ABSTRACT

Although institutionalized in the Unified Health System, the dynamics of implementing Integrative and Complementary Practices (PICS) in the Family Health Strategy, from the perspective of dentistry, represents an unprecedented field of study. The aim was to understand the perception of dental surgeons working in this context in Vitória, Espírito Santo, Brazil, regarding the incorporation and implementation of these practices. Semi-structured interviews were carried out with forty dentists, which were recorded, transcribed and submitted to Bardin’s content analysis. Three categories emerged from the data: the understanding of PICS, the perception of incorporation and implementation, and the perception of PICS policies. There was unanimous understanding, acceptance and interest in the practices, showing their value in line with the guidelines of the related policies, highlighting the significant potential available in the municipality. However, challenges such as gaps in knowledge of specific dental policies and regulations, as well as shortcomings in the continuing education process, highlight the importance of improving strategies for disseminating information and training professionals. The conclusion is that, although they have been incorporated and there is considerable potential for expansion, barriers need to be overcome to achieve effective implementation of PICS in the municipality, including in specific contexts such as dentistry.

KEYWORDS
Primary Health Care; National health strategies; Dentistry; General practice; dental; Complementary therapies.

Introduction

Integrative and Complementary Practices (PICS), as defined by the World Health Organization (WHO)^{11 World Health Organization. Who Traditional Medicine Strategy 2014-2023 [Internet]. Geneva: WHO; 2013 [acesso em 2023 set 15]. Disponível em: https://www.who.int/publications/i/item/9789241506096
https://www.who.int/publications/i/item/...} and the Brazilian Ministry of Health^{22 Ministério da Saúde (BR), Secretaria de Atenção à Saúde. Política Nacional de Práticas Integrativas e Complementares no SUS [Internet]. PNPIC-SUS. Brasília, DF: Ministério da Saúde; 2006 [acesso em 2023 set 15]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/politica_nacional_praticas_integrativas_complementares_2ed.pdf
https://bvsms.saude.gov.br/bvs/publicaco...} , comprise a diverse set of practices that contribute to conventional treatment, based on holistic approaches and traditional knowledge. They involve complex medical systems and therapeutic resources, which broaden the understanding of the health-disease process, focusing on the global promotion of human care and using natural mechanisms of prevention and health recovery^{33 Habimorad PH, Catarucci FM, Bruno VH, et al. Potencialidades e fragilidades de implantação da Política Nacional de Práticas Integrativas e Complementares. Ciênc saúde coletiva. 2020;25(2):395-405. DOI: https://doi.org/10.1590/1413-81232020252.11332018
https://doi.org/10.1590/1413-81232020252...} .

Initially, five PICS were instituted in the Unified Health System (SUS) through the National Policy on Integrative and Complementary Practices (PNPIC), established by Ordinance GM/MS No. 971/2006, namely homeopathy, acupuncture/traditional Chinese medicine, anthroposophic medicine, medicinal plants/phytotherapy, and social balneotherapy/crenotherapy^{22 Ministério da Saúde (BR), Secretaria de Atenção à Saúde. Política Nacional de Práticas Integrativas e Complementares no SUS [Internet]. PNPIC-SUS. Brasília, DF: Ministério da Saúde; 2006 [acesso em 2023 set 15]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/politica_nacional_praticas_integrativas_complementares_2ed.pdf
https://bvsms.saude.gov.br/bvs/publicaco...} .

These approaches have expanded. Thus, in 2017, Ordinance GM/MS No. 849 added 14 practices: art therapy, ayurveda, biodance, circular dance, meditation, music therapy, naturopathy, osteopathy, chiropractic, reflex therapy, reiki, shantala, integrative community therapy, and yoga^{44 Ministério da Saúde (BR), Departamento de Atenção Básica. Ampliação da PNPIC [Internet]. Brasília, DF: Ministério da Saúde; 2017 [acesso em 2023 set 15]. Disponível em: http://189.28.128.100/dab/docs/portaldab/documentos/informe_pics_maio2017.pdf
http://189.28.128.100/dab/docs/portaldab...} . In 2018, Ordinance GM/MS No. 702 expanded the scope to apitherapy, aromatherapy, bioenergetics, family constellation, chromotherapy, geotherapy, hypnotherapy, therapeutic touch, ozone therapy, and floral therapy, totaling 29 PICS available at SUS, aiming to offer comprehensive and effective healthcare^{55 Ministério da Saúde (BR). Portaria nº 702, de 21 de março de 2018. Altera a Portaria de Consolidação nº 2/GM/MS, de 28 de setembro de 2017, para incluir novas práticas na Política Nacional [Internet]. Diário Oficial da União, Brasília, DF. 2018 mar 21 [acesso em 2023 out 18]; Edição 56; Seção I:74. Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2018/prt0702_22_03_2018.html
https://bvsms.saude.gov.br/bvs/saudelegi...} .

