Recomendação nº 046, de 11 de outubro de 2018: recomenda ao Ministério da Saúde que realize a alocação de créditos financeiros suplementares ao Programa Anual de Saúde (PAS) 2018, de modo, a garantir o cumprimento das metas das ações e serviços de saúde bucal previstas e não executadas do PAS 2017, no caso, as ações relativas à ampliação e qualificação da atenção especializada em saúde bucal, uma das linhas estratégicas da PNSB, por meio da implantação adicional (além da prevista para este ano) de 52 (cinquenta e dois) Centros de Especialidades Odontológicas (CEO) e 196 (cento e noventa e seis) Laboratórios Regionais de Prótese Dentária (LRPD) nos estados e municípios, bem como, na qualificação do acompanhamento técnico e na definição dos critérios de repasses federais / Recommendation No. 046, of October 11, 2018: recommends to the Ministry of Health to allocate supplementary financial credits to the Annual Health Program (PAS) 2018, in order to ensure compliance with the goals of oral health actions and services foreseen and not executed by PAS 2017, in this case, the actions related to the expansion and qualification of specialized oral health care

Recomenda ao Ministério da Saúde que realize a alocação de créditos financeiros suplementares ao Programa Anual de Saúde (PAS) 2018, de modo, a garantir o cumprimento das metas das ações e serviços de saúde bucal previstas e não executadas do PAS 2017, no caso, as ações relativas à ampliação e qualificação da atenção especializada em saúde bucal, uma das linhas estratégicas da PNSB, por meio da implantação adicional (além da prevista para este ano) de 52 (cinquenta e dois) Centros de Especialidades Odontológicas (CEO) e 196 (cento e noventa e seis) Laboratórios Regionais de Prótese Dentária (LRPD) nos estados e municípios, bem como, na qualificação do acompanhamento técnico e na definição dos critérios de repasses federais; que cumpra, de forma integral, ou seja, em 100%, a execução financeira prevista na PAS 2018 em ações e serviços de saúde bucal; que cumpra, de forma integral, as metas do Plano Nacional de Saúde 2016-2019 para as ações de saúde bucal e estabeleça, no Plano Nacional de Saúde 2020-2023, metas anuais de ampliação do número de Equipes de Saúde Bucal (ESB) implantadas na Atenção Básica de modo a garantir o completo equilíbrio na proporção entre o número destas e das Equipes de Saúde da Família (ESF) e a ampliação da cobertura das ações de saúde bucal da população brasileira; que execute, de forma integral, os R$ 344 milhões em ações e serviços de saúde bucal anunciados pelo governo em 2017 por meio da adição de R$ 152 milhões à título de crédito suplementar à PAS 2018; que a área técnica do Ministério da Saúde apresente ao CNS e torne público relatório pormenorizado dos gastos relativos à fluoretação das águas de consumo; e que empenhe, de forma imediata, os recursos orçamentários e financeiros previstos no orçamento de 2018 relativos a execução do Levantamento Epidemiológico de Saúde Bucal SB 2020. Aos Conselhos Estaduais e Municipais de Saúde: Que sejam convocadas, nestas instâncias, representações das Coordenações Estaduais de Saúde Bucal e das Comissões Intersetoriais Bipartites (CIB) e se paute a necessidade de construção de mecanismos de acompanhamento, nos estados e municípios, do processo de credenciamento e implantação dos Centros Especializados de Odontologia e Laboratórios Regionais de Prótese Dentária.

Management of dental caries among children: a look at the cost-effectiveness.

INTRODUCTION: Dental caries is the most prevalent non-communicative disease worldwide. Although the etiological factors are well known for years, reducing the number of decayed and missing teeth in children still remains as a barrier. Preventive and curative options are numerous but little is known about their economical advantages. Selecting the intervention that offers the best balance of effectiveness and financial resources becomes crucial in the current situation of budget restrictions worldwide. AREAS COVERED: This expert review summarizes available evidence on cost-effectiveness analyses of preventive and curative measures to manage dental caries in children. EXPERT COMMENTARY: Preventive measures have been more extensively studied than dental caries treatment. Only water fluoridation and tooth brushing are well-established as cost-effective preventive approaches. Despite the increasing number of cost analysis treatment studies in the literature, most of them focus on the cost description, with no correlation to the intervention effectiveness. There is a current need of well-designed and well-reported cost-effectiveness regarding dental caries management.

