This study showed that the seeking for dental appointments in Primary Health Care is related to variables of individuals and also of the organization of oral health teams; additionally, it showed that only 58.1% of the users interviewed at these Primary Health Care Units seek the available dental care. With a pioneering and bold approach in comparison with other public health systems worldwide, Brazil offers its citizens universal oral health care services, from prevention to rehabilitation. By taking on the task of evaluating the indicators of the search for dental appointments in Primary Health Care Units with an Oral Health Team, this study aims to bring a contribution to oral health management, instrumentalizing the fight for the reduction of inequalities regarding the access to oral health in Brazil.
Therefore, it is evident that despite the historical debt the Brazilian government has with its citizens regarding the offer of universal oral health services, the search for these services – currently, finally offered to all age groups of the population – remains modest. There is an epidemiologically recorded accumulation of oral health needs in the country. For instance, the latest national oral health survey disclosed that 75.2% of the adult population (aged 35 to 44 years) needed dental care in Brazil . However, the services offered at the PHC level are sought after, on average, by slightly more than 50% of the citizens of the territory, even when more than 75% of the Brazilian population is totally dependent on SUS health care .
As for individual indicators, our study showed that the seek for dental care is greater among younger patients, a result that has been explained, since edentulism is a predominant condition among elderly Brazilians . Maintaining the idea of dental care focused on tooth care discourages the elderly from performing oral health self-care. Our study also showed that people living in a more crowded household are more likely to seek dental appointments. This result can be explained by the importance of the family in health care, in the search for information, in the search for a diagnosis, in the construction of therapeutic itineraries, in daily, permanent and long-term care .
The fact that men seek health services less frequently than women, even if they have serious health problems, is well established in the literature [28, 29], and such behaviour is attributed to cultural issues. In turn, the greater demand for dental care among black, brown and indigenous patients in comparison to white patients can be understood, as dental treatment needs also reflect racial inequalities, with worse indicators of oral health (caries, tooth loss, pain and need for prosthesis) being observed in the black and indigenous population [3, 30].
Regarding the contextual indicators, considering the results found in our study, we could understand that the seeking for dental care is directly related to a better interaction and the articulation of the oral health team with the other members of the Primary Care Health team and with the population of the assisted territory. In 2004, through the Brasil Sorridente program, a series of policies were implemented aiming at the expansion and qualification of oral health in PHC [2, 11]. The program highlights the importance of knowing the reality of the covered areas and the building of problem-solving and effective practices regarding the care offered by the OHT.
The inclusion of the Oral Health Team in the Family Health Strategy brought as the directive the performance of actions in an integrated perspective of health prevention, promotion and provision of care. Brasil Sorridente underlines that OHTs must have knowledge of the territory, be close to those assisted and joint planning and participation of the entire team to assist the population . However, despite all the attained advances, oral health access difficulties still persist in SUS. The challenges faced by the oral health teams are related to the comprehensive care, expansion and qualification of assistance, teamwork, planning, monitoring and evaluation of actions and working conditions .
The reasons for the persistence of these difficulties can be identified when the results of our study show that the Oral Health Teams provide assistance, on average, to 1.2 PHC teams and the vast majority attend to individuals living outside the covered area on at least some days of the week. Such findings reflect the failure to match the number of OHTs affiliated to family health teams (FHTs) as recommended by the Brasil Sorridente guidelines. This situation becomes even more serious in the face of changes in the Brazilian political and economic framework in recent years. Constitutional Amendment number 95 of 2016 imposed a severe withdrawal of investments in oral health in SUS .
In the wake of the political-institutional decisions that Brazil made as of 2016, the new National Primary Care Policy (PNAB, Política Nacional de Atenção Básica) published in 2017 sees oral health as non-mandatory in the Family Health Strategy. PNAB has already reflected in an increase in the number of municipalities that reduced the number of oral health teams in the Family Health Strategy [11, 33]. It is already possible to detect loss of implantation amplitude, indicated by the stabilization trend line regarding the number of these teams after January 2018. Between the 1st and the 21st months of the publication of the PNAB 2017 Ordinance, a three-fold increase was observed regarding the number of municipalities that reduced the number of OHTs in the Family Health Strategy . Obviously, the direct negative impact of this fact on citizens’ access to oral health services should be more clearly perceived in the coming years.
The concept of Primary Health Care, the field in which the present investigation was developed, demonstrates that, in essence, PHC is aimed at caring for people, not diseases. Therefore, it has to be accessible, comprehensive, continuous and guarantee the coordination of care for cases that require referrals [34, 35]. This explains the fact that the present study has demonstrated that the user’s chance to seek dental care is greater in OHTs that discuss cases and therapeutic projects. It is evident the need to rethink health work processes, changing the focus of attention, currently on the disease, so that it is focused on the individual and the community. This is not merely about improving the quality of care (albeit it is) but, above all, it is about the observance of Integrality in health, a fundamental SUS principle.
From the perspective of overcoming the challenges that citizens meet to have access to dental care in the context of SUS, we point out the determining role of Community Health Agents (CHAs) regarding the relationship between the community and health services. The present investigation showed that the search for dental appointments was significantly higher in OHTs that carry out actions articulated with other social facilities in the territory and that perform user embracement together with the Primary Care team. Worldwide, CHAs are seen as an important link to increase the access of communities to services, especially for people living in areas of greater vulnerability and, thus, to accelerate and sustain the progress in meeting health targets in Sustainable Development Goals (SDGs) [36, 37].
The strengths of this research comprise the sample size and distribution, which included participants from all over the national territory of a country known for its continental dimensions. In turn, we point out possible limitations of our study. A cross-sectional design does not allow the identification of causal relationships and the absence of questions related to behaviour or about the needs perceived by users, variables that were not collected in the PMAQ.
In this sense, further research, particularly with a qualitative analysis, can contribute to the consolidation of scientific knowledge. Furthermore, it is important to emphasize that in Brazil health care can be provided by the public health system and also by the private system, through direct payment from the patient to the service provider.
It should be clarified that health financing systems can have a different impact on the patient’s decision-making regarding the search for dental care . Our study used information related only to public financing of health care and this can be pointed out as a limitation of the research. Another limitation is that the questionnaire did not ask whether users who did not seek to schedule an appointment in the public service did so in the private service. However, it is estimated that the SUS is exclusively responsible for assisting more than 75% of the Brazilian population . Percentage for dental care needs can be even higher.
Based on the findings of the present study, we suggest the need for strengthening oral health teams in the Unified Health System and for following guidelines proposed by the Brasil Sorridente program. Policies that reinforce the need for articulation among oral health teams and other Primary Care members, as well territory, will contribute to the improvement of access to services and to the oral health epidemiological profile of the assisted population. In addition, it can be observed that individual indicators reflect the oral health inequalities that still persist in the Brazilian population. These inequalities can be fought with greater investment in public oral health policies.