The regulation of the PICS policy extended to several municipalities and states, underscoring the Municipal Policy on Integrative and Complementary Practices in Health (PMPICS) in Vitória-ES, adopted in 2016 with the active participation of social and institutional actors^{66 Sacramento HT. Vitória, Espírito Santo (ES): experiência exitosa em Práticas Integrativas e Complementares (PICs). J Manag Prim Heal. 2017;8(2):333-42. DOI: https://doi.org/10.14295/jmphc.v8i2.556
https://doi.org/10.14295/jmphc.v8i2.556...} . Faced with a therapeutic and fragmented biomedical care model, with evident limitations of effectiveness in the epidemiological pattern of diseases^{77 Scherer CI, Scherer MD. Advances and challenges in oral health after a decade of the “Smiling Brazil” Program. Rev Saúde Pública. 2015;49(98):1-12. DOI: https://doi.org/10.1590/S0034-8910.2015049005961
https://doi.org/10.1590/S0034-8910.20150...} , there is a gradual advance of integrative practices to transform health paradigms^{88 Ruela LO, Moura CC, Gradim CV, et al. Implementação, acesso e uso das práticas integrativas e complementares no Sistema Único de Saúde: revisão da literatura. Ciênc saúde coletiva. 2019;24(11):4239-4250. DOI: https://doi.org/10.1590/1413-812320182411.06132018
https://doi.org/10.1590/1413-81232018241...} .

The predominant offer of PICS services in Primary Health Care (PHC) represents an advance in the implementation of PNPIC^{22 Ministério da Saúde (BR), Secretaria de Atenção à Saúde. Política Nacional de Práticas Integrativas e Complementares no SUS [Internet]. PNPIC-SUS. Brasília, DF: Ministério da Saúde; 2006 [acesso em 2023 set 15]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/politica_nacional_praticas_integrativas_complementares_2ed.pdf
https://bvsms.saude.gov.br/bvs/publicaco...} . The conceptions of PICS and PHC, such as an expanded and holistic approach, family and community focus, attention to the social and cultural context of individuals, establishment of therapeutic bonds, and active participation of users, among other aspects, are aligned^{99 Tesser CD, Souza IM. Atenção Primária, Atenção Psicossocial, Práticas integrativas e complementares e suas afinidades eletivas. Saúde soc. 2012;21(2):336-50. DOI: https://doi.org/10.1590/S0104-12902012000200008
https://doi.org/10.1590/S0104-1290201200...} .

Several studies have explored the perceptions of managers and professionals about PICS, revealing a favorable receptivity, but highlighting the need to expand the debate on the subject among actors and related instances<sup>1010 Machado DC, Czermainski SB, Lopes EC. Percepções de coordenadores de unidades de saúde sobre a fitoterapia e outras práticas integrativas e complementares. Saúde debate [Internet]. 2012 [acesso em 2023 set 15];36(95):615-23. Disponível em: https://www.scielo.br/j/sdeb/a/HXjxZqZYbMMnqB4j9LFMvst/abstract/?lang=pt
https://www.scielo.br/j/sdeb/a/HXjxZqZYb...

11 Fontenele RP, Sousa DM, Carvalho AL, et al. Fitoterapia na Atenção Básica: olhares dos gestores e profissionais da Estratégia Saúde da Família de Teresina (PI), Brasil. Ciênc saúde coletiva. 2013;18(8):2385-94. DOI: https://doi.org/10.1590/S1413-81232013000800023
https://doi.org/10.1590/S1413-8123201300... -1212 Bruning MC, Mosegui GB, Vianna CM. A utilização da fitoterapia e de plantas medicinais em unidades básicas de saúde nos municípios de Cascavel e Foz do Iguaçu - Paraná: a visão dos profissionais de saúde. Ciênc saúde coletiva. 2012;17(10):2675-85. DOI: https://doi.org/10.1590/S1413-81232012001000017
https://doi.org/10.1590/S1413-8123201200...</sup> .

