Brazilian primary dental care in a universal health system: Challenges for training and practice.

OBJECTIVES: To report the challenges for training and practice for the Brazilian primary dental care in a universal health system. METHODS: Health, education and protection rights against poverty are guaranteed by the 1988 Brazilian Constitution and public health in Brazil is provided by the Unified Health System (SUS), one of the largest public health systems in the world. According to SUS, every Brazilian citizen has the right to free primary oral health care as secondary and tertiary care, offering a unique opportunity to integrate oral care within general health care. RESULTS: The Brazilian undergraduate Dental curriculum was updated in 2021 aiming to graduate general practitioners with a major in comprehensive health care in primary health care, integrated with public and general health. This curriculum update requires at least 20% of the academic hours to be exercised outside the university walls (extramural or community work), preferably within the SUS. CONCLUSIONS: Considering the World Health Organization (WHO) agenda, Brazil needs to advance the innovative oral health workforce, the integration of oral health into primary care, the population access to essential dental medicines and optimal fluorides for caries control. CLINICAL SIGNIFICANCE: It is necessary political action and the engagement of multiple stakeholders, mainly from the health and education sectors, to improve primary health care.

Machine learning to predict untreated dental caries in adolescents.

OBJECTIVE: This study aimed to predict adolescents with untreated dental caries through a machine-learning approach using three different algorithms METHODS: Data came from an epidemiological survey in the five largest cities in Mato Grosso do Sul, Brazil. Data on sociodemographic characteristics, consumption of unhealthy foods and behaviours (use of dental floss and toothbrushing) were collected using Sisson's theoretical model, in 615 adolescents. For the machine learning, three different algorithms were used: (1) XGboost; (2) decision tree and (3) logistic regression. The epidemiological baseline was used to train and test predictions to detect individuals with untreated dental caries, through eight main predictor variables. Analyzes were performed using the R software (R Foundation for Statistical Computing, Vienna, Austria). The Ethics Committee approved the study.. RESULTS: For the 615 adolescents, xgboost performed better with an area under the curve (AUC) of 84% versus 81% for the decision tree algorithm. The most important variables were the use of dental floss, unhealthy food consumption, self-declared race and exposure to fluoridated water. CONCLUSIONS: Family health teams can improve the work process and use artificial intelligence mechanisms to predict adolescents with untreated dental caries, and, in this way, schedule dental appointments for the treatment of adolescents earlier.

Racial inequality in complete dental prosthesis delivered: can public services reduce inequities?

OBJECTIVES: To investigate the association between access and delivery of complete dental prosthesis according to the proportion of the black population in Brazilian municipalities and to oral health policies. MATERIALS AND METHODS: Ecological data from 2017 to 2021 relating to the delivery of complete dentures stratified by race was collected in all Brazilian cities. We calculated a racial inequality indicator by subtracting the percentage of the black population from the percentage of complete dental prostheses that were delivered to blacks in each municipality. Logistic and linear regression models were carried out. RESULTS: We found that 49.2% (2737) of municipalities delivered complete prostheses. The service was more frequently available in municipalities where black individuals made up 20-80% (odds ratio [OR] = 1.45, 95% confidence interval [CI] 1.15; 1.81), those with dental specialty centers (DSC) (OR = 3.04, 95%CI 2.50; 3.68), and those with more oral health teams (OHTs) (OR = 3.43, 95%CI 2.81; 4.18). Where dental prostheses were available, racial inequities favored the white population by 7.7 percentage points (p < 0.01). Increased inequality was observed in municipalities with more OHTs and/or a higher proportion of black individuals (>80%). CONCLUSIONS: Although municipalities with a DSC, and with more OHTs offer better access to complete dental prosthesis for blacks, racial inequality still impacts the delivery of the service. Primary and secondary healthcare services may even exacerbate this. CLINICAL RELEVANCE: Policymakers should monitor racial inequities in healthcare services. The currently unmet needs of black people are critical, especially in cities with more OHTs and/or increased proportions of black people.

Last dental visit and severity of tooth loss: a machine learning approach.

