Uso de fluoretos em nível populacional: aspectos científicos e normativos no Brasil e na Colômbia / Fluorides use at the population level: scientific and normative aspects in Brazil and Colombia

OBJETIVO: Produzir uma análise comparativa sobre as diretrizes relativas ao uso de fluoretos como estratégia de saúde pública no Brasil e na Colômbia, antes e depois da aprovação do direito à saúde nas constituições dos dois países. MÉTODO: O estudo foi executado em três fases. Na primeira, foi realizada uma revisão narrativa com busca sistemática de artigos científicos e dispositivos normativos relativos ao uso de fluoretos em cada país durante o período prévio à inserção do direito à saúde na Constituição. Para o período posterior à promulgação das Constituições, foi feita uma análise documental qualitativa com uma amostra intencional de documentos normativos de estratégias para o uso de fluoreto. Os dispositivos normativos selecionados foram submetidos à análise de conteúdo, considerando regras e ferramentas para aumentar a cobertura e implementar mecanismos regulatórios de vigilância. Depois, foram efetuadas entrevistas semiestruturadas com informantes chave ligados ao campo científico e às instituições de saúde pública, com conhecimentos e experiência em diretrizes do uso de fluoretos. Os principais alcances, limitações e desafios do uso de fluoretos em cada país foram identificados. RESULTADOS: Antes da Constituição, em ambos os países havia intensa interação entre organizações governamentais, pesquisadores, lideranças acadêmicas e profissionais, e ainda entre empresas ligadas ao saneamento e à produção do sal de cozinha. Depois da Constituição, notou-se que a atenção à saúde bucal estava consolidada na agenda normativa e institucional da saúde em ambos os países. A fluoretação do sal na Colômbia apresentava deficiências na vigilância, bem como na vigilância do teor natural de fluoreto na água. O programa de vigilância de exposição aos fluoretos foi interrompido, assim como a ferramenta de vigilância da aplicação tópica de verniz de fluoreto, cuja cobertura ainda era muito baixa. No Brasil existiam desigualdades regionais na cobertura e na vigilância da fluoretação da água. A regulação de dentifrícios fluoretados precisava ser aprimorada em ambos os países. Na Colômbia, as entrevistas apontaram desafios relacionados à vigilância da fluoretação do sal, atualização das regulamentações sobre o sal, preocupações sobre a interrupção do sal enquanto veículo de acesso ao fluoreto, cobertura de verniz fluoretado, acesso e disseminação de informações. No Brasil, os desafios estavam relacionados à expansão da fluoretação da água para as regiões Norte e Nordeste, e ao aprimoramento dos meios de monitoramento e vigilância da água e do dentifrício fluoretados. CONCLUSÕES: Antes da Constituição, as estratégias de uso de fluoretos nos dois países passaram por um estágio inicial de características semelhantes, e depois se diferenciaram enquanto opções de política pública de uso sistêmico/tópico de fluoretos. No Brasil, a opção recaiu no ajuste da concentração do fluoreto na água, enquanto na Colômbia, a adição do fluoreto ao sal de cozinha se consolidou enquanto política pública. Embora ambos os países tenham uma estrutura legal que apoia a continuidade dos programas de fluoretação, há razões econômicas, logísticas e políticas que afetam o monitoramento, a avaliação e o aprimoramento desses programas. É necessária uma maior aproximação entre pesquisadores e agências governamentais a fim de permitir o aprimoramento, tanto dos meios de monitoramento da exposição, quanto dos mecanismos para assegurar a vigilância oportuna das estratégias. Arranjos e dispositivos promotores da coordenação intergovernamental e intersetorial são necessários para superar as barreiras decorrentes das diferenças geográficas dentro de cada país e entre o setor saúde e os setores responsáveis pela implementação das políticas (o saneamento no Brasil e a indústria salineira na Colômbia).