Integrative dentistry, emerging from the PICS base, enables holistic care, characterized by welcoming listening and contextualizing users in a transdisciplinary scenario^{1313 Simões SC. Odontologia integrativa: abordagem sistêmica na odontologia. Rev Fitos. 2020;14(3):407-9. DOI: https://doi.org/10.32712/2446-4775.2020.921
https://doi.org/10.32712/2446-4775.2020....} . In this sense, the existence of dentistry regulations for specializations in acupuncture and homeopathy, in addition to qualifications in herbal medicine, floral therapy, hypnosis, laser therapy, anthroposophic dentistry, and ozone therapy, reinforces this perspective in PHC^{1414 Conselho Federal de Odontologia (BR). Resolução nº 82, de 25 de setembro de 2008. Reconhece e regulamenta o uso pelo cirurgião-dentista de práticas integrativas e complementares à saúde bucal [Internet]. Diário Oficial da União, Brasília, DF. 2008 out 1 [acesso em 2023 set 12]; Edião 190; Seção I:90. Disponível em: https://sistemas.cfo.org.br/visualizar/atos/RESOLU%C3%87%C3%83O/SEC/2008/82
https://sistemas.cfo.org.br/visualizar/a... ,1515 Conselho Federal de Odontologia (BR). Resolução nº 160, de 02 de outubro de 2015. Reconhece a acupuntura, homeopatia e odontologia do esporte como especialidades odontológicas [Internet]. Diário Oficial da União, Brasília, DF. 2015 out 7 [acesso em 2023 set 13]; Edição 192; Seção I:124. Disponível em: https://website.cfo.org.br/wp-content/uploads/2015/11/Resolu%C3%A7%C3%A3o-CFO-160-15-novas-especialidades.pdf
https://website.cfo.org.br/wp-content/up...} .

Therefore, several approaches to PICS are suggested as viable options for dental surgeons in treating users^{1616 Carvalho ML, Soares Filho JC, Silva CJ. Práticas integrativas e complementares em odontologia. Rev saúde coletiva. 2021;11(71):9043-54. DOI: https://doi.org/10.36489/saudecoletiva.2021v11i71p9043-9054
https://doi.org/10.36489/saudecoletiva.2...} . Although institutionalized in the SUS, the implementation of PICS in the Family Health Strategy (FHS) is a new field of study in dentistry.

Given the above, we sought to understand how dental surgeons working in the FHS of the municipality of Vitória-ES perceive the incorporation and implementation of PICS from the perspective of disease prevention, promotion, and health recovery.

Material and methods

This is an exploratory and descriptive study, with a qualitative perspective, that analyzes interviews with 40 dental surgeons working in the 25 FHS units of the Municipal Health Department (SEMUS) of Vitória-ES, from April to July 2023, covering its six health regions: Santo Antônio, Maruípe, São Pedro, Forte de São João, Continental, and Centro. The sample was defined by saturation, representing the diversity and complexity of perspectives within the population of interest, achieving equivalence in the collected data.

The inclusion criteria for participation in the research was: being a dental surgeon working in the FHS of Vitória-ES, regardless of age, sex, or professional experience in the position. Those unable to answer the questions during the data collection period due to official leave or absence from the units after three contact attempts were considered in the exclusion criteria. The professionals received an invitation letter with the Informed Consent Form (ICF), with detailed information related to the study. The work contributes to the Graduate Program in Public Health thesis of the Federal University of Espírito Santo.

In this study, we follow Merleau-Ponty’s concept of perception^{1717 Merleau-Ponty M. O primado da percepção e suas consequências filosóficas. Campinas: Papirus Editora;1990. p. 63.(63)}:

The profile of the interviewees was outlined considering the workplace, professional experience, professional status, graduate degree, and use of PICS in professional practice. A preliminary interview was carried out, which was the same interview as the data collection, so that the researcher could understand the research scenario. Data were collected through a semi-structured interview previously scheduled, according to the availability of dental surgeons, in a research scenario in a reserved environment. The interviews were guided by two master’s students, trained to apply standardized scripts that were previously prepared, and the questions were answered orally and recorded and registered in notes, with an average length of 30 minutes. They were fully transcribed and filed by the author of the research.

Based on Bardin’s method^{1818 Bardin L. Análise de Conteúdo. São Paulo: Edição 70; 2016.}, content analysis covers a set of analytical techniques to examine enunciation, seeking meaningful inferences about emerging topics systematically and objectively. Data were ordered in three stages: 1) pre-analysis, when the researchers skimmed through the material to identify the participants’ perceptions regarding the incorporation and implementation of PICS; 2) material exploration, encompassing the accurate reading of the meanings identified, aiming at the synthesis of prominent convergent and divergent points; and 3) interpretation of the results.