The aims of the present study were to investigate last dental visit as a mediator in the relationship between socioeconomic status and lack of functional dentition/severe tooth loss and use a machine learning approach to predict those adults and elderly at higher risk of tooth loss. We analyzed data from a representative sample of 88,531 Brazilian individuals aged 18 and over. Tooth loss was the outcome by; (1) functional dentition and (2) severe tooth loss. Structural Equation models were used to find the time of last dental visit associated with the outcomes. Moreover, machine learning was used to train and test predictions to target individuals at higher risk for tooth loss. For 65,803 adults, more than two years of last dental visit was associated with lack of functional dentition. Age was the main contributor in the machine learning approach, with an AUC of 90%, accuracy of 90%, specificity of 97% and sensitivity of 38%. For elders, the last dental visit was associated with higher severe loss. Conclusions. More than two years of last dental visit appears to be associated with a severe loss and lack of functional dentition. The machine learning approach had a good performance to predict those individuals.

Regulation of dental consultations in primary health care and performance of services in dental speciality centers.

OBJECTIVE: This study analyzed the regulation of dental specialty centers (CEOs) coordinated exclusively by Primary Health Care (PHC) in four primary outcomes: access and dental consultation, reception services, bonding and responsibility, and social participation. METHODS: A cross-sectional study was carried out using secondary data from the National Program for the Improvement of Access and Quality of Dental Specialty Centers (PMAQ-CEO): second cycle, using multilevel logistic regression to calculate the odds ratio (OR) and individual covariates. RESULTS: The analytical sample consisted of 9,599 CEO users who had completed all the variables analyzed. Of these, 63.5% were referred to the CEO by PHC. Dental care regulated by PHC was related to better access (OR 1.36, CI 95% 1.10-1.68), better reception (OR 1.33, CI 95% 1.03-1.71), better bonding and responsibility (OR 1.36, CI 95% 0.91-2.04), and social participation (OR 1.13, CI 95% 0.93-1.35) compared to those not regulated by primary health care as the exclusive pathway. CONCLUSION: The regulation of access to the CEO coordinated by PHC presented the best performance. It is suggested that this form of PHC regulation, as a route for dental specialty centers, can be established in the national oral health care policy for better service performance.

Validation of pairs of antagonist teeth for the evaluation of shortened dental arch in epidemiological studies.

The aim of this study was to evaluate the accuracy of pairs of antagonist teeth (epidemiological criterion) for defining pairs of teeth in occlusal contact (clinical criterion) and to estimate the agreement between the prevalence of "shortened dental arch" (SDA) and "functional dentition" (FD) when occlusal units (OUs) or posterior occluding pairs (POPs) are defined by the epidemiological or clinical criterion. Data were collected in an epidemiological oral health survey conducted in a municipality in Minas Gerais, Brazil. OUs and POPs were defined by the epidemiological criterion (dental crown status) or clinical criterion "gold standard" (carbon paper record of occlusal contacts during habitual maximum intercuspation). SDA corresponded to the presence of an intact anterior region and three to five OUs. FD was based on the concomitant presence of ≥ 1 tooth in each arch, 10 teeth in each arch, 12 anterior teeth, ≥ 3 premolar POPs, and ≥ 1 molar POP bilaterally. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of the epidemiological criterion were calculated. The study included 197 adults. Sensitivity, specificity, PPV, and NPV were 88.5, 87.9, 92.5, and 81.9%, respectively, and accuracy was 88.3%. The epidemiological criterion proved to be valid and could be used in epidemiological studies to calculate the prevalence of reduced dental configurations that consider POPs. The assessment of oral functionality is an aspect that should be included in the diagnosis of the clinical condition of patients, contributing to a more effective individual and collective oral health care plan.

Sedentary behaviour and traumatic dental injuries in adolescents: A population-based study.

