Level of natural fluoride in public water supply: geographical and meteorological factors in Brazil's Northeast.

This study analyzed the relationships between the concentration of natural fluoride in public water supply and meteorological and hydrographic factors in a northeastern region of Brazil. This was a descriptive, analytical, ecological, longitudinal, and field study conducted by collecting water in 23 municipalities (2019 to 2020) of four macroregions of Paraíba (Brazil): coast (1), borborema (2), agreste (3), and outback (4). Four collection sites were selected per municipality: two near and two distant from the water treatment plant. Fluoride concentration was determined using a combined ion-specific electrode and classified according to the Collaborating Center of the Ministry of Health in Oral Health Surveillance. Meteorological, hydrographic, and population characteristics were also collected. All analyzed samples showed natural fluoride; macroregions 2 and 4 showed the highest mean fluoride concentration, macroregion 4 presented the highest mean temperature, and all macroregions showed a similar pattern of precipitation. The mean fluoride concentration of the four macroregions was below the appropriate value to prevent caries. An increase in precipitation would decrease the fluoride concentration in water. In conclusion, the concentration of natural fluoride varied according to meteorological and hydrographic factors. The concentration in surface waters increased during periods of low precipitation. Therefore, this study provided important information to support implementation of community water fluoridation in this region.

Dental care for persons with disabilities: discretion on the frontline.

OBJECTIVE: To depict the influence of discretionary actions exercised by frontline professionals and organizations on the implementation of diverse modalities of access to specialized dental care within the Care Network for Persons with Disabilities. METHODS: A case study conducted in two Brazilian health regions characterized by distinct means of access to specialized dental care employing documentary analysis and interviews with key stakeholders across the period spanning from July to December 2019. RESULTS: In the referenced access region, there was a notable centrality of Primary Health Care (PHC) in caregiving, wherein planning and assessment were integral components of institutional routines. Where spontaneous demand scheduling was accepted, sporadic exchanges of information were evident between PHC units and specialized facilities. The coordination role in caregiving was not vested in PHC teams, and activities such as planning and assessment were not assimilated into organizational routines. CONCLUSIONS: The implementation of policies for specialized dental care for persons with disabilities relied on the coordination furnished by PHC and the orchestration of planning and assessment endeavors aimed at establishing an integrated care network. This implementation proved subject to the discretionary authority of frontline professionals and organizations, highlighting the significant role of relational and institutional environments in the context of public policy implementation within a decentralized and regionalized healthcare system.

The Trajectory of Brazilian Immunization Program between 1980 and 2018: From the Virtuous Cycle to the Vaccine Coverage Decline.

BACKGROUND: Public health policies are crossed by economic and political interests that can affect the maintenance of the immunization programs and their vaccination coverages. The aim was to investigate the political and economic conditions that marked the trajectory of the Brazilian immunization program from 1980 to 2018. METHODS: Documentary research gathered data on public expenditures with epidemiological surveillance and vaccine procurement and nationwide estimates of vaccine coverage. The scientific literature on the program's implementation and the country's political and economic conditions was examined. The theoretical approach was based on historical institutionalism. RESULTS: The results showed rising, high rates maintaining and falling vaccination coverages in the period. As of 2010, there was a tendency for a reduction in total federal spending on epidemiological surveillance, putting pressure on the budgets of the sub-national governments in their respective areas of coverage, and on federal spending in dollars for the acquisition of immunobiologicals and inputs. CONCLUSIONS: The amplitude and complexity of the program's trajectory have been crossed by diverse dynamics conditioned by economic and political interests reflecting at a deeper level the advance of capitalism through fiscal austerity measures over democracy's aspirations for greater balance and justice in the distribution of resources.

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.

