Direito, justiça e judicialização em saúde bucal / Right, justice and judicialization in oral health

O direito à saúde é um direito social respaldado em nossa Constituição, imprescindível ao bem-estar e à dignidade do ser humano. O objetivo deste trabalho é analisar as solicitações de tratamentos odontológicos no Sistema Único de Saúde do Estado de Minas Gerais levadas ao Poder Judiciário, para conhecer suas características e as argumentações jurídicas, de princípios e biológicas, utilizadas pelos desembargadores na elaboração dos votos. Foram pesquisados no site do Tribunal de Justiça de Minas Gerais os acórdãos proferidos no período de 2006 a 2016, resultando 27 acórdãos adequados ao estudo. Os resultados denotam que as ações foram postuladas individualmente, com 93% de êxito em favor dos usuários, sendo que foram apresentados laudos ou requisições em 88% das ações. As principais queixas que originaram as solicitações por tratamento odontológico foram agrupadas em cinco grupos. O tratamento odontológico mais solicitado foi cirurgia para colocação de implantes (sete acórdãos), seguido por aparelho ortodôntico (cinco acórdãos). A fundamentação jurídica foi embasada na Constituição, sendo que o artigo 196 foi o mais citado, constando em 25 dos 27 acórdãos. Na fundamentação baseada na argumentação de princípio, o direito à saúde foi o mais utilizado (20 acórdãos), fortalecendo esse direito social, seguido do princípio da dignidade da pessoa humana (12 acórdãos), do princípio da reserva do possível (10 acórdãos) e do direito à vida (oito acórdãos). A Justiça tem sido procurada como alternativa de acesso aos serviços de saúde, devendo os reflexos desse fato serem analisados além do indivíduo beneficiado, pois envolvem toda a sociedade.

The right to health is a social right provided by the Constitution, essential to the well-being and dignity of the human being. The aim of this study is to analyze the requests for dental treatments in the Brazilian National Health System of Minas Gerais state, in order to know their characteristics, the legal, principle and biological argumentation used by the judges in their decisions. A survey was made covering the judgments listed on websites of Minas Gerais Court of Justice in the period from 2006 to 2016, resulting in 27 judgments. The results denote that the actions were postulated individually, with 93% of success in favor of users, and reports or requisitions were submitted in 88% of the actions. The main complaints that originated the requests for dental treatment were grouped into five groups. The most requested dental treatments were surgery for the placement of implants, followed by orthodontic appliance. The legal basis was based on the Constitution for theoretical justification, and the article 196 was the most cited, in 25 of the 27 judgments. In the reasoning based on the principle argumentation, the right to health was the most used, strengthening this social right, followed by the principle of the dignity of the human person, the principle of reserve of possible and the right to life. Justice has been sought as an alternative to access health services, but the consequences of this fact must be analyzed beyond the individual benefited because it involves the whole society.

Contextual and individual determinants of tooth loss in adults: a multilevel study.

BACKGROUND: Tooth loss represents a known marker of health inequality. The association between tooth loss and unfavorable socioeconomic conditions is evident when analyzed at an individual level. However, the effects of contextual characteristics on tooth loss need to be better investigated and understood. The objective of this study was to analyze tooth loss among Brazilian adults (35-44 years of age), in accordance with individual and contextual social characteristics. METHODS: This was a multilevel cross-sectional study with data from 9564 adult participants from the Brazilian Oral Health Survey - SBBrasil 2010. The dependent variable was the number of lost teeth and the independent variables were grouped into structural (socioeconomic & political context) and intermediary (socioeconomic position, behavioral & biological factors, and health services) determinants. Multilevel Hierarchical Negative Binomial Regression was conducted and the Mean Ratio (MR) was estimated. RESULTS: Brazilian adults lost a mean of 7.57 (95% CI 7.1-8.1) teeth. Among the contextual variables, the number of teeth lost was higher among residents of municipalities with high and medium/low Municipal Human Development Index (MHDI) and in municipalities that did not have public water fluoridation. Among the individual variables, dental loss was higher among those who declared themselves yellow/black/brown/indigenous, were older, who had lower income, who had never visited a dentist, who had used dental services for more than a year and those whose most recent visit to the dentist was due to oral health problems. On the other hand, dental loss was lower among adults with higher education levels and males. CONCLUSIONS: The number of missing teeth was associated with unfavorable contextual and individual conditions, which reinforces the need to reduce social inequality and guarantee regular, lifetime access to dental services.

