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.

The door is open, but not everyone may enter: racial inequities in healthcare access across three Brazilian surveys.

Health policies in Brazil have sought to expand healthcare access and mitigate inequities, but recent revisions of their content have weakened the Brazilian Unified Health System. This study estimates three healthcare indicators across three national surveys conducted in 2008, 2013, and 2019 to assess the impact of changes to the National Primary Care Policy on racial inequities in healthcare. Considering the survey design and sampling weights, we estimated the prevalence of each outcome among both whites and Blacks for the whole country, and according to the Brazilian regions. We test the following hypotheses: compared to whites, Blacks showed higher frequency of coverage by the Family Health Strategy, lower frequency of health insurance coverage, and higher frequency of perceived difficulty accessing health services (H1); Racial inequities decreased in the ten-year period but remained constant between 2013-2019 (H2); Racial gaps have widened among regions with lower proportions of Blacks (H3). Our findings fully support H1, but not H2 and H3. Racial inequities either remained constant or decreased in the 2013-2019 period. By downplaying the importance of the universality and equity principles, the latest revision of the National Primary Care Policy has contributed to the persistence of racial inequities in healthcare.

The door is open, but not everyone may enter: racial inequities in healthcare access across three Brazilian surveys / A porta está aberta, mas nem todos podem entrar: iniquidades raciais no acesso à saúde em três inquéritos brasileiros

Abstract Health policies in Brazil have sought to expand healthcare access and mitigate inequities, but recent revisions of their content have weakened the Brazilian Unified Health System. This study estimates three healthcare indicators across three national surveys conducted in 2008, 2013, and 2019 to assess the impact of changes to the National Primary Care Policy on racial inequities in healthcare. Considering the survey design and sampling weights, we estimated the prevalence of each outcome among both whites and Blacks for the whole country, and according to the Brazilian regions. We test the following hypotheses: compared to whites, Blacks showed higher frequency of coverage by the Family Health Strategy, lower frequency of health insurance coverage, and higher frequency of perceived difficulty accessing health services (H1); Racial inequities decreased in the ten-year period but remained constant between 2013-2019 (H2); Racial gaps have widened among regions with lower proportions of Blacks (H3). Our findings fully support H1, but not H2 and H3. Racial inequities either remained constant or decreased in the 2013-2019 period. By downplaying the importance of the universality and equity principles, the latest revision of the National Primary Care Policy has contributed to the persistence of racial inequities in healthcare.

Resumo As políticas de saúde no Brasil têm buscado expandir o acesso e mitigar as iniquidades, mas recentes revisões de seu conteúdo enfraqueceram o Sistema Único de Saúde. Este estudo estima três indicadores de saúde em três inquéritos nacionais, realizados em 2008, 2013 e 2019, para avaliar o impacto das mudanças na Política Nacional de Atenção Básica sobre as iniquidades raciais na saúde. Considerando o desenho da pesquisa e os pesos amostrais, estimou-se a prevalência de cada desfecho entre indivíduos brancos e negros para todo o país e segundo suas macrorregiões. Testamos as hipóteses: comparados aos brancos, negros apresentaram frequência maior de cobertura pela Estratégia Saúde da Família, menor de cobertura de plano de saúde e maior de dificuldade de acesso aos serviços (H1); as iniquidades raciais diminuíram no período de dez anos, mas estagnaram entre 2013-2019 (H2); as iniquidades raciais aumentaram entre as regiões com menores proporções de negros (H3). Os resultados apoiam integralmente H1, mas não H2 e H3. As iniquidades raciais permaneceram estáveis ou diminuíram entre 2013-2019. Ao contrapor os princípios de universalidade e equidade, a última revisão da Política Nacional de Atenção Básica contribuiu para a persistência das iniquidades raciais na saúde.

Mapping the Margins in Health Services Research: How Does Race Intersect With Gender and Socioeconomic Status to Shape Difficulty Accessing HealthCare Among Unequal Brazilian States?

Research on healthcare inequities has centralized whether marginalized racial, gender, or socioeconomic (SES) groups are afforded equitable access to care, yet scant investigations have focused on how race intersects with other social statuses to shape difficulty accessing health services. Contextual specificity has also been under-researched in this field of knowledge. Data from 59,249 respondents 18 years of age and over from the 2013 Brazilian National Health Survey were analyzed using multilevel regressions models. We test 3 hypotheses: racial, gender, and socioeconomically oppressed groups are each more likely to report difficulty accessing health services (H1); compared to high-SES white men, low-SES Black women report expressively higher frequencies of the outcome (H2); and intersectional healthcare inequities are larger among low-SES Brazilian states (H3). Partially supporting H1 and H2, results suggest that race and SES, but not gender, are each strong predictors of difficulty accessing healthcare, with low-SES Black respondents facing the highest odds of reporting this outcome. Although H3 was not supported, intersectional groups residing in low-SES Brazilian states were more likely to report difficulty accessing healthcare. This study demonstrated that, together with contextual specificity, the intersections of race with other axes of marginalization should be at the forefront of research and policy addressing healthcare inequities.