Level of natural fluoride in public water supply: geographical and meteorological factors in Brazil's Northeast

Abstract This study analyzed the relationships between the concentration of natural fluoride in public water supply and meteorological and hydrographic factors in a northeastern region of Brazil. This was a descriptive, analytical, ecological, longitudinal, and field study conducted by collecting water in 23 municipalities (2019 to 2020) of four macroregions of Paraíba (Brazil): coast (1), borborema (2), agreste (3), and outback (4). Four collection sites were selected per municipality: two near and two distant from the water treatment plant. Fluoride concentration was determined using a combined ion-specific electrode and classified according to the Collaborating Center of the Ministry of Health in Oral Health Surveillance. Meteorological, hydrographic, and population characteristics were also collected. All analyzed samples showed natural fluoride; macroregions 2 and 4 showed the highest mean fluoride concentration, macroregion 4 presented the highest mean temperature, and all macroregions showed a similar pattern of precipitation. The mean fluoride concentration of the four macroregions was below the appropriate value to prevent caries. An increase in precipitation would decrease the fluoride concentration in water. In conclusion, the concentration of natural fluoride varied according to meteorological and hydrographic factors. The concentration in surface waters increased during periods of low precipitation. Therefore, this study provided important information to support implementation of community water fluoridation in this region.

Dental care for persons with disabilities: discretion on the frontline / Assistência odontológica à pessoa com deficiência: discricionariedade na linha de frente

ABSTRACT OBJECTIVE To depict the influence of discretionary actions exercised by frontline professionals and organizations on the implementation of diverse modalities of access to specialized dental care within the Care Network for Persons with Disabilities. METHODS A case study conducted in two Brazilian health regions characterized by distinct means of access to specialized dental care employing documentary analysis and interviews with key stakeholders across the period spanning from July to December 2019. RESULTS In the referenced access region, there was a notable centrality of Primary Health Care (PHC) in caregiving, wherein planning and assessment were integral components of institutional routines. Where spontaneous demand scheduling was accepted, sporadic exchanges of information were evident between PHC units and specialized facilities. The coordination role in caregiving was not vested in PHC teams, and activities such as planning and assessment were not assimilated into organizational routines. CONCLUSIONS The implementation of policies for specialized dental care for persons with disabilities relied on the coordination furnished by PHC and the orchestration of planning and assessment endeavors aimed at establishing an integrated care network. This implementation proved subject to the discretionary authority of frontline professionals and organizations, highlighting the significant role of relational and institutional environments in the context of public policy implementation within a decentralized and regionalized healthcare system.

RESUMO OBJETIVO Descrever a influência da discricionariedade dos profissionais e organizações da linha de frente na implementação de diferentes formas de acesso à assistência odontológica especializada na Rede de Cuidados à Pessoa com Deficiência. MÉTODOS Estudo de caso em duas regiões de saúde brasileiras cujo acesso à assistência odontológica especializada era distinto, com análise documental e entrevista com atores-chave, entre julho e dezembro de 2019. RESULTADOS Na região com acesso referenciado, observou-se que a atenção primária à saúde (APS) tinha centralidade no cuidado e o planejamento/avaliação faziam parte da rotina institucional dos serviços. Na região onde o agendamento era possível por demanda espontânea, notou-se trocas episódicas de informação entre as unidades de APS e as especializadas; o papel de coordenação do cuidado não era um atributo das equipes de APS e as atividades de planejamento/avaliação não estavam incorporadas à rotina das organizações. CONCLUSÕES A implementação da política de assistência odontológica especializada à pessoa com deficiência se mostrou dependente da coordenação da APS e da condução de atividades de planejamento/avaliação voltadas à construção de uma rede de cuidados integrada e sujeita ao poder discricionário dos profissionais e das organizações da linha de frente, sugerindo que o ambiente relacional e institucional possui um papel importante no processo de implementação de políticas públicas em um sistema descentralizado e regionalizado de saúde.

Adverse oral conditions associated with worse emotional and social well-being of Brazilian teenagers: a population-based study in a deprived rural-urban boundary / Condições bucais adversas associadas a pior bem-estar emocional e social de adolescentes brasileiros: um estudo de base populacional em uma periferia rural-urbana negligenciada

Abstract Background The relationship between dental appearance and emotional/social well-being in underprivileged areas undergoing rapid urbanization is unknown. Objective To assess if the emotional and social well-being of teenagers living in urban areas might be more affected by unfavorable dental appearance determined by oral conditions. Method A population-based cross-sectional exploratory study with 12-year-old Brazilian schoolchildren was carried out in two poor, underserviced districts of Sao Paulo City, Brazil. Outcome was severity of oral health-related quality of life (QHRQoL) due to the emotional and social well-being and exposures were oral conditions and residence district (rural or urban). Results The impact on severity of QHRQoL due to emotional well-being and due to social well-being, respectively, were 14% and 16% higher for those presenting at least one untreated decayed tooth; 36% and 54% higher for those with unfavorable dental appearance and 25% and 39% higher for those from the urban district. No association between malocclusion and district was observed. Conclusion Despite higher prevalence of untreated dental caries in the rural district, teenagers from the urban district felt that their OHRQoL, adjusted by oral conditions investigated, was more negatively affected. This suggests that urban environmental influences can lead to stressful social pressures stemming from dental appearance, leading to diminished emotional and social well-being.