The analysis of the empirical material revealed ten subcategories: convictions about PICS; personal and professional experience in PICS; offer of PICS in the FHS; contribution to oral health; regulation by the Federal Council of Dentistry (CFO); potentialities and challenges in offering PICS; continuing education in PICS; interest in specific training; knowledge about PNPIC and PMPICS; and application of the principles of PNPIC and PMPICS in the FHS. From these subcategories, three central categories emerged: the understanding of PICS; the perception of the incorporation and implementation of PICS, and the perception of PICS policies (box 1).

Data analysis was enhanced using MAXQDA software, a tool that improves the accuracy of qualitative investigation. In addition, to ensure the research’s clarity and completeness, the Consolidated Criteria for Reporting Qualitative Research (COREQ) was used, a checklist for texts from studies of this nature^{1919 Tong A, Sainsbury P, Craig, J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Care. 2007;19(6):349-57. DOI: https://doi.org/10.1093/intqhc/mzm042
https://doi.org/10.1093/intqhc/mzm042...} .

This research adhered to the ethical principles established for studies involving human beings, in line with the guidelines of Resolution No. 46620, of December 12, 2012, of the National Health Council (CNS), Ministry of Health. To ensure confidentiality, participants received a code, ‘CD’ (cirurgião-dentista, dental surgeon in English), followed by a randomly assigned numeral between 1 and 40. The project received approval from the Research Committee of the Technical School and Professional Health Training of the Municipal Health Department of Vitória-ES, and the Research Ethics Committee of the Federal University of Espírito Santo, CAAE: 63122522. 1.0000. 5060, under opinion No. 5696.573.

Results and discussion

The 25 FHS units throughout the six municipal health regions were included, providing an overview of the perceptions of working dental surgeons. Of the 62 oral health teams in the FHS, each containing a dental surgeon, a sample of 40 respondents was obtained through saturation sampling, as previously described.

Most professionals, 60% (n = 24), have been working for more than 10 years, reflecting the broad and consolidated experience of dental surgeons in the FHS of the municipality. Regarding professional status, 90% (n = 36) are employees, and 55% (n = 22) of them perform some PICS in their professional practice. In addition, concerning graduate degree, all interviewees have at least one specialization, with 37.5% (n = 15) in public health, 35% (n = 14) in family health, and 15% (n = 6) in public policies, among other graduate courses mentioned, highlighting the diversity and depth of the training of dental surgeons (table 1).

Understanding PICS

This category highlights the respondents’ unanimous understanding of PICS as complementary to conventional medicine, prioritizing integral health. They are perceived as holistic approaches, based on traditional knowledge, with reports of promising results in clinical practice.

By agreeing with the perceptions exposed by dental surgeons, the research highlights that PICS provide an expanded view of the human being and the surrounding universe. The integrality of the health-disease relationship is emphasized, and the individual is considered within a global perspective, valuing their individuality^{22 Ministério da Saúde (BR), Secretaria de Atenção à Saúde. Política Nacional de Práticas Integrativas e Complementares no SUS [Internet]. PNPIC-SUS. Brasília, DF: Ministério da Saúde; 2006 [acesso em 2023 set 15]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/politica_nacional_praticas_integrativas_complementares_2ed.pdf
https://bvsms.saude.gov.br/bvs/publicaco...} .

Transparency between respondents’ beliefs and official definitions strengthens the understanding of PICS as practices aligned with the principles established by bodies that are a reference in health. In addition, they shared experiences related to PICS, reflecting familiarity with acupuncture, homeopathy, laser therapy, phytotherapy, among other approaches. In addition, they recognized positive therapeutic effects, enriching the professionals’ perception of the potential of PICS in PHC.

These findings corroborate the observations of Dalmolin and Heidemann^{2121 Dalmolin IS, Heidemann IT. Práticas integrativas e complementares na Atenção Primária: desvelando a promoção da saúde. Rev Latino-Am. 2020;28(1):1-10. DOI: https://doi.org/10.1590/1518-8345.3162.3277
https://doi.org/10.1590/1518-8345.3162.3...} , emphasizing that PICS are more than alternative or complementary methods of treatment, which represent health care approaches that encompass the entire human being, emphasizing self-knowledge, improved quality of life, and co-responsibility in the health-disease-care process. This harmony in perceptions reflects a growing appreciation of PICS in the context of contemporary health.