OBJECTIVE: Analyse factors associated with dental trauma in 12-year-old adolescents. METHODS: An epidemiological survey was carried out in the five largest cities in the state of Mato Grosso do Sul, Brazil. Data on traumatic dental injuries (TDI) based on the World Health Organization (WHO), sociodemographic characteristics and individual clinical and behavioural characteristics in 615 adolescents were collected. Univariate and adjusted multilevel logistic regressions were performed to test the association of dental trauma with behavioural and sociodemographic factors. The study was approved by the Ethics Committee (CAAE number 85647518.4.0000.0021). RESULTS: The prevalence of TDI at 12 years was 3.4% (95% CI 1.8; 6.4). In the adjusted models, clinical characteristics of adolescents such as overjet >3 mm (OR = 1.51 [95% CI 1.00; 2.41]) were associated with trauma. Sociodemographic characteristics such as female sex (OR = 0.13 [95% CI 0.07; 0.25]), income above the poverty level (OR = 0.34 [95% CI 0.15; 0.78]), who declared themselves white (OR = 0.23 [95% CI 0.11; 0.47]) and with sedentary behaviour (OR = 0.69 [95% CI 0.59; 0.80]) were associated with trauma, as protective factors. CONCLUSION: Sociodemographic, behavioural and individual clinical characteristics were associated with TDI in adolescents. Oral health teams should focus on the most vulnerable groups, encouraging the use of mouthguards and access to treatment services.

Associated factors of prosthetic rehabilitation in specialized dental care in Brazil: a cross-sectional study.

OBJECTIVE: This study aimed to analyze the individual and contextual factors associated with prosthetic rehabilitation in Dental Specialty Centers (DSC) in Brazil. A cross-sectional study, with secondary data from modules II and III of the External Assessment of the 2nd Cycle of the National Program for the Improvement of Access and Quality (PMAQ) of DSCs, was conducted in 2018. Individual variables considered were socioeconomic conditions and perceptions about the structure and service of the DSC. Contextual variables were related to DSC. We considered the region of the country (capital or countryside), geographic location and work process of the DSC for prosthetic rehabilitation. The association between individual and contextual variables and prosthetic rehabilitation in the DSC was analyzed by multilevel logistic regression. RESULTS: Ten thousand three hundred ninety-one users from 1,042 DSC participated. Of these, 24.4% used dental prosthesis and 26.0% performed at the DSC. In the final analysis, performed dental prostheses in the DSC individuals with less education (OR = 1.23; CI95%:1.01-1.50) and residents of the same city as the DSC (OR = 1.69; CI95%:1.07-2.66), at a contextual level, DSCs of the countryside (OR = 1.41; CI95%:1.01-1.97) were associated with the outcome. Individual and contextual factors were associated with prosthetic rehabilitation in the DSC.

Explaining income inequities in tooth loss among Brazilian adults.

OBJECTIVE: To determine the extent to which individual and contextual variables explain income inequities in tooth loss in Brazilian adults. METHODS: A nationally representative sample of 65,784 Brazilian adults aged 18-59 who participated in the Brazilian National Health Survey 2019 was analyzed. Self-reported tooth loss was the outcome. Per capita income was the main exposure, and minimum wage was the cutoff point. Individual covariates included sex, race, and schooling, dental visits, smoking status, use of dental floss, and self-reported chronic conditions. Contextual covariates included access to treated water and geographic region of residence. Blinder-Oaxaca decomposition analysis was used to estimate the share of each factor in income-related tooth loss inequities by age groups. RESULTS: Age-standardized tooth loss showed large income inequities. The average difference in tooth loss related to income inequities in the 18-34-year-old group was 0.50 (95% CI 0.39; 0.60), increasing to 4.51 (95% CI 4.09; 4.93) in the 45-59 years. Individual and contextual covariates explained almost 90% of income inequities in the 45-59 year group. Use of dental floss, schooling, and geographic region of residence (a proxy for human development level) had a higher proportion of contribution to the inequities examined. CONCLUSIONS: Individual and contextual covariates (proxy for human development level and water fluoridation coverage) explained a large share of income-related tooth loss inequities. Tailored strategies to act at both levels can help reduce tooth loss inequities among Brazilian adults.

Tooth loss severity and core and non-core food consumption among older Brazilian adults.