Epidemiological and spatial characteristics of interpersonal physical violence in a Brazilian city: A comparative study of violent injury hotspots in familial versus non-familial settings, 2012-2014.

This study explores both epidemiological and spatial characteristics of domestic and community interpersonal violence. We evaluated three years of violent trauma data in the medium-sized city of Campina Grande in North-Eastern Brazil. 3559 medical and police records were analysed and 2563 cases were included to identify socioeconomic and geographic patterns. The associations between sociodemographic, temporal, and incident characteristics and domestic violence were evaluated using logistic regression. Using Geographical Information Systems (GIS), we mapped victims' household addresses to identify spatial patterns. We observed a higher incidence of domestic violence among female, divorced, or co-habitant persons when the violent event was perpetrated by males. There was only a minor chance of occurrence of domestic violence involving firearms. 8 out of 10 victims of domestic violence were women and the female/male ratio was 3.3 times greater than that of community violence (violence not occurring in the home). Unmarried couples were twice as likely to have a victim in the family unit (OR = 2.03), compared to married couples. Seven geographical hotspots were identified. The greatest density of hotspots was found in the East side of the study area and was spatially coincident with the lowest average family income. Aggressor sex, marital status, and mechanism of injury were most associated with domestic violence, and low-income neighbourhoods were coincident with both domestic and non-domestic violence hotspots. These results provide further evidence that economic poverty may play a significant role in interpersonal, and particularly domestic violence.

Gender differences in predictors of self-rated health among older adults in Brazil and Chile.

BACKGROUND: The determinants of self-rated health (SRH) have been widely investigated to explain social differences and gender differences in health. This study aimed to investigate the gender differences in predictors of SRH among Brazilian and Chilean older adults. METHODS: We used two samples of older people: 2052 Brazilian community-dwelling participants (1226 women and 862 men) and 1301 Chilean community-dwelling participants (855 women and 446 men). Sequential logistic regression analysis was used to examine the relationships between SRH and potential predictors in a hierarchical model. RESULTS: Overall, 35.5% and 52.1% of individuals in Chile and Brazil, respectively, reported good SRH. There was a gradient association between good SRH and chronic diseases in both countries. Chilean men without chronic disease or with one had a higher chance of good SRH, compared to two or more diseases. For Brazilian men, no or one chronic disease was associated with good SRH. For women, the set of independent predictors for good SRH included no chronic diseases or one chronic disease, and no activities of daily living limitation. For men, the set also included instrumental activities limitation. For Brazilian adults of both genders, depression demonstrated the strongest independent association with good SRH. CONCLUSIONS: We conclude that when examining gender differences in predictors of SRH, the similarities are greater than the differences between Brazilian and Chilean older adults. In both countries, physical health was the most important predictor of SRH. In addition, absence of depression was the strongest predictor of good health in older Brazilian adults.

Assessment of the management of the Family Health Strategy via the tool Assessment for Quality Improvement in municipalities of Minas Gerais, Brazil.

The self-assessment of the quality ofthe Family Health Strategy(FHS) was assessed in the context ofmanagement and its correlation with characteristics of FHS and of the municipality. Managers, coordinators and Family Health Unit managers of municipalities in the Northeast region of Minas Gerais replied with tools 1, 2 and 3 of the Assessment for Improving the Quality of Family Health Strategy (AIQ). Scores were defined for each subdimension, according to the number of features compliant with the standards of the AIQ. We tested the correlation of this score with coverage and the deployment time of the FHS, with the municipal population and the HDI (Human Development Index). The lowest scores were for Work Management, Permanent Education and Inputs, Immunobiologicals and Medicines. There was a positive correlation between the municipal population and Strengthening of Coordination, Support for Teams, Permanent Education Management and Standardization and a negative one with Infrastructure and Equipment. The use of the AIQ tools permitted the identification of subdimensions and municipalities which will require greater attention and intervention by the municipal management.