Resumo Introdução A relação entre aparência dentária e bem-estar emocional/social em áreas carentes com urbanização acelerada é desconhecida. Objetivo Avaliar se o bem-estar emocional e social de adolescentes residentes em área urbana pode ser mais impactado pela aparência dentária desfavorável controlada pelas condições bucais. Método Um estudo exploratório transversal de base populacional envolvendo escolares brasileiros de 12 anos foi realizado em dois bairros carentes foi realizado, na cidade de São Paulo, Brasil. O desfecho foi a gravidade da qualidade de vida relacionada à saúde bucal (QVRSB) devido ao bem-estar emocional e social, e as exposições foram condições bucais e distrito de residência (rural e urbano). Resultados O impacto sobre a gravidade da QVRSB em decorrência do bem-estar emocional e do bem-estar social, respectivamente, foi 14% e 16% maior para aqueles que apresentavam pelo menos um dente cariado não tratado; 36% e 54% maior para aqueles com aparência dentária desfavorável e 25% e 39% maior para aqueles moradores em distrito urbano. Nenhuma associação entre má oclusão e distrito foi observada. Conclusão Apesar da maior prevalência de cárie dentária não tratada no distrito rural, os adolescentes do distrito urbano sentiram-se mais afetados negativamente em sua qualidade de vida relacionada à saúde bucal ajustada pelas condições bucais, sugerindo que as possíveis influências do ambiente urbano podem trazer experiências sociais estressantes devido à aparência dentária impactando no bem-estar emocional e social.

The Use of Fluorides in Public Health: 65 Years of History and Challenges from Brazil.

Untreated dental caries is the most common disease globally and fluoride use at the population level is crucial for its control. To investigate the economic and political conditions under which the trajectory of population-based fluoride use has occurred is key for a more comprehensive view on its current and future challenges. The objective was to give a brief history and summarize the information on the use of fluorides at the population level in Brazil from 1952 to 2017 and to point to current and future challenges. A critical overview was undertaken based on country-level analyses comprising political and economic conditions. The analytical approach adopted a set of premises applicable to the study of capitalist democracies. Fluoride methods of systemic and topic use began to be employed in Brazilian public health programs in the 1950s and in a combined way from 1974. Differences in political and economic contexts were highlighted for four periods: the first interventions from 1952 to 1974, when the fluoridated water law was approved; the expansion after 1974 until 1988, when a new constitution was enacted; the following time until 2010; and the final period. From the 1980s to 2008, water fluoridation coverage increased progressively, consolidating as a major strategy of systemic use in spite of inequalities among territories. Activities aimed to promote access to topical fluoride use increased and maintained stability until 2014, when they dropped sharply. Regulation of fluoride dentifrice's quality remained insufficient. It was hypothesized that the strengthening of conservative liberalism and the increase in fiscal austerity observed in recent years might produce serious constraints on public investment and limit access to fluorides. To reduce inequities and promote benefits for all, including the most vulnerable groups, policies based on egalitarian and social justice theoretical perspectives are needed more than ever.

Coverage of fluoride data in water supply systems using the R software.