[Multiple aspects of the use of fluorine in public health from the viewpoint of healthcare leaders]. / Múltiplos aspectos do uso do flúor em saúde pública na visão de lideranças da área de saúde.

The article describes the perceptions of health care leaders on issues relating to the use of fluorine in public health. This is a descriptive study with a qualitative approach, using Collective Subject Discourse (DCS) as technique for processing the statements. The study population was comprised of delegates to the 13th National Health Conference; the sample was defined by convenience and consisted of 310 delegates: 56 at municipal level in Fortaleza (CE), 143 at state level (Ceará) and 111 at national level. Data were collected by semi-structured questionnaires. There were gaps in knowledge about various aspects of the use of fluorine in public health, which indicates the need to improve the level of information of society on issues relating to fluoridation. The lack of knowledge of delegates, together with the data found in the literature about the shortcomings in the monitoring and control of fluorine levels in water, are indicative of the need to reassess the role of social actors and the mechanisms used in social control.

Múltiplos aspectos do uso do flúor em saúde pública na visão de lideranças da área de saúde / Multiple aspects of the use of fluorine in public health from the viewpoint of healthcare leaders

O artigo descreve as percepções de lideranças da área de saúde sobre aspectos relativos ao uso do flúor em saúde pública. Trata-se de uma pesquisa descritiva, com abordagem qualitativa, utilizando-se como técnica de processamento de depoimentos o Discurso do Sujeito Coletivo (DSC). A população de estudo foi constituída pelos delegados à 13ª Conferência Nacional de Saúde, sendo a amostra definida por conveniência e composta por 310 delegados: 56 na etapa municipal, em Fortaleza (CE), 143 na estadual (Ceará) e 111 na nacional. Os dados foram coletados por meio de questionários semiestruturados. Verificaram-se lacunas de conhecimento sobre diversos aspectos do uso do flúor em saúde pública, o que indica a necessidade de se melhorar o nível de informação da sociedade sobre questões relativas à fluoretação. O desconhecimento dos delegados aliado aos dados encontrados na literatura sobre as deficiências no monitoramento e controle dos níveis de flúor na água são indicativos da necessidade de se reavaliar o papel dos atores sociais e dos mecanismos utilizados no controle social.

The article describes the perceptions of health care leaders on issues relating to the use of fluorine in public health. This is a descriptive study with a qualitative approach, using Collective Subject Discourse (DCS) as technique for processing the statements. The study population was comprised of delegates to the 13th National Health Conference; the sample was defined by convenience and consisted of 310 delegates: 56 at municipal level in Fortaleza (CE), 143 at state level (Ceará) and 111 at national level. Data were collected by semi-structured questionnaires. There were gaps in knowledge about various aspects of the use of fluorine in public health, which indicates the need to improve the level of information of society on issues relating to fluoridation. The lack of knowledge of delegates, together with the data found in the literature about the shortcomings in the monitoring and control of fluorine levels in water, are indicative of the need to reassess the role of social actors and the mechanisms used in social control.

Evaluación económica del programa de fluoración del agua de beber en Chile / Economic evaluation of the fluoridation program of drinking water in Chile

El propósito de este estudio fue realizar un Análisis Costo-Efectividad (ACE), desde el punto de vista social, de añadir fluoruros al agua de beber para prevenir caries dentales en niños de 12 años de edad, versus el status-quo, en la realidad chilena. Método: En un ACE, los costos de programas alternativos se miden y los resultados se valoran en unidades de efectividad. Para el caso, dientes con historia de caries dental, usando el índice de dientes cariados, obturados o perdidos debido a caries dental (COPD). La comparación se hizo respecto de un grupo no expuesto a fluoruración del agua. Todos los costos y los beneficios se calcularon desde una perspectiva de análisis económico social. Los datos sobre efectividad se obtuvieron de la literatura. Los costos de tratamientos dentales se calcularon usando aranceles de referencia. Costos en gastos a nivel familiar en términos de pérdida de producción, viajes hacia/desde el dentista se tomaron en cuenta. Los costos y beneficios se descontaron usando una tasa de descuento del 3 por ciento. Resultados: El costo de la intervención, sobre la estrategia de no intervención se comparó con los beneficios obtenidos por la intervención. El cociente costo-efectividad indica que, en promedio, este programa dio lugar a ahorros en Pesos Chilenos (2009) (RCH$) de 8.930,49 por diente afectado por caries evitado. Esta mejora se alcanzó a un costo anual de RCH$ 841,33 por niño. Conclusiones: Considerando nuestros supuestos y para situaciones equivalentes a las que prevalecen en Chile, un programa de fluoruración del agua representa un uso eficiente de los recursos de la comunidad.

