13. doi: https://doi.org/10.1111/cdoe.12583.
https://doi.org/10.1111/cdoe.12583... behaviors possible to be modified, pointing out, once again, the importance of the Family Health Strategy action in this context.

Implementation of changes, in the reorganization of the workflow and work process in PHC, requires proposition for strategies and innovations.²⁹29. Bomfim RA, Braff EC, Frazão P. Cross-cultural adaptation and psychometric properties of the Brazilian-Portuguese version of the organizational readiness for implementing change questionnaire. Rev Bras Epidemiol. 2020 Oct 9;23:e200100. doi: https://doi.org/10.1590/1980-549720200100.
https://doi.org/10.1590/1980-54972020010... Possible ways to be taken into consideration by managers are the organization of services/programs for prevention that meet the attributes of PHC, interdisciplinary work qualification and the use of innovative educational approaches in order to achieve family and individual changes. Public policies to promote healthy eating, such as taxing sugary drinks, could also be taken into account by health managers in Brazil. Future research on the use of public and private dental services should analyze racial issues in greater depth, given the importance of the SUS for certain racial groups.³⁰30. Constante HM. Racial inequalities in public dental service utilization: Exploring individual and contextual determinants among middle-aged Brazilian adults. Community Dent Oral Epidemiol. 2020;48(4):302-8. doi: https://doi.org/10.1111/cdoe.12533.
https://doi.org/10.1111/cdoe.12533...

This is a cross-sectional study, therefore some limitations for the analysis should be pointed out. It is not possible to establish a causal relationship between the associations found. However, the instruments used were validated for the Brazilian context, and the questionnaire adopted is used in the Food and Nutrition Surveillance System (Sisvan-Web) of the Ministry of Health to access the frequency of unhealthy food consumption.¹⁹19. Bomfim RA, Frias AC, Cascaes AM, Mazzilli LEN, Souza LB, Carrer FCA, et al. Sedentary behavior, unhealthy foods consumption and dental caries in 12 year-olds: a population-based study. Braz Oral Res; 2021 Apr 26;35:e041. doi: https://doi.org/10.1590/1807-3107bor-2021.vol35.0041.
https://doi.org/10.1590/1807-3107bor-202... These associations may imply public policies aimed at reducing inadequate food consumption, especially the consumption of ultra-processed foods, and implementing strategies for changes in health services.²⁹29. Bomfim RA, Braff EC, Frazão P. Cross-cultural adaptation and psychometric properties of the Brazilian-Portuguese version of the organizational readiness for implementing change questionnaire. Rev Bras Epidemiol. 2020 Oct 9;23:e200100. doi: https://doi.org/10.1590/1980-549720200100.
https://doi.org/10.1590/1980-54972020010... The strong point of the study is the fact that this was a research conducted in the most affluent and representative cities in the four macro-regions of an important State in the Midwest region of Brazil, responsible for a strong agribusiness that supplies other geographic areas.

It can be concluded that higher coverage of ESF-SB was associated with higher use of public dental services, lower use of dental services for prevention and higher unhealthy food consumption. Oral health teams should organize access and qualify the work process, focusing on comprehensive care, in addition to contributing to the implementation of transdisciplinary actions aimed at reducing the consumption of unhealthy foods by school adolescents.

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