OBJECTIVE: To present a protocol to criticize data on fluoride monitoring in water with R software programming features, illustrating its application to describe data coverage, and fluoridation quality in 2015. METHODS: The study used big data from the Sistema de Informação de Vigilância da Qualidade da Água para Consumo Humano (Information System for Surveillance of Water Quality for Human Consumption) that included all the Brazilian municipalities. Data criticism procedures were performed with the aid of R software. Filters were applied to remove municipalities with less than four months of records (1), and records with null values (2) and outliers (3). Municipalities were classified regarding the presence of valid information and fluoridation quality according to macro-region, federation units, and population size, presenting the roadmap at each step. RESULTS: Approximately 134,000 records were reviewed. Of the Brazilian municipalities, 39% had data on the fluoride parameter, and only 33.3% had four months or more of information frequency. After applying filters, 1,810 (32.5%) municipalities had valid information for the fluoride parameter, with substantial variation between the South (83.6%) and North (0.7%) macro-regions. Of these, 726 (40.1%) showed very good fluoridation quality, determined by 80% or more records within the optimal concentration interval for prevention of dental caries, with higher value (54.3%) in municipalities with 50,000 inhabitants or more, and lower (34.2%) in those with less than 10,000 inhabitants. CONCLUSIONS: Important differences persist within and between the Brazilian macro-regions regarding both the availability of information on the parameter, and the quality of water fluoridation in public supply systems in Brazil. The protocol for data review and processing with R software programming resources proved to be very useful for the production of information for decision-making based on a standardized method.

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.

Population-based virucidal phthalocyanine gargling/rinsing protocol to reduce the risk of coronavirus disease-2019: a community trial.

Aim: In this community trial, the objective was to evaluate the incidence of coronavirus disease-2019 (COVID-19) cases in two similar communities in three distinct phases: 1 (before the intervention), 2 (during the intervention), and 3 (after the intervention). Methods: The test community received the oral antiseptic intervention (experimental), while the control community did not. The official information agency ("Statewise System for Data Analysis") provided the number of confirmed COVID-19 cases. Data were analyzed according to the three phases per epidemiological week (epi) using the R Core Team (2021) program. The relative risk and 95% confidence intervals between the cumulative incidence values of the test and control communities were calculated for each period. In the test community, a total of 995 residents over 10 years of age received two bottles containing 600 ml of mouthwash containing antiviral phthalocyanine derivative (APD). The participants were asked to gargle/rinse with of 5 mL of the mouthwash containing ADP 3 to 5 times a day, for 1 min, until the bottles were empty. Results: In phases 1 and 3, the disease risk between the two communities did not differ significantly (p>0.05), while in phase 2, the disease risk was 54% lower in the test community than in the control community. Conclusion: The use of the APD mouthwash protocol seems to reduce the COVID-19 incidence at the population level, and further studies are needed to confirm its protective effect under more precisely controlled conditions.

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.

Effectiveness of water fluoridation in an upper-middle-income country: A systematic review and meta-analysis.

AIM: To summarize the information on the effectiveness of community water fluoridation (CWF) on the reduction of dental caries in the context of the wide use of fluoridated toothpaste in Brazil. DESIGN: A systematic review was conducted regarding the effect of CWF based on studies with Brazilian population groups using the following electronic databases: MEDLINE/PubMed, LILACS, SciELO, and SCOPUS. The literature search was conducted up to August 2019. Studies that compared caries experience in at least two areas, one fluoridated and the other non-fluoridated, by mean dmft/DMFT (decayed, missing, and filled teeth) index or caries prevalence (caries vs. caries-free) were included. Considering the beginning of widespread use of fluoride dentifrice and the time for producing dental caries decline, studies published before 1995 were excluded. Descriptive analysis and meta-analyses were carried out. The effect size was measured by mean difference for dmft and DMFT ± SD and odds ratios on a logarithmic scale for caries prevalence. RESULTS: Of the 574 studies retrieved, 16 and 10 were included in the qualitative and quantitative analysis, respectively. Fluoridated areas exhibited lower mean dmft/DMFT than non-fluoridated areas did. The mean difference in the dmft between non-fluoridated and fluoridated areas was -2.28 (95% CI -3.26; -1.30) for children aged 5-8 years and -1.12 (95% CI -1.93; -0.32) for those aged 3-12 years; the mean difference in the DMFT was -0.61 (95% CI -0.80; -0.42) for the children aged between 7 and 12 years. The caries prevalence was 1.4 times and 57% lower, respectively, at primary and permanent dentition in fluoridated areas. Heterogeneity was observed in all age groups, ranging from 77.6% to 98.2%. CONCLUSION: Community water fluoridation remains effective in preventing dental caries in children younger than 13 years, even with the widespread use of fluoridated toothpaste.