Orofacial trauma and mouthguard use in Brazilian rugby union players.

BACKGROUND/AIM: Rugby union represents a high-risk sport for orofacial trauma due to its impact collisions and repetitive tackles. The aim of this study was to investigate the prevalence of orofacial trauma according to mouthguard use among a sample of Brazilian rugby union players. METHODS: An online questionnaire was sent to the 16 best rugby union clubs in Brazil. The questionnaire contained questions about the training history of each athlete, prevalence of orofacial trauma, and details about mouthguard use. Only participants who reported using a mouthguard were selected for this analysis. RESULTS: A total of 244 individuals were included. The prevalence of orofacial trauma was 34.4%, and 61.9% of them did not wear a mouthguard at the time of the incident. The only type of mouthguard reported was the pre-fabricated ("boil and bite" and "ready-to-wear") type. A stronger association was observed between the reason for using a mouthguard and the outcome, whereas a lower proportion of trauma was observed among individuals who claimed mandatory mouthguard use at the gym/sport (20.0%). Time since the respondent started playing rugby union and who instructed them to use a mouthguard were not associated with orofacial trauma. CONCLUSION: Prevalence of orofacial trauma was high among this sample of rugby union players from Brazil, even with the use of pre-fabricated mouthguards. This study encourages further investigation on the use of custom-made mouthguards in rugby union and the role of coach/physical educators to reduce the prevalence of orofacial trauma.

Racial inequalities in public dental service utilization: Exploring individual and contextual determinants among middle-aged Brazilian adults.

OBJECTIVES: To investigate differences between Pardos (mixed) and Blacks with their White counterparts in the use of public dental service among a sample of Brazilian adults taking into consideration the role of individual and contextual characteristics. METHODS: A total of 6196 adults aged 35-44 years were sampled from the 2010 Brazilian National Oral Health Survey and nested in one of 27 Brazilian State Capitals. Binary multilevel logistic analyses were conducted. Use of public dental service in the last visit was the outcome, and self-reported colour/race (Pardo, Black, White) was the explanatory variable. Individual covariates were sex, level of education, family income, self-reported need for treatment, dental pain in the last 6 months, presence of decayed, filled and missing teeth. The State Capital covariates were proportion of Pardos/Blacks, Human Development Index, Gini coefficient, Integration of dental teams into Brazil Family Health Program and dentist per population rate. RESULTS: Pardos and Blacks were 1.25 (95% CI 1.10-1.42) and 1.73 (95% CI 1.41-2.11) times, respectively, more likely to visit the public dental service than Whites. Adjustments for level of education and income were more relevant in affecting the estimates between groups than any other covariate, but differences persisted. Colour/race was independently associated with the type of service used in the last dental visit after fully adjusted for individual and State Capital characteristics. CONCLUSIONS: Racial differences in dental service utilization were evident for middle-aged adults in Brazil. The results found highlight the importance of investments in public dental service as Pardos and Blacks relied more on this type of service than Whites.

Trends in dental caries rates over 45 years (1971-2016) among schoolchildren in Florianópolis, southern Brazil.

OBJECTIVE: The present study aimed to estimate the prevalence and severity of dental caries in schoolchildren from Florianópolis, southern Brazil, in 2016, as well as to compare these findings with data obtained from six previous studies carried out in the same school since 1971. METHODS: A cross-sectional study was conducted with 133 schoolchildren, 12 and 13 years of age. Clinical data were collected by three previously calibrated examiners, according to the 2013 World Health Organization diagnostic criteria, in order to estimate the mean count of decayed, missing and filled teeth/surfaces (DMFT/DMFS indexes) and the Significant Caries Index (SiC). RESULTS: The study response rate was 87.2% (n = 116), and the prevalence of dental caries decreased from 98.0% (95% CI: 96.0-100.0) in 1971 to 39.6% (95% CI 30.7-49.2) in 2016. The mean DMFT index fell from 9.2 in 1971 to 0.9 in 2016, while the DMFS index ranged from 2.0 (95% CI: 1.2-2.8) in 2009 to 1.5 (95% CI: 1.0-1.9) in 2016. The SiC index, which was 3.4 (95% CI: 3.0-3.8) in 2002, reached 2.5 (95% CI: 2.0-2.9) in 2016. CONCLUSION: Over the 45 years of monitoring, a significant decline in rates of dental caries has been observed. However, the SiC index suggests that dental caries lesions are unequally distributed in the study sample, with one-third of the schoolchildren showing a significantly higher mean DMFT score compared with the entire sample.