Assessment of the management of the Family Health Strategy via the tool Assessment for Quality Improvement in municipalities of Minas Gerais, Brazil / Avaliação da gestão da Estratégia Saúde da Família por meio do instrumento Avaliação para Melhoria da Qualidade em municípios de Minas Gerais, Brasil

The self-assessment of the quality ofthe Family Health Strategy(FHS) was assessed in the context ofmanagement and its correlation with characteristics of FHS and of the municipality. Managers, coordinators and Family Health Unit managers of municipalities in the Northeast region of Minas Gerais replied with tools 1, 2 and 3 of the Assessment for Improving the Quality of Family Health Strategy (AIQ). Scores were defined for each subdimension, according to the number of features compliant with the standards of the AIQ. We tested the correlation of this score with coverage and the deployment time of the FHS, with the municipal population and the HDI (Human Development Index). The lowest scores were for Work Management, Permanent Education and Inputs, Immunobiologicals and Medicines. There was a positive correlation between the municipal population and Strengthening of Coordination, Support for Teams, Permanent Education Management and Standardization and a negative one with Infrastructure and Equipment. The use of the AIQ tools permitted the identification of subdimensions and municipalities which will require greater attention and intervention by the municipal management.

Aferiu-se a autoavaliação da qualidade da Estratégia Saúde da Família (ESF) no âmbito da gestão e sua correlação com características das ESF e do município. Gestores, coordenadores e gerentes das Unidades Saúde da Família de municípios da região Nordeste de Minas Gerais responderam os instrumentos 1, 2 e 3 de Avaliação para Melhoria da Qualidade da Estratégia Saúde da Família (AMQ). Foram definidos escores para cada subdimensão, segundo número de conformidades aos padrões da AMQ. Testou-se a correlação desse escore com a cobertura e o tempo de implantação das ESF, com a população e o IDH (Índice de Desenvolvimento Humano) municipal. Os escores menores foram para Gestão do Trabalho, Educação Permanente e Insumos, Imunobiológicos e Medicamentos. Houve correlação positiva entre população municipal e Fortalecimento da Coordenação, Acompanhamento das Equipes, Gestão da Educação Permanente e Normatização e negativa com Infraestrutura e Equipamentos. O uso dos instrumentos da AMQ permitiu identificar as subdimensões e municípios que necessitarão de maior atenção e intervenção da gestão municipal.

Is there an association between traumatic dental injury and social capital, binge drinking and socioeconomic indicators among schoolchildren?

OBJECTIVES: Traumatic dental injury is defined as trauma caused by forces on a tooth with variable extent and severity. The aim of the present study was to investigate the prevalence of traumatic dental injury and its association with overjet, lip protection, sex, socioeconomic status, social capital and binge drinking among 12-year-old students. RESEARCH DESIGN AND METHOD: A cross-sectional study was conducted with a sample of 633 12-year-old students. Data were collected through a clinical exam and self-administered questionnaires. Socioeconomic status was determined based on mother's schooling and household income. The Social Capital Questionnaire for Adolescent Students and Alcohol Use Disorders Identification Test (AUDIT-C) were used to measure social capital and binge drinking, respectively. RESULTS: The prevalence of traumatic dental injury was 29.9% (176/588). Traumatic dental injury was more prevalent among male adolescents (p = 0.010), those with overjet greater than 5 mm (p < 0.001) and those with inadequate lip protection (p < 0.001). In the multiple logistic regression analysis, overjet [OR = 3.80 (95% CI: 2.235-6.466), p < 0.0001], inadequate lip protection [OR = 5.585 (95% CI: 3.654-8.535), p < 0.0001] and binge drinking [OR = 1.93 (95% CI: 1.21-3.06), p = 0.005] remained significantly associated with traumatic dental injury. CONCLUSIONS: The present findings suggest that a high level of total social capital and trust are not associated with TDI in adolescents, unlike binge drinking. The effects of social and behavioral factors on TDI are not well elucidated. Therefore, further research involving other populations and a longitudinal design is recommended.

Aging, Gender and Quality of Life (AGEQOL) study: factors associated with good quality of life in older Brazilian community-dwelling adults.