In addition, when contrasting these findings with the literature, there is a significant change in the understanding and application of PICS by dental surgeons. While Lima Júnior et al.^{2222 Lima Júnior JF, Dimenstein M. Fitoterapia na Saúde Pública em Natal/RN: visão do odontólogo. Saúde Rev [Internet]. 2006 [acesso em 2023 out 05];8(19):37-44. Disponível em: https://docplayer.com.br/12710678-A-fitoterapia-na-saude-publica-em-natal-rn-visao-do-odontologo.html
https://docplayer.com.br/12710678-A-fito...} pointed to a lack of knowledge and training in this professional group, current data indicate an increase in the familiarity and practical use of PICS in dentistry. This trend suggests an evolution in dental training and the adoption of holistic practices in oral health.

Perception of the Incorporation and Implementation of PICS

The incorporation and implementation of PICS in the FHS from the perspective of dentistry emerged in a multifaceted and interprofessional scenario. Laser therapy emerged as an innovation in the scope of dentistry. Auriculotherapy was used by various professional categories and phytotherapy, including therapeutic gardens used in different units, underlined the value of natural therapies and sustainability. Other practices offered were mentioned, reinforcing the integral vision. Furthermore, the perception of the positive impact on the lives of users highlighted the effectiveness and transformative potential of PICS in the practice of care in the FHS.

The advancement of PICS, reflected in the experiences reported in this study, resonates with Telesi’s^{2323 Telesi Júnior E. Práticas integrativas e complementares em saúde, uma nova eficácia para o SUS. Estud Av. 2016;30(86):99-112. DOI: https://doi.org/101590/s0103-40142016.00100007
https://doi.org/101590/s0103-40142016.00...} perspective on new ways of learning and practicing health. Characterized by interdisciplinarity and their own approaches, PICS are opposed to the technological and profitable health model, emphasizing an integral approach that encompasses the prevention of diseases, promotion, and recovery of human health in its entirety.

The data analyzed also showed relevant perceptions about the contribution of PICS to oral health, highlighting the knowledge of its diverse application and effectiveness in different clinical situations.

The connection between PICS and oral health highlights its relevance in dentistry. As mentioned in Lucas et al.^{2424 Lucas AS, Fagundes ML, Amaral Júnior OL, et al. Associação entre práticas integrativas e complementares em saúde e uso de serviços odontológicos em idosos no Brasil: estudo transversal. Epidemiol Serv Saúde. 2019;31(3):1-11. DOI: https://doi.org/10.1590/S2237-96222022000300007
https://doi.org/10.1590/S2237-9622202200...} , individuals who adopt PICS are generally more attentive to their integral well-being, and are also more proactive concerning general and oral health, demonstrating greater frequency in the search for dental services in the health system.

The results of this study indicate a promising start in the incorporation of PICS in FHS dentistry, as they diversify care options and contribute to the humanization of care by bringing dentists and users closer together, promoting a more holistic and integrated approach to oral health, in line with SUS principles.

In this sense, the research reinforces the view of Carvalho et al.^{1616 Carvalho ML, Soares Filho JC, Silva CJ. Práticas integrativas e complementares em odontologia. Rev saúde coletiva. 2021;11(71):9043-54. DOI: https://doi.org/10.36489/saudecoletiva.2021v11i71p9043-9054
https://doi.org/10.36489/saudecoletiva.2...} , who emphasized the importance of PICS in dentistry as a means of reducing the distance between professional and user, emphasized the need for a deep historical and conceptual understanding, as well as the knowledge of the modalities of PICS by health professionals in the SUS, including dentists.

Thus, the perceptions of the interviewees in this study also indicate the direction in which the use of PICS promotes greater participation of individuals in their treatment decisions, enhancing their response and feeling of well-being^{2525 Tesser CD. Práticas complementares, racionalidades médicas e promoção da saúde: contribuições pouco exploradas. Cad Saúde Pública. 2009;25(8):1732-42. DOI: https://doi.org/10.1590/S0102-311X2009000800009
https://doi.org/10.1590/S0102-311X200900...} . These practices are considered important for oral health self-care and can encourage people to seek regular dental care^{2424 Lucas AS, Fagundes ML, Amaral Júnior OL, et al. Associação entre práticas integrativas e complementares em saúde e uso de serviços odontológicos em idosos no Brasil: estudo transversal. Epidemiol Serv Saúde. 2019;31(3):1-11. DOI: https://doi.org/10.1590/S2237-96222022000300007
https://doi.org/10.1590/S2237-9622202200... ,2626 Arcury TA, Bell RA, Anderson AM, et al. Oral health self-care behaviors of rural older adults. J Public Health Dent. 2009;69(3):182-9. DOI: https://doi.org/10.1111%2Fj.1752-7325.2009.00121.x
https://doi.org/10.1111%2Fj.1752-7325.20...} .