To Extract or to Restore the Tooth? Color/Race and Clinical Decision Making among Undergraduate Dental Students from Southern Brazil

Objective: To evaluate whether the color/race of a hypothetical patient is associated with the clinical decision to extract or restore a specific tooth, as well as with the recommendation for additional procedures for its adequate treatment. Material and Methods: Respondents assessed an anterior tooth with an extensive carious lesion and were asked: whether it should be extracted or restored; how much time should be spent in the first consultation; whether or not root canal retreatment was necessary; and whether complementary exams should be requested. While a Black hypothetical patient was assessed in the first stage of data collection, a White individual was subsequently shown to the study respondents. Results: The clinical decision on whether to extract or restore the decayed tooth was not associated with the patient's color/race (p=0.64). The mean time estimated for the first clinical consultation (p=0.28), the need for root canal retreatment (p=0.56), as well as the request for complementary exams were not associated with the patient's color/race (p=0.82). Analyses stratified by the participants' characteristics confirmed the lack of such an association. Conclusion: As opposed to previously published findings in Brazil, the patient's color/race was not associated with clinical decision making among undergraduate dental students.

Trends in dental caries among Brazilian schoolchildren: 40 years of monitoring (1971-2011).

The study aimed to estimate the prevalence, severity, and inequality in the distribution of dental caries in schoolchildren from Florianópolis, Santa Catarina, Brazil, in 2011, and to compare the results with data from previous studies carried out since 1971. All 12- and 13-year-old schoolchildren enrolled in a public school were eligible. Dental caries were assessed according to the World Health Organisation diagnostic criteria. Decayed, missing and filled surfaces and teeth (DMFS/DMFT) indexes, the Significant Caries Index (SiC) and the Gini coefficient (to assess inequalities in the distribution of dental caries) were estimated. The response rate was 82.3% (n = 130). The prevalence of dental caries decreased from 98.0% (95% CI 96.0-100.0) in 1971 to 36.9% (95% CI 28.5-45.3) in 2011. The mean DMFT ranged from 9.2 in 1971 to 0.7 in 2011. The mean DMFS index was 1.2 (95% CI 0.8-1.6) in 2011. The Gini coefficient was 0.624 in 2002 but increased to 0.725 in 2011; the Lorenz curve showed that 70-75% of dental caries attacks was restricted to 20% of the population in 2011. A reduction of 41.2% in the mean SiC index was observed between 2002 (3.4, 95% CI 3.0-3.8) and 2011 (1.9, 95% CI 1.6-2.1). An effective decline in the prevalence and severity of dental caries in schoolchildren was observed throughout 40 years of monitoring. However, a small proportion of the population has experienced most of the caries burden in the recent years studied.

Trends in dental caries in 12- and 13-year-old schoolchildren from Florianópolis between 1971 and 2009

Aim: To estimate the prevalence and severity of dental caries in schoolchildren from the city of Florianópolis, SC, Brazil, in 2009 and to compare these results with data from previous studies carried out in the same institution since 1971. Methods: All 145 12- and 13-year-old school children enrolled in a public school were eligible for the study. Dental caries was assessed with the DMFS/DMFT indexes, the significant caries index (SiC) and their 95% confidence intervals (CI 95%).Results: The response rate was 68.2%. The DMFT ranged from 9.2 in 1971 to 0.78 in 2009,although different diagnostic criteria were adopted to estimate these counts. The prevalence of dental caries declined from 98.0% (CI 95% 96.0-100.0) in 1971 to 43.5% (CI 95% 33.7-53.4) in2009. There was a reduction of 47% in the mean SiC index between 2002 and 2009, i.e. from 3.4(CI 95% 3.0-3.8) to 1.8 (CI 95% 1.5-2.1). The mean DMFS index was 2.0, and it was composed of an average of 1.8 and 0.2 decayed and filled surfaces, respectively. Conclusions: Even though different diagnostic criteria were adopted during the study period, an effective decline in the prevalence and severity of dental caries in adolescents was observed throughout 38 years of monitoring.