OBJECTIVE: To investigate the association between tooth loss severity and core and non-core food consumption in the older Brazilian population. METHODS: We analysed data from 20 756 people aged 60 years or older who participated in the 2019 Brazilian National Health Survey. The average consumption days a week of core (8-item) and non-core (4-item) foods were the outcomes, measured using a Food Frequency Questionnaire. Tooth loss severity was the main exposure, using a four-category ordinal variable: mild (1-12 teeth missing), moderate (13-22), severe (23-31) and edentulous (all 32). Sociodemographic, tobacco smoking, use of dental prosthesis, difficulty in chewing and systemic conditions were among the covariates. Linear regression models estimated the association between tooth loss and food consumption. RESULTS: Almost two-thirds of participants had moderate or worse levels of tooth loss. Older adults with more severe tooth loss reported an overall lower consumption of core and higher non-core foods than those with mild tooth loss. Worse tooth loss severity was associated with lower consumption of vegetables and/or legumes and fruits, and higher consumption of beans, artificial fruit juices and confectionery. CONCLUSIONS: Older Brazilian adults with more severe tooth loss are consuming lower core and higher non-core foods. Our findings reinforce the importance of the common risk factor approach to tackle the adverse effects of tooth loss on diet.

Validation of pairs of antagonist teeth for the evaluation of shortened dental arch in epidemiological studies

Abstract The aim of this study was to evaluate the accuracy of pairs of antagonist teeth (epidemiological criterion) for defining pairs of teeth in occlusal contact (clinical criterion) and to estimate the agreement between the prevalence of "shortened dental arch" (SDA) and "functional dentition" (FD) when occlusal units (OUs) or posterior occluding pairs (POPs) are defined by the epidemiological or clinical criterion. Data were collected in an epidemiological oral health survey conducted in a municipality in Minas Gerais, Brazil. OUs and POPs were defined by the epidemiological criterion (dental crown status) or clinical criterion "gold standard" (carbon paper record of occlusal contacts during habitual maximum intercuspation). SDA corresponded to the presence of an intact anterior region and three to five OUs. FD was based on the concomitant presence of ≥ 1 tooth in each arch, 10 teeth in each arch, 12 anterior teeth, ≥ 3 premolar POPs, and ≥ 1 molar POP bilaterally. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of the epidemiological criterion were calculated. The study included 197 adults. Sensitivity, specificity, PPV, and NPV were 88.5, 87.9, 92.5, and 81.9%, respectively, and accuracy was 88.3%. The epidemiological criterion proved to be valid and could be used in epidemiological studies to calculate the prevalence of reduced dental configurations that consider POPs. The assessment of oral functionality is an aspect that should be included in the diagnosis of the clinical condition of patients, contributing to a more effective individual and collective oral health care plan.

Factors associated with physical activity levels in adolescents / Factores asociados a los niveles de actividad física en adolescentes / Fatores associados ao nível de atividade física em adolescentes

ABSTRACT Objective: to analyze the factors associated with physical activity levels in adolescents. Method: cross-sectional, quantitative study, conducted with adolescents enrolled in two educational institutions in a capital of the midwest region of Brazil. Data collection occurred from April to October 2021, through a self-administered questionnaire composed of validated scales. The association between the variables was verified by logistic regression. Results: 219 adolescents participated in the study, with a mean age of 15.7 years, more than half were girls (52.5%) from medium economic class (51.1%); 55.3% were very active/active; 39.3% had low self-esteem; 17.8% were at risk for developing an eating disorder; 12.3% at risk for severe anxiety symptoms; and 13.3% at risk for moderate depression symptoms. The factors associated with the level of physical activity were self-esteem and risk for depression. Conclusion: Early screening of adolescents with low self-esteem and risk for symptoms of depression is proposed as an initial strategy to direct actions that encourage the practice of physical activity.