Objective: This paper models the cost-effectiveness, from a social viewpoint, of a dental caries prevention program for children 12 years of age using water fluoridation, compared with non intervention (or status quo).Method: In cost-effectiveness analysis (CEA,) the costs of alternative programs are measured as economic costs and the results are valued in units of effectiveness. In this case, teeth with history of dental caries were measured using the DMFT index. The control group was a group that was not exposed to water fluoridation. Data on effectiveness were obtained from the literature. Costs of dental treatments were calculated using current established prices. Family expenses for the treatment were based on lost income, as well as transport costs to and from the clinic. The costs and benefits were calculated using a discount rate of 3 percent. Results: To find the cost of the intervention, the non-intervention strategy was compared to the additional benefits gained as a result of the intervention. The cost-effectiveness ratio indicates that on average, this program saved $ 8,930.49 Chilean pesos at the 2009 value (RCH$) per cavity-affected tooth. This was achieved with an annual cost of RCH$ 841.33 per child. Conclusions: Taking into account our assumptions, for situations similar to those in Chile, a water fluoridation program would be an efficient use of community resources.

Economic evaluation of preventive dental programs: what can they tell us?

The role of public health program planners is to determine the effectiveness of public health programs, what recommendations should be made, what future initiatives should be taken, and what policies should be developed. At a basic level, to choose between competing alternatives, two characteristics of an intervention must be considered; these are its outcome and its cost. Based on cost and outcome, planners must select the option that offers the most advantages. Economic evaluation is commonly adopted by decision makers in the health sector to investigate the effectiveness of public health programs and to help plan future initiatives. Economic evaluation assists decision makers who must weigh the information it provides in the context of many and often competing options. In this way, an economic evaluation is an aid to decision making rather than the decision itself. Economic evaluation is becoming essential for informed decision making, with potential implications for public health policy and practice and for clinical practice too. While economic evaluations are commonly used in decision-making processes about health programs, few examples exist in the oral health literature. In the case of preventive oral health programs, economic analysis is often difficult, largely because it makes demands on epidemiological and demographic data that are hard to meet. This study will address the concepts and tools required to conduct economic evaluations of prevention programs. The emphasis will be on oral health and preventive dental programs, although the concepts presented could be useful for other public health programs by practitioners and managers with the aim of producing effective and efficient oral health programs.

Cost-effectiveness models for dental caries prevention programmes among Chilean schoolchildren.

AIM: This study aims to estimate the cost-effectiveness from a societal perspective of seven dental caries prevention programmes among schoolchildren in Chile: three community-based programmes: water-fluoridation, salt-fluoridation and dental sealants; and four school-based programmes: milk-fluoridation; fluoridated mouthrinses (FMR); APF-Gel, and supervised toothbrushing with fluoride toothpaste. METHODS: Standard cost-effectiveness analysis methods were used. The costs associated with implementing and operating each programme, using a societal perspective, were identified and estimated. The comparator was non-intervention. Health outcomes were measured as dental caries averted over a 6-year period. Costs were estimated as direct treatment costs, programmes costs and costs of productivity losses as a result of each dental caries prevention programme. Incremental cost-effectiveness ratios were calculated for each programme. Sensitivity analyses were conducted over key parameters. RESULTS: Primary cost-effectiveness analysis (discounted) indicated that four programmes showed net social savings by the DMFT averted. These savings encompassed a range of values per diseased tooth averted; US$16.21 (salt-fluoridation), US$14.89 (community water fluoridation); US$14.78 (milk fluoridation); and US$8.63 (FMR). Individual programmes using an APF-Gel application, dental sealants, and supervised tooth brushing using fluoridated toothpaste, represent costs for the society per diseased tooth averted of US$21.30, US$11.56 and US$8.55, respectively. CONCLUSION: Based on cost required to prevent one carious tooth among schoolchildren, salt fluoridation was the most cost-effective, with APF-Gel ranking as least cost-effective. Findings confirm that most community/school-based dental caries interventions are cost-effective uses of society's financial resources. The models used are conservative and likely to underestimate the real benefits of each intervention.

[Cost of fluoridating the public water supply: a study case in the city of São Paulo, Brazil, 1985-2003]. / Custo da fluoretação das águas de abastecimento público, estudo de caso--Município de São Paulo, Brasil, período de 1985-2003.