OBJECTIVE: To produce a comparative analysis of the guidelines on the use of fluorides as a public health strategy in Brazil and Colombia, before and after the approval of the right to health in the constitutions of both countries. METHOD: The study was carried out in three phases. In the first one, a narrative review was carried out with a systematic search of scientific articles and normative provisions relating to the use of fluorides in each country during the period prior to the inclusion of the right to health in the Constitution. For the period following the promulgation of the Constitutions, a qualitative documentary analysis was carried out with an intentional sample of normative documents on strategies for the use of fluoride. The selected normative provisions were subjected to content analysis, considering rules and tools for increasing coverage and implementing regulatory surveillance mechanisms. In-depth semi-structured interviews were then carried out with key informants linked to the scientific field and public health institutions, with knowledge and experience in fluoride use guidelines. The main achievements, limitations and challenges of fluoride use in each country were identified. RESULTS: Before the Constitution, in both countries there was intense interaction among government organizations, researchers, academic and professional leaders, and also between companies linked to sanitation and the production of table salt. After the Constitution, it was identified that the attention to oral health was consolidated in the health normative and institutional agenda in both countries. Salt fluoridation in Colombia had deficiencies in surveillance, as well as in the surveillance of the natural fluoride content in water. The fluoride exposure surveillance program had been discontinued, as well as the surveillance tool for the topical application of fluoride varnish, which coverage was still very low. In Brazil there were regional inequalities in the coverage and surveillance of water fluoridation. The regulation of fluoridated toothpastes needed to be improved in both countries. In Colombia, the interviews pointed out challenges related to monitoring salt fluoridation, updating salt regulations, concerns about the interruption of salt as a fluoride access vehicle, fluoride varnish coverage, access and dissemination of information. In Brazil, the challenges were related to water fluoridation expansion to North and Northeast regions and, the monitoring and surveillance means of water and fluoridated toothpaste. CONCLUSIONS: Before the Constitution, fluoride use strategies in the two countries went through an initial stage of similar characteristics, later on, differed in terms of the public policy options for the systemic/topic use of fluorides. In Brazil, the option was to adjust the concentration of fluoride in the water, while in Colombia, the addition of fluoride to table salt was consolidated as a public policy. Although both countries have a legal framework that supports the continuity of fluoridation programs, there are economic, logistical and political reasons that affect the monitoring, evaluation and improvement of these programs. A major closeness between researchers and governmental agencies is needed, for both, the monitoring means of exposition and the mechanisms to ensure an opportune surveillance of strategies is shared by everyone. Arrangements and promoting devices of intergovernmental and intersectoral coordination are needed to overcome the barriers arising from geographical differences in each country and, between health sector and sectors responsible for policies implementation (sanitation in Brazil and the salt industry in Colombia).

Public Policies for Fluoride Use in Colombia and Brazil before and during the Adoption of the Right to Health.

The use of fluorides is essential in the prevention of dental caries, considered to be the main dental public health problem. The formulation and implementation of public health policies can vary from country to country, depending on multiple factors. This study aims to analyze the interaction model between the knowledge produced about the use of fluorides and its implementation through public policies in two South American countries until the period of constitutional reform in each country. A narrative review was conducted with a systematic search of scientific articles and normative devices regarding the use of fluorides in public health in each country during the period prior to the implementation of the right to health in the Constitution. In both countries, there was an intense interaction among governmental organizations, researchers, academic and professional leaders, and companies involved in sanitation and salt production. Fluoride use strategies in Brazil and Colombia after an initial stage of similar characteristics began to differ in terms of public policy options for systemic fluoride use. In Brazil, the option was to adjust the concentration of fluoride in the water, while in Colombia, the addition of fluoride to table salt was consolidated as a public policy.

Effect of birth weight and nutritional status on transverse maxillary growth: Implications for maternal and infant health.

We analyzed the association between birthweight, nutritional status and transverse maxillary growth in 7- to 9-year-old schoolchildren. We undertook a cross-sectional survey nested in a population-based cohort study of 158 schoolchildren. The participants lived in the urban area of a small town within the Western Brazilian Amazon. The outcome was represented by the upper intermolar distance given in millimeters (mm), as an indicator of the degree of maxillary bone growth in its transverse dimension. The exposures were sex, birthweight, the bottle-feeding pattern operationalized by a scale corresponding to the age of introduction of the bottle and Body Mass Index-for-age z-score (BAZ) at 4 to 6 ys. Path analysis was employed to estimate standardized direct, indirect and total effects of exposures on the outcome using structural equations model (SEM) supported by Mplus 7 program. The values of standardized coefficients (SC) showed significant direct positive effects of sex (SC = 0.203; p = 0.006), birth weight (SC = 0.155; p = 0.030) and BAZ (SC = 0.165; p = 0.014) on transverse maxillary growth. The indirect effects (SC = 0.057; p = 0.012) and the total effect (SC = 0.261; p<0.001) of sex on the outcome were statistically significant. The indirect effects of birth weight on the outcome were not significant (SC = 0.018; p = 0.488), however, the total effect was significant (SC = 0.174; p = 0.011). In conclusion, sex, birthweight, bottle beginning age and BAZ showed association with the transverse growth of the maxillary bone. In addition to contributing to an adequate birth weight of the child, policies and programs that favor prenatal care and conditions to guarantee a full-term birth can positively affect transverse growth of the maxilla. From a Public Health Surveillance point of view, children with reduced birthweight, inadequate breastfeeding pattern and nutritional deficit for age may be more likely to develop atrophy of the jaws which, depending on the severity, may result in malocclusion with an important impact on quality of life.