As for the potentialities offered, the results reveal a favorable perception of dental surgeons. The most prominent ones include the diversity of therapeutic options to promote integral health, community acceptance, reduced financial cost, the presence of municipal technical reference and the support infrastructure of the municipality.

The evidence of multiple potentialities of PICS in the FHS shown in this study is supported by the findings of Barros et al.^{2727 Barros LC, Oliveira ES, Hallais JA, et al. Práticas Integrativas e Complementares na Atenção Primária à Saúde: Percepções dos Gestores dos Serviços. Esc Anna Nery. 2020;24(2):1-8. DOI: https://doi.org/10.1590/2177-9465-EAN-2019-0081
https://doi.org/10.1590/2177-9465-EAN-20...} , who highlighted benefits such as the strengthening of the bond between users and health units, the reduction of expenses with medication, the improvement in self-esteem and quality of life, in addition to the promotion of more humanized and comprehensive care. In line with these findings, Tesser^{2525 Tesser CD. Práticas complementares, racionalidades médicas e promoção da saúde: contribuições pouco exploradas. Cad Saúde Pública. 2009;25(8):1732-42. DOI: https://doi.org/10.1590/S0102-311X2009000800009
https://doi.org/10.1590/S0102-311X200900...} pointed out that there is an increase in the demand for PICS among users.

The perspective of this study is also in line with that of Barros et al.^{2828 Barros NF, Spadacio C, Costa MV. Trabalho interprofissional e as práticas integrativas e complementares no contexto da Atenção Primária à Saúde: potenciais e desafios. Saúde debate. 2018;41(1):163-73. DOI: https://doi.org/10.1590/0103-11042018S111
https://doi.org/10.1590/0103-11042018S11...} when they emphasize that the benefits of PICS impact users and health professionals, by promoting interprofessional integration, improving the organization of work, strengthening the bond with the community, and improving the professional-community bond, highlighting them as a valuable instrument, especially in PHC, given the distribution of PICS services by level of complexity in Brazil: primary care (78%), average complexity (18%), and high complexity (4%) in PHC^{2929 Ministério da Saúde (BR). Rio de Janeiro: Ministério da Saúde; [sem data]; Saúde de A a Z. Práticas integrativas e complementares em saúde (PICS) [Internet]. [acesso em 2023 dez 12]. Disponível em: https://www.gov.br/saude/pt-br/assuntos/saude-de-a-a-z
https://www.gov.br/saude/pt-br/assuntos/...} .

As for the presence of municipal technical reference and support infrastructure in Vitória-ES, in the Municipal Health Plan 2010-2013, there was a commitment to institutionalize the PMPICS. It became official in 2013, with the new health management, which expanded the responsibilities of the technical area of phytotherapy, creating the technical area of PICS in the municipality^{66 Sacramento HT. Vitória, Espírito Santo (ES): experiência exitosa em Práticas Integrativas e Complementares (PICs). J Manag Prim Heal. 2017;8(2):333-42. DOI: https://doi.org/10.14295/jmphc.v8i2.556
https://doi.org/10.14295/jmphc.v8i2.556...} .

In addition to the potentialities, important challenges were mentioned by dental surgeons in the implementation of PICS in the FHS, such as deficiency in the dissemination of practices, lack of incentive for training, insufficient support and lack of agreement between the different levels of management, and turnover of the team’s professionals.

This study supports Aguiar et al.^{3030 Aguiar J, Kanan LA, Masiero AV. Práticas integrativas e complementares na atenção básica em saúde: um estudo bibliométrico da produção brasileira. Saúde debate. 2019;43(123):1205-18. DOI: https://doi.org/10.1590/0103-1104201912318
https://doi.org/10.1590/0103-11042019123...} when they mention that, despite the existence of a national PICS policy, in many scenarios, implementation occurs autonomously, driven by engaged professionals, and limited by the lack of strategic management planning and resources allocated for this purpose. This scenario is reinforced by Tesser et al.^{3131 Tesser CD, Souza IM, Nascimento MC. Práticas integrativas e complementares na Atenção Primária à Saúde brasileira. Saúde debate. 2018;42(1):174-88. DOI: https://doi.org/10.1590/0103-11042018S112
https://doi.org/10.1590/0103-11042018S11...} , as they point out that when such professionals leave the establishment, the supply of PICS tends to be extinguished.