The aim of this study was to estimate the cost of fluoridating the public water supply in the city of São Paulo, Brazil, from 1985 to 2003. Cost calculation for fluoridation of the public water supply used the following: capital cost of initial installation, chemical product (hydrofluosilicic acid), system's operational cost (maintenance, electricity, and human resources), and monitoring fluoride levels. Fluoridation was effective, since there was a decrease of 73% in dental caries in 12-year-olds--mean DMF was 6.47 (6.12-6.82) in 1986, having decreased to 1.75 (1.48-2.92) in 2002. In this age group, 40% of children presented DMF = 0 in 2002. Average cost per inhabitant/year for 2003 was R$ 0.08 (USD 0.03). The accumulated cost for 18 years of implementation and maintenance of the fluoridation system was R$ 1.44 (USD 0.97) per capita.

Custo da fluoretação das águas de abastecimento público, estudo de caso ¡ Município de São Paulo, Brasil, período de 1985-2003 / Cost of fluoridating the public water supply: a study case in the city of São Paulo, Brazil, 1985-2003

O objetivo do artigo é estimar o custo da fluoretação das águas de abastecimento público no Município de São Paulo no período de 1985-2003. Para o cálculo da composição de custos da fluoretação das águas levou-se em conta os seguintes custos: (a) capital inicial de instalação; (b) produto químico (ácido fluorsilícico); (c) operacionalização do sistema (manutenção do sistema, energia elétrica e recursos humanos); e (d) controle dos teores de flúor. A ação do flúor mostrou-se efetiva, pois para a idade de 12 anos observou-se redução de 73 por cento na experiência de cárie dentária, sendo que em 1986 a média do índice CPO-D era de 6,47 (6,12-6,82) e em 2002 foi de 1,75 (1,48-2,92). Nesta idade-índice 40 por cento das crianças apresentaram CPO-D = 0 em 2002. O custo médio per capita/ano na Cidade de São Paulo foi de R$ 0,08 (US$ 0,03) em 2003. O custo acumulado em 18 anos de implantação do sistema de fluoretação foi de R$ 1,44 (US$ 0,97) per capita.

Inequality of water fluoridation in Southern Brazil--the inverse equity hypothesis revisited.

The purpose of this ecological study was to investigate the association between social and economic indicators at the municipal level and the presence of water fluoridation and time when water fluoridation was implemented in the 293 municipalities of Santa Catarina State in Southern Brazil. Several social and economic indicators were obtained from official Brazilian agencies as well as from UNICEF. Questionnaires were sent to local authorities and to the local government water supply Company to obtain information about the presence or not of a fluoridated water supply and the year when fluoridation was implemented. Differences in social and economic indicators between municipalities with and without fluoridated water and between those that have had this service for different lengths of time were compared by the Mann-Whitney U test. In addition, multiple logistic regression analyses was performed to identify associations between social and economic indicators at the municipal level and presence and time of implementation of water fluoridation. Results indicated that larger populations are associated with municipalities with fluoridated water. Larger populations, higher child development indexes and low illiteracy rates are associated with a longer time since the implementation of water fluoridation. The finding that less developed municipalities delayed the provision of water fluoridation corroborates the inverse equity hypothesis.

[Caries prevention through a nutritional vehicle]. / La prevención de caries a través de un vehículo nutricional.

In order to evaluate the efficacy of fluoridated milk as a cariostatic nutritional product, the biological and technical possibilities of adding fluoride (F) as monofluorophosphate (MFP) to milk were studied, together with a preliminary cost estimation for this procedure. F ingestion by preschool children pertaining to the low and medium-low levels of population was estimated through polls and chemical analyses. The values of F ingestion obtained were in the range of 0.15-0.30 mg/day. The bioavailability of F in those dietary elements which have the highest F concentration was determined. Taking a value of 1.00 for F absorption from sodium fluoride (NaF) in water, relative values of 0.58 and 0.32 were obtained for tea ingestion on a fasting stomach, and together with solid food, respectively. The corresponding value for fish was 0.34. Through another bioavailability experiment it was shown that the absorption of F (from MFP) in milk, is as high as that of F (from NaF) in water. By means of a comparative cost estimation study, it was found that, for the Chilean situation, milk fluoridation is, at least, 1,000 times more economic than water fluoridation. It is concluded that milk fluoridation is an economical and viable alternative for some less developed countries.