Coalizão partidária, aporte financeiro e desempenho da assistência médica e odontológica em duas regiões de saúde brasileiras / Party coalitions, budget outlay, and performance of medical and dental care in two health regions of Brazil / Coalición partidaria, aporte financiero y desempeño de la asistencia médica y odontológica en dos regiones de salud brasileñas

Coalizações de governo distintas encontram limites para produzir mudanças na orientação de políticas. O objetivo foi descrever a orientação política dos partidos de coalização, o aporte financeiro, a estrutura e o desempenho da assistência médica e odontológica em duas regiões de saúde brasileiras distintas socioeconomicamente e na oferta de serviços. Utilizaram-se indicadores a partir de dados oficiais relativos ao período de 2007 a 2014 e caraterísticas da coalização partidária definidas pelas preferências eleitorais municipais e de intensidade da competição eleitoral em cada estado da respectiva região. Maior aporte financeiro per capita e maior porcentagem de população potencialmente coberta pela atenção básica e pelas equipes de saúde bucal da Estratégia Saúde da Família estavam relacionados com o município-polo da região de coalização partidária mais à esquerda, ao passo que o município-polo da região de coalização partidária mais à direita mostrou aumento expressivo na porcentagem de população potencialmente coberta por médicos. Em ambos os municípios-polo, a efetividade melhorou. Os achados confirmaram a noção de que as coalizações mais à esquerda aportam mais recursos em políticas sociais, mas encontram limites para superar desigualdades estruturais e converter suas preferências programáticas em políticas efetivas.

Various government coalitions encounter limits when attempting to implement policy changes. The study aimed to describe the policy orientation of party coalitions, budget outlay, and the structure and performance of medical and dental care in two health regions of Brazil with different socioeconomic conditions and supplies of services. The indicators used were based on official data from 2007 and 2014 and characteristics of the party coalition defined by municipal electoral preferences and the intensity of electoral competition in each state of the respective major geographic region. Higher per capita budget outlay and higher percentage of the population potentially covered by primary care and by the oral health teams under the Family Health Strategy were related to the regional hub municipality with a more left-leaning party coalition, while the regional hub municipality with the more right-leaning party coalition showed an important increase in the percentage of the population potentially covered by physicians. The effectiveness improved in both hub municipalities. The findings confirmed the notion that more left-leaning coalitions tend to earmark more budget resources for social policies but encounter limits for overcoming structural inequalities and for converting their platform preferences into actual policies.

Coaliciones de gobierno distintas encuentran límites para producir cambios en la orientación de políticas. El objetivo fue describir la orientación política de los partidos de coalición, el aporte financiero, la estructura y desempeño de la asistencia médica y odontológica en dos regiones de salud brasileñas, distintas socioeconómicamente y en la oferta de servicios. Se utilizaron indicadores a partir de datos oficiales relacionados con el período de 2007 a 2014 y características de la coalición partidaria, definidas por las preferencias electorales municipales y de intensidad en la competición electoral en cada estado de la respectiva región. Mayor aporte financiero per cápita y mayor porcentaje de población potencialmente cubierta por la atención básica y por los equipos de salud bucal de la Estrategia Salud de la Familia estaban relacionados con el municipio polo de la región de la coalición partidaria más a la izquierda, mientras que el municipio polo de la región de coalición partidaria más a la derecha mostró un aumento expresivo en el porcentaje de población potencialmente cubierta por médicos. En ambos municipios polo, la efectividad mejoró. Los resultados confirmaron la noción de que las coaliciones más a la izquierda aportan más recursos en políticas sociales, pero encuentran límites para superar desigualdades estructurales y convertir sus preferencias programáticas en políticas efectivas.

Structure and performance of medical and dental care in two Brazilian health regions between 2007 and 2014. / Estrutura e desempenho da assistência médica e odontológica em duas regiões de saúde brasileiras entre 2007 e 2014.

The structure and performance of medical and dental care were analyzed in two health regions that differed socioeconomically and in the provision of services, through case study in the Norte-Barretos (São Paulo) and Juazeiro (Bahia) regions from 2007 and 2014, taking into account political, organizational and structural dimensions and structure and performance indicators. The results showed that the regionalization was positively recognized, the distribution of services did not meet the population demand, and the installed capacity of the health care network was not adequate for the health needs of the population. Norte-Barretos stood out regarding structure (except for potential coverage of oral health teams in the Family Health Strategy) and effectiveness, while Juazeiro stood out concerning efficiency; e.g. although with fewer resources, the use of services was relatively higher. The observed pattern seems to reflect aspects related to the regionalization and the political path of each care provided, the so-called "silos effect". The results may support the design of health policies aimed at overcoming the undersized structure of public health services in regions of lower socioeconomic development and search for parameters and coordination mechanisms to balance performance indicators better.