RESUMEN Objetivo: analizar los factores asociados a los niveles de actividad física en adolescentes. Método: estudio transversal, cuantitativo, realizado con adolescentes matriculados en dos instituciones educativas de una capital de la región Centro-Oeste de Brasil. La recolección de datos ocurrió de abril a octubre de 2021, a través de un cuestionario autoadministrado compuesto por escalas validadas. La asociación entre las variables se verificó por regresión logística. Resultados: Participaron del estudio 219 adolescentes, con una edad media de 15,7 años, más de la mitad eran niñas (52,5%) de clase económica media (51,1%); el 55,3% eran muy activos/activos; el 39,3% tenía baja autoestima; el 17,8% tenían riesgo de desarrollar un trastorno alimentario; 12,3% en riesgo de síntomas de ansiedad severa; y 13,3% en riesgo de síntomas de depresión moderada. Los factores asociados al nivel de actividad física fueron la autoestima y el riesgo de depresión. Conclusión: El cribado precoz de adolescentes con baja autoestima y riesgo de síntomas depresivos puede constituir una estrategia inicial para encaminar acciones que incentiven la práctica de actividad física.

RESUMO Objetivo: analisar os fatores associados ao nível de atividade física em adolescentes. Método: estudo transversal, de abordagem quantitativa, realizado com adolescentes matriculados em duas instituições de ensino de uma capital da região Centro-Oeste brasileira. A coleta de dados ocorreu no período de abril a outubro de 2021, por meio de questionário autoaplicado composto por escalas validadas. A associação entre as variáveis foi verificada por meio de regressão logística. Resultados: participaram do estudo 219 adolescentes, com média de idade de 15,7 anos, mais da metade eram meninas (52,5%) e de classe econômica média (51,1%); 55,3% eram muito ativo/ativo; 39,3%, com autoestima baixa; 17,8% apresentaram risco para desenvolver transtorno alimentar; 12,3% risco para sintomas de ansiedade grave; e 13,3%, risco para sintomas de depressão moderada. Os fatores associados ao nível de atividade física foram a autoestima e o risco para depressão. Conclusão: O rastreamento precoce de adolescentes com baixa autoestima e risco para sintomas de depressão pode constituir estratégia inicial para direcionar ações de estímulo à prática de atividade física.

Factors associated with the absence of Brazilians in specialized dental centers.

AIM: To identify the individual and contextual factors associated with the absence of Brazilians at a scheduled appointment in Dental Specialties Centers (DSC). METHODS: This cross-sectional design uses the National Program for Improving Access and Quality of Dental Specialties Centers database, 2018. The outcome was the users' lack of at least one of the scheduled appointments. Contextual and individual independent variables were used, considering Andersen's behavioural model. The analyses were performed with the R Core Team and SAS (Studio 3.8, Institute Inc, North Carolina, U.S, 2019) programs. RESULTS: Of the 10,391 patients interviewed, 27.7% missed at least one of the consultations. In the adjusted multivariate model, the interpretation based on the effect size and 95% CI showed that the behaviour individual predisposing factors such as age ≤ 42 years (OR = 1.10; 95%CI:1.01-1.21), individual need factors such as participation in the "Bolsa Família" program (OR = 1,14; 95%CI:1.02-1.27), not being covered by the Family Health Strategy (OR = 1.15; 95% CI:1.02-1.30), and users of periodontics services (OR = 1.22;95%CI:1.05-1.40) were associated with absences. The behavioural factor associated with the outcome was that the DSC facilities were not in good condition (OR = 1.18; 95%CI:1.03-1.34). DSC located in the capital (OR = 1.12; 95% CI: 0.92-1.48) were 12% more likely to have dental absences than those in the interior region. CONCLUSION: There are individual and contextual barriers associated with patients not attending specialised public dental consultations. DSC should offer adequate hours to patients, especially young adults and vulnerable people.

Ultra-processed food consumption and dental caries in children and adolescents: a systematic review and meta-analysis.