However, it is relevant to note that 90% (n = 36) of the dental surgeons interviewed in this research are municipal employees (table 1). This stability suggests a greater potential to implement and maintain PICS on an ongoing basis, mitigating the challenge of staff turnover. Thus, the predominance of dental surgeons who are municipal employees in favors the continuity of PICS in the local FHS.

In the context of continuing education in PICS, the participants mentioned short-term training sessions, focused on laser therapy, phytotherapy and reiki. Among these training courses, laser therapy, performed in the public sector, was the most prominent, being mentioned by 55% (n = 22) of the interviewees (table 1).

However, there are challenges, such as few offers of training and limited diversity in the modalities of PICS addressed. In addition, different levels of management struggle to reach an agreement regarding the inclusion of dental surgeons in the training sessions when available.

In view of the challenges previously reported, professionals have a lack of knowledge about PICS, highlighting the need for training and the expansion of information dissemination^{3232 Thiago SC, Tesser CD. Percepção de médicos e enfermeiros da Estratégia Saúde da Família sobre terapias complementares. Rev Saúde Pública. 2011;(45)2:249-257. DOI: https://doi.org/10.1590/S0034-89102011005000002
https://doi.org/10.1590/S0034-8910201100...} . In addition, there is a lack of management support to include professionals in PICS training^{3030 Aguiar J, Kanan LA, Masiero AV. Práticas integrativas e complementares na atenção básica em saúde: um estudo bibliométrico da produção brasileira. Saúde debate. 2019;43(123):1205-18. DOI: https://doi.org/10.1590/0103-1104201912318
https://doi.org/10.1590/0103-11042019123...} .

The results show the unanimous interest of dental surgeons in additional training in PICS. Acupuncture is the most mentioned training, with 30% (n = 12), followed by laser therapy, with 25% (n = 10), and phytotherapy, with 15% (n = 6), which shows the search for complementary skills to enrich their performance in the FHS.

Tesser et al.^{3131 Tesser CD, Souza IM, Nascimento MC. Práticas integrativas e complementares na Atenção Primária à Saúde brasileira. Saúde debate. 2018;42(1):174-88. DOI: https://doi.org/10.1590/0103-11042018S112
https://doi.org/10.1590/0103-11042018S11...} , in line with the present study, pointed out that training in PICS in Brazil is limited and not comprehensive, focusing on private educational institutions, as evidenced by Barros et al.^{3333 Barros NF, Siegel P, Otani MA, organizadores. O ensino das práticas integrativas e complementares: experiências e percepções. São Paulo: Hucitec; 2011.}. In addition, according to Soares et al.^{3434 Soares RD, Pinho JR, Tonello AS. Diagnóstico situacional das práticas integrativas e complementares na Atenção Primária à Saúde do Maranhão. Saúde debate. 2022;44(126):749-61. DOI: https://doi.org/10.1590/0103-1104202012612
https://doi.org/10.1590/0103-11042020126...} , the lack of trained professionals and investment in more simple care technologies hinders the implementation of PICS in the SUS. Therefore, Nascimento et al. ³⁵ point out that expanding the specialization in PICS committed to the principles of SUS represents a challenge for teaching these practices.

The conduct of these professionals should reflect the guidelines of SUS health policies, based on technical-scientific, ethical, and humanistic bases, integrated from the beginning of the training to the professional career^{3535 Nascimento MC, Romano VF, Chazan AC, et al. Formação em práticas integrativas e complementares em saúde: desafios para as universidades públicas. Trab Educ Saúde. 2018;16(2):751-72. DOI: https://doi.org/10.1590/1981-7746-sol00130
https://doi.org/10.1590/1981-7746-sol001...} . This ideal position, already identified among the dentists interviewed, demonstrates an alignment with SUS’ expectations. However, the challenges related to training in PICS limit the full capacity of these professionals to contribute to promoting integral health.

Thus, the training of health professionals should focus on the development of skills for a comprehensive approach to health. This includes incorporating health literacy since the beginning of undergraduate courses, integrating it into the global assessment and anamnesis of individuals, being vital for promoting integral health^{3636 Siqueira MM, Carvalho MT. Enfermagem em saúde mental: promoção, prevenção e cuidado. 1. ed. Curitiba: Appris; 2022.}.