O artigo analisa a estrutura e o desempenho das assistências médica e odontológica de duas regiões, distintas socioeconomicamente e na oferta de serviços, por meio de estudo de caso nas regiões Norte-Barretos (São Paulo) e Juazeiro (Bahia) entre 2007-2014, a partir das dimensões política, organizacional e estrutural e de indicadores de estrutura e desempenho. Observou-se que a regionalização foi reconhecida de forma positiva, a distribuição dos serviços não atendia à demanda populacional e a capacidade instalada da rede de atenção à saúde não estava adequada às necessidades da população. Norte-Barretos se sobressaiu em relação à estrutura (exceto para cobertura potencial da ESB na ESF) e efetividade; enquanto Juazeiro se destacou em relação à eficiência; embora com menos recursos, a utilização dos serviços foi relativamente mais elevada. O padrão observado parece refletir aspectos relacionados à re gionalização e à trajetória política de cada assistência, o efeito silos. Os resultados podem subsidiar o desenho de políticas de saúde voltadas a superar o subdimensionamento da estrutura de serviços públicos assistenciais nas regiões de menor desenvolvimento socioeconômico e a busca de parâmetros e mecanismos de coordenação a fim de equilibrar indicadores de desempenho.

Intervening factors in the costs of fluoridation in water supply systems: a case study in seven population sizes / Fatores intervenientes nos custos da fluoretação em sistemas de abastecimento de água: estudo de caso em sete portes populacionais

ABSTRACT The aim of this study was to analyze the costs of fluoridation in water supply systems of different population sizes. A case study was carried out comprising cities in the state of Espírito Santo, Brazil. The costs of initial installation, the chemical product, the operation of the system, and the control of fluoride levels between the years 2012 and 2017 were considered. The annual per capita cost of the treatment was calculated to estimate the fluoridation weight concerning the total expenses. The fluoridation annual per capita cost ranged from R$ 20.14 (US$ 7.23) in towns with less than two thousand inhabitants to R$ 0.39 (US$ 0.14) in cities with a population of approximately 520 thousand inhabitants. In systems that supply up to 30 thousand inhabitants, the running cost was responsible for most of the expenses, ranging from 98.2 to 84%. For cities with 520 thousand inhabitants, the costs with the chemical product corresponded to 74.7% of the expenses. Compared with the total treatment cost, the water fluoridation cost ranged from 0.2 to 0.6% for population sizes of 30 thousand inhabitants or more and varied from 1.3 to 7.3% for towns with less than 10 thousand inhabitants. Considering that the decision-making process is complex in the field of public policies, and decision-makers suffer multiple influences as for different policy alternatives, knowing the implications of population size for costs is essential for informed decision-making.

RESUMO O objetivo foi analisar os custos da fluoretação em sistemas de abastecimento de água de diferentes portes populacionais. Realizou-se estudo de caso em municípios do estado do Espírito Santo, Brasil. Foram considerados dados referentes aos custos de instalação inicial, do produto químico, da operacionalização do sistema e do controle dos teores de flúor nos anos de 2012 a 2017. Foi calculado o custo per capita anual do tratamento da água a fim de estimar o peso do custo da fluoretação na totalidade das despesas. O custo per capita anual da fluoretação variou de R$ 20,14 (US$ 7,32) para o porte com menos de 2 mil habitantes a R$ 0,39 (US$ 0,14) para o porte com cerca de 520 mil habitantes. Nos sistemas que servem até 30 mil habitantes, o custo de operacionalização foi responsável por maior parte dos gastos, variando de 98,2 a 84%. No porte de 520 mil habitantes, os custos com o produto químico corresponderam a 74,7% dos gastos. O custo da fluoretação da água em relação ao custo total variou de 0,2 a 0,6% nos portes populacionais de 30 mil habitantes ou mais e de 1,3 a 7,3% nos portes abaixo de 10 mil habitantes. Como o processo de tomada de decisão no campo das políticas públicas é complexo e os tomadores de decisão sofrem múltiplas influências em torno de diferentes alternativas de políticas, conhecer a implicação do porte populacional nos custos é essencial para uma tomada de decisão informada.