This study summarised the association between ultra-processed food (UPF) consumption and dental caries in children and adolescents through a systematic review and meta-analysis. The search of PubMed, Cochrane, Web of Science and Scopus databases using the 'PECOS' strategy retrieved 1462 eligible articles. Only studies with humans aged ≤ 19 years; that assessed groups of any UPF or specific UPF items; that measured dental caries as the decayed, filled and missing surfaces or teeth indexes, based on the WHO criteria; cross-sectional, case-control, cohort and all types of interventions that examined the adjusted association between UPF consumption and dental caries were included. All studies received qualitative evaluation. Meta-analysis using random-effects models combined multivariable-adjusted OR for case-control and cross-sectional studies and risk ratio (RR) for longitudinal studies of the highest v. lowest category of UPF consumption. Forty-two studies were included in the qualitative synthesis and twenty-seven in the meta-analysis. The pooled RR was 1·71 (95 % CI 1·31, 2·24), and the pooled OR was 1·55 (95 % CI 1·37, 1·75). The highest OR was found among participants who had dental caries prevalence >70 % (OR = 3·67, 95 % CI 2·16, 6·23). Better evidence quality was found among cohort studies that evaluated children <6 years old. The findings suggest that higher UPF consumption is associated with greater dental caries in children and adolescents. Public health efforts to reduce UPF consumption are needed to improve the oral health of children and adolescents.

Attributes of primary health care in Mato Grosso do Sul state: PCAT-Brazil paired for users and health professionals, 2018.

OBJECTIVE: The objective of the present study was to analyse the quality of adults and older adults health care in Primary Health Care (PHC) services in the State of Mato Grosso do Sul, 2018. METHODS: A quantitative survey was carried out in which the municipalities participating in the study included the four macro-regions following the Director Regional Plan (DRP). In this study, the quality of care was verified using the validated version of the PCAT-Br for adult and older adults users over 18 years of age and professionals. The professional's and users' views were compared between PHC attributes in the State of Mato Grosso do Sul. We performed the paired student t-test. STATA v.14.2 software (College Station, TX, USA) was used for the analyses. Sensitivity analysis was done to compare socio-demographic characteristics. RESULTS: Eight hundred twenty-five users and 424 professionals participated in the study. According to users, the Accessibility attribute had the worst performance in all macro-regions (mean score PCAT = 3.58). There were significant differences between the perception of users and professionals (PCAT = 5.32 for users and PCAT = 7.11 for professionals) in all attributes evaluated. CONCLUSIONS: There was a difference in users' and professionals' perceptions between PHC attributes. Therefore, it is necessary to strengthen PHC care networks in the State, mainly considering the users' perspectives.

Impact of water fluoridation on dental caries decline across racial and income subgroups of Brazilian adolescents.

OBJECTIVES: The aim of this study was to assess the impact of community water fluoridation (CWF) on differences in dental caries decline across racial and socioeconomic subgroups of Brazilian adolescents. METHODS: Two nationwide Brazilian population-based oral health surveys were used (Brazilian Oral Health Survey 2003 and 2010). In total, 7,198 adolescents from 15 years to 19 years old living in 50 cities investigated in both surveys were included. The mean numbers of untreated decayed teeth (DT) according to racial (Whites vs. Browns/Blacks) and socioeconomic subgroups (at or above the minimum wage per capita vs. under) were analysed. Difference-in-differences negative binomial regressions were adjusted by schooling, age, and sex. Decayed, missing, and filled teeth and DT prevalence, calculated as a categorical variable, were used in sensitivity analyses. RESULTS: The adjusted difference of reduction in DT was similar across socioeconomic subgroups (ß=-0.05; 95% confidence interval [CI], -0.45 to 0.35) and favoured, but not to a significant degree, Whites (ß=-0.34; 95% CI, -0.74 to 0.04) compared to Brown/Blacks in fluoridated areas. In non-fluoridated areas, significant differences were observed in the mean number of DT, favouring the higher socioeconomic subgroup (ß=-0.26; 95% CI, -0.53 to -0.01) and Whites (ß=-0.40; 95% CI, -0.69 to -0.11) in relation to their counterparts. The sensitivity analyses confirmed the findings. CONCLUSIONS: The similar reduction in DT across income subgroups suggests that CWF has had a beneficial effect on tackling income inequalities in dental caries within a 7-year timeframe.

Health ombudsman and racial inequities in Dental Specialities Centers performance in Brazil: A multilevel analysis.