Regarding the PNPIC and the regulation of PICS by the CFO, there was unanimous support from the interviewees, consolidating their legitimacy in dental practice in the SUS and evidencing their growing recognition. However, only a small portion of dentists, 25% (n = 10), were aware of this regulation by the CFO, while the majority were unaware, 45% (n = 18), or had a superficial understanding, 30% (n = 12).

Through online meetings, the CFO has been working to formulate recommendations to strengthen PICS in SUS, including dentistry. At the same time, the debate on PICS continues in the CNS, extended by the Intersectoral Commission on Protection, Promotion and Integrative and Complementary Practices in Health^{3737 Conselho Nacional de Saúde (BR). CFO contribui com o fortalecimento das práticas integrativas e complementares em saúde no SUS [Internet]. Brasília, DF. 2021 mar 17 [acesso em 2023 dez 12]. Disponível em: https://website.cfo.org.br/cfo-contribui-com-o-fortalecimento-das-praticas-integrativas-e-complementares-em-saude-no-sus/
https://website.cfo.org.br/cfo-contribui...} .

However, the gap identified underscores the urgency of better outreach strategies, ensuring that dental surgeons are informed about PICS policies and regulations. For example, the CRO of Rio Grande do Norte created the PICS Commission, through Ordinance No. 9/2018, to raise knowledge and apply PICS, in addition to guiding the population^{3838 Conselho Regional de Odontologia do Rio Grande do Norte (RN). Conheça as Práticas Integrativas e Complementares (PICS) na Odontologia [Internet]. Natal: CRORN; 2019 abr 11 [acesso 2023 set 14]. Disponível em: https://www.crorn.org.br/artigos/ver/111#:~:text=A%20comiss%C3%A3o%20das%20PICS%20%C3%A9,%2D2152
https://www.crorn.org.br/artigos/ver/111...} .

Perception of PICS Policies

This category revealed a gap between the practice of PICS and the knowledge of ESF dental surgeons about PICS policies: only 27.5% (n = 11) of the 40 interviewees are well-informed about PNPIC and PMPICS (table 1).

Those who knew about it showed positive perceptions.

They also emphasized the importance of institutionalizing these policies in the context of PHC.

However, most reported having superficial knowledge, 25% (n = 10), or no knowledge, 47.5% (n = 19), about the PNPIC and PMPICS (table 1).

These findings corroborate those of Thiago et al.^{3232 Thiago SC, Tesser CD. Percepção de médicos e enfermeiros da Estratégia Saúde da Família sobre terapias complementares. Rev Saúde Pública. 2011;(45)2:249-257. DOI: https://doi.org/10.1590/S0034-89102011005000002
https://doi.org/10.1590/S0034-8910201100...} , who found that the FHS professionals did not know about the guidelines for the implementation of PICS despite agreeing with their inclusion in SUS and showing interest in training.

The results show the need to expand the dissemination of existing policy guidelines, as well as to invest in permanent education, to ensure the effectiveness of the implementation of PICS in the FHS.

Final considerations

The understanding and acceptance of PICS by the dental surgeons interviewed show their potential in the prevention of diseases, promotion, and recovery of integral health, in line with the guidelines of the PNPIC and PMPICS, signaling a privileged position for incorporation and implementation of these practices within the scope of PHC.

The offer of PICS evolves in a promising, multifaceted and interprofessional scenario. In addition, it reveals engaged professionals with positive perceptions about the process of implementing PICS in the FHS, such as diversity of therapeutic options to promote integral health, community acceptance, reduced financial cost, active presence of municipal technical reference in PICS, and adequate supporting infrastructure of the municipality. Still, with resilience and commitment, they face challenges, such as deficiency in the dissemination of practices, failures in the incentive and in the offer of training in PICS, lack of agreement between the different levels of management, in addition to the turnover of professionals in some teams.

There is a gap in the knowledge of dental surgeons about PICS policies and specific dental regulations, despite the support for the inclusion of PICS in the SUS and the interest in training, indicating the urgent need to expand dissemination and strengthen permanent education to ensure a more effective implementation of PICS in the FHS.

The limitations of this study include the sample restricted to FHS dental surgeons. Therefore, future research is suggested through multicenter studies and comparisons of contexts of action of other categories that make up these teams for more comprehensive investigations in PHC.

References

Publication Dates

History