Community interventions and strategies for caries control in Latin American and Caribbean countries.

Dental caries remains highly prevalent in Latin American and Caribbean countries (LACC). However, this disease can be controlled through interventions that implement evidence-based strategies in an affordable manner and that target all population groups instead of the most affluent only. Therefore, the aim of this report was to summarize the main scientifically documented community interventions and strategies based on restriction of sugars consumption, use of fluoride, and the use of occlusal sealants for caries control in LACC. A critical literature review was carried out in a systematic manner that included defined search strategies, independent review of the identified publications, and compilation of results in this report. Three systematic searches were conducted using the PubMed, LILACS, and SciELO databases to identify studies related to community interventions and strategies for caries control in LACC. Of the 37 publications identified, twenty-six focused on fluoride use, eight on occlusal sealant use, and three on the restriction of sugar consumption. Documented community interventions for sugars restriction were scarce in the region and were based on food supplementation, sugar replacement, and education. Thus, local and/or national policies should prioritize investment in upstream, coherent, and integrated population-wide policies such as taxes on sugary drinks and stronger regulation of advertising and promotion of sugary foods and drinks mainly targeting children. The main fluoride-based strategies used drinking water, refined domestic salt, cow milk, toothpaste and, to a lesser extent, mouth-rinses, acidulated phosphate fluoride (APF) gels, and varnishes to deliver fluoride to the population. Evidence of fluoride use was seen in Argentina, Belize, Bolivia, Brazil, Chile, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, El Salvador, Guatemala, Haiti, Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, Uruguay, and Venezuela. Studies reporting the use of occlusal sealants were mainly located in Brazil, Chile, Colombia, Costa Rica, Peru, Mexico, and Venezuela. Community interventions restricting sugar consumption should be implemented at the individual level and through public policies. The use of fluoride must be monitored at the local, regional, and national levels so as to achieve maximum anti-caries effect while also minimizing the risk of dental fluorosis. Moreover, fluoridated water and salt programs, used as a mutually exclusive community level strategy for caries control, should expand their benefits to reach non-covered areas of the LACC while also simultaneously providing adequate surveillance of the fluoride concentration delivered to the population. Regulating the concentration of soluble fluoride (for anti-caries effect) in dentifrice formulations is also necessary in order to provide the population with an effective strategy for disease control. Targeting culturally appropriate, economically sustainable caries control interventions to rural populations and native ethnic groups such as indigenous people, quilombolas (African-origin), and riverside Amazonian people remains a crucial challenge.

Deprived areas and community water fluoridation in Brazil: a multilevel approach for refocusing public policy.

OBJECTIVES: The aim of this study was to determine whether geographic location, socioeconomic status, infant mortality, and mortality from diarrheal disease in health regions are associated with the provision of community water fluoridation (CWF) in Brazilian municipalities. METHODS: A multilevel ecological study was conducted based on data from the National Survey of Basic Sanitation and Human Development Atlas. A multilevel analysis was carried out considering Brazilian municipalities as the first level and health regions as the second level, comprising sanitation, demographic, socioeconomic, and health characteristics. RESULTS: The observation units comprised 5,565 municipalities clustered in 438 health regions in Brazil. The lack of CWF provision was positively associated with the following municipal characteristics: a below-median proportion of inhabitants covered by the sewage network, medium to very low human development index, below-median per capita gross domestic product, and an above-median percentage of expenditures on sanitation. In relation to the health regions, the likelihood of a lack of CWF provision was greater in the municipalities belonging to the health regions located in the Northern and Northeastern areas of Brazil and in those where child mortality due to acute diarrheal disease and the proportion of people with low income were higher when adjusted by municipal indicators. CONCLUSIONS: Information on the characteristics associated with CWF provision constitutes important input for refocusing public policy to reduce inequalities among Brazilian municipalities and health regions. These findings may help policy-makers to understand the challenges facing CWF expansion in low-, middle-, and high-income countries.