BACKGROUND: In Brazil, a rapidly aging country suffering from large inequalities, the study of the quality of life (QOL) of aged people is important for the future health. The aim of this study was to examine the associations among QOL, gender, and physical and psychosocial health in older Brazilian community-dwelling adults to identify factors that are associated with better QOL. METHODS: The "Aging, Gender and Quality of Life (AGEQOL)" study, which included 2,052 respondents aged 60 or older, was conducted in Sete Lagoas, Brazil between January and July 2012. The respondents answered questions regarding their socioeconomic and demographic information, health and social situations, cognitive impairment, depressive symptoms and family satisfaction. The authors also applied the Brazilian version the World Health Organization Quality of Life QOL Assessment-Brief Instrument (WHOQOL-BREF) and the World Health Organization Quality of Life Instrument-Older Adults Module (WHOQOL-Old). Ordinal logistic regression with the Proportional-Odds and Logit function was used to test the association between QOL and physical and psychosocial health according to age and socioeconomic status. RESULTS: Older adults of both genders with five or more years of education, good self-rated health, an absence of depressive symptoms, and no family dysfunction reported better QOL. Retired men had a better QOL compared to non-retired men (OR = 2.2; 95% CI = 1.4-3.2), but this association was not observed in females. Men living in mixed arrangements (OR = 0.5; p = 0.033) and women who did not practice physical activity (OR = 0.7; p = 0.022) tended to have poorer QOL. CONCLUSIONS: We conclude that there are gender differences related to better QOL in this sample. Women with good physical and psychosocial health are more likely to have a better QOL. For men, the best QOL was associated with high socioeconomic conditions and good physical and psychosocial health.

Validity and reproducibility of the revised oral assessment guide applied by community health workers.

OBJECTIVE: To determine the validity and reproducibility of the Revised Oral Assessment Guide (ROAG) as pre-diagnostic tool used in elderly citizens by community health workers (CHWs) of the Family Health Strategy (FHS). MATERIAL AND METHODS: Initially, we adjusted the English version to Portuguese and then developed a training program for use of ROAG, with the participation of CHWs, in selected districts that had the highest enrolled number of elderly people in the city. The elderly persons were distributed among 10 previously trained CHWs. To assess the validity of the ROAG, a CHW and a dentist (considered as the gold standard) independently evaluated the same individual. The reproducibility of the ROAG was evaluated by each of the CHWs examining 5-6 elderly individuals twice with a 7-day interval. RESULTS: The sensitivity ranged from 0.17 for evaluation of saliva to 0.80 for voice. The specific ranged from 0.69 for teeth/dentures to 0.98 for saliva using mirror and the accuracy ranged from 0.92 for swallow to 0.64 for mucosa. The intra-rater reproducibility of the ROAG was perfect for evaluation of voice, lips and swallow (κ=1.000). CONCLUSION: When used by trained CHWs, the ROAG is a tool with high sensitivity and specificity to assess voice, swallowing, tongue and teeth/dentures. Moreover, it can efficiently detect patients showing no alteration in lips, saliva, mucosa and gums. High reproducibility was observed in almost all the categories. Trained CHWs can use this tool to improve the access of elderly patients to dental services.

Programmatic actions in oral health: coping with social inequities.

Inequities are health imbalances that are avoidable, unfair and unnecessary. Studies on health inequities address the need for emergency care related to oral-dental lesions from external causes, toothache or prevalence of oral lesions, taking into account the differences between individuals and/or populations in terms of risk conditions to acquiring disease or access to health services. Inequities may be caused by the health service itself, because diseases affect socially deprived individuals more frequently and severely, especially because of multimorbidity. In the current Brazilian public health situation, programmatic actions are based on technological knowledge, especially epidemiology, focused on specific pathologies or disease risk groups, and relate closely to the organization of programmed demand. Moreover, programmatic actions should strategically use technological devices, without disregarding technical and policy flexibility, and should be closely related to inter-subjectivity and ethics, in order to develop emancipating capabilities. An action having this structure could make it easier to achieve Universality, Equity and Integrality.

Complete removable prostheses: from expectation to (dis)satisfaction.

OBJECTIVE: The purpose of this survey was to increase our knowledge on the experience and feelings of edentulous people, 6 months after having acquired and worn a pair of complete removable prostheses. BACKGROUND: The incorporation of conventional, complete removable prostheses may be an appropriate treatment which can result in an improvement in the quality of life of people who have lost their teeth. METHODS: The 12 patients of the sample were interviewed individually according to a semi-structured questionnaire so as to create an atmosphere for open conversation regarding the subject matter. For each participant, photographs, before dental treatment and after the use of the prostheses, were taken. The images of the prostheses were reviewed and impressions were collected. RESULTS: The analysis of participant's statements allowed one to verify if the complete removable prostheses improved the quality of life; however, difficulties encountered could lead users to abandon their prostheses. CONCLUSION: Appropriate investment on the part of health professionals, together with the clarification of information and the monitoring of patients, may well minimise these difficulties.