OBJECTIVE: This study aimed to verify racial differences in the performance of Dental Specialities Centers in Brazil, according to the presence of active health ombudsman on four primary outcomes: (1) access and dental appointment, (2) reception services, (3) bond and responsibility, and (4) social participation. METHODS: Data came from the PMAQ-CEO national evaluation of public healthcare services, 2018-2019. The two main explanatory variables were the self-classified race at the individual level and the presence of the health ombudsman at the second level (level of services provision). Individual covariates included age, sex and schooling. Multilevel logistic regression was used to calculate the OR (Odds Ratios) in racial gaps according to the primary outcomes with individuals at the first level and public health services at the second level. RESULTS: The analytical sample comprised of 8993 respondents. Brown people were less likely to report better Access (27%), good reception services (31%), bond and responsibility (30%) and social participation (22%) than Whites. Black people showed similar patterns. Dental Specialities Centers that use health ombudsman for planning have attenuated racial inequities in all analysed dimensions. CONCLUSIONS: Dental Specialities Centers that use active health ombudsman for planning showed lower racial inequities in access, reception, bond and responsibility and social participation than those who did not use. Therefore, the health ombudsman should be implemented and used for planning better specialized dental services in Brazil.

Intersectoral collaboration and coordination mechanisms for implementing water fluoridation: Challenges from a case study in Brazil.

OBJECTIVES: Community water fluoridation has been associated with better oral health conditions globally and reduced dental caries. While oral health policies are governed by the health sector agenda, water fluoridation is undertaken by public, private, and mixed public/private companies of the sanitation sector. The first aim of this study was to investigate the degree of intersectoral collaboration, and the second was to investigate how the coordination mechanisms are perceived by the sanitation agents of the sectors involved in water quality management, for the potential establishment of water fluoridation in a central-west state in Brazil. METHODS: Semi-structured interviews were conducted with chief sanitation agents from nonprofit, profit, and mixed public/private companies responsible for water quality and fluoridation in a purposive sample. Theoretical frameworks of intersectoral collaboration and coordination mechanisms were used for analysis. RESULTS: Twelve interviews were conducted. Informal collaboration was identified in the sanitation sector within companies involved in water provision. The main coordination mechanisms were network-type mechanisms, which involve consultations and knowledge sharing, and market-type mechanisms, which explore new job opportunities and cost-effectiveness, especially in water quality measures. Enabling themes (enablers) were identified, such as positive attitude toward including water quality and fluoridation in a collaborative health and sanitation common agenda. Moreover, fluoridation did not meet the regulatory and surveillance agenda at the state level, and until that moment, there was no proposal of the health sector for water fluoridation. CONCLUSIONS: Partnership creation, consolidation, and shared mission, especially between health and sanitation sectors, were identified as main challenges for implementing water fluoridation policy.

Does water fluoridation influence ethnic inequalities in caries in Brazilian children and adolescents?

OBJECTIVES: This study aimed to investigate the influence of community water fluoridation on ethnic inequalities in untreated dental caries among children and adolescents in Brazil while taking the human development context into account. METHODS: Data from a nationwide Brazilian epidemiological population oral health survey were used (SB Brazil 2010). Outcomes were caries prevalence measured by the proportion of individuals with one or more untreated decayed teeth and caries severity defined by the mean number of untreated decayed teeth (DT). Three different contexts were considered: 1-cities with no water fluoridation; 2-cities with water fluoridation and low Human Development Index (HDI); and 3-cities with water fluoridation and high HDI. The exposure was ethnic/racial group (White, Pardo, Black) and covariates were age, sex and household income. Multilevel logistic and negative binomial regressions were performed with 6696 children (aged 5 years) and 11 585 adolescents (aged 12 and 15-19 years). RESULTS: For both children and adolescents, ethnic differences in caries prevalence and mean DT were found in the nonfluoridated cities with low HDI and also in cities with high HDI, most of which were fluoridated. For example in nonfluoridated cities with low HDI, 5-year-old Pardo children were more likely to have untreated decay (OR = 1.22; 95% CI: 1.02, 1.46) and had more decayed teeth (RR = 1.18; 95% CI: 1.04, 1.34) than their White counterparts after adjusting for sex and household income. No statistically significant differences were observed in fluoridated cities with low HDI. CONCLUSION: Water fluoridation appears to be associated with reduced ethnic inequalities in dental caries prevalence and mean DT among children and adolescents in more disadvantaged settings.