Oral health technicians in Brazilian primary health care: potentials and constraints.

Different perspectives on the role of mid-level workers in health care might represent a constraint to health policies. This study aimed to investigate how different agents view the participation of oral health technicians in direct activities of oral healthcare with the goal of understanding the related symbolic dispositions. Theoretical assumptions related to inter-professional collaboration and conflicts in the field of healthcare were used for this analysis. A researcher conducted 24 in-depth interviews with general dental practitioners, oral health technicians and local managers. The concepts of Pierre Bourdieu supported the data interpretation. The results indicated inter-professional relations marked by collaboration and conflict that reflect an action space related to different perspectives of primary care delivery. They also unveiled the symbolic devices related to the participation of oral health technicians that represent a constraint to the implementation of oral health policy, thus reducing the potential of primary health care in Brazil.

Accumulated knowledge and prevention practices in oral health.

This text begins by reflecting on health promotion and equity/ inequity. In health, inequity is understood as a political concept that has moral implications and that is committed to social justice. A discussion follows on some issues regarding the risk and prevention of diseases, still considered a hegemonic practice, and lack of experience in oral health-care, bearing in mind the concept of vulnerability. The risk is probabilistic and involves the mathematical chances of acquiring a disease in a certain group, whereas vulnerability addresses the potential of acquiring or not acquiring a disease in a certain environment. The need for systematic studies on determinants is stressed, with the ultimate goal of improving health and reducing inequities, and with the concern and political intention of including health equity in governmental policies.

Oral health technicians in Brazilian primary health care: potentials and constraints / Técnicos em saúde bucal na atenção primária à saúde no Brasil: possibilidades e limitações / Técnicos en salud oral dentro de la atención primaria de salud en Brasil: posibilidades y limitaciones

Different perspectives on the role of mid-level workers in health care might represent a constraint to health policies. This study aimed to investigate how different agents view the participation of oral health technicians in direct activities of oral healthcare with the goal of understanding the related symbolic dispositions. Theoretical assumptions related to inter-professional collaboration and conflicts in the field of healthcare were used for this analysis. A researcher conducted 24 in-depth interviews with general dental practitioners, oral health technicians and local managers. The concepts of Pierre Bourdieu supported the data interpretation. The results indicated inter-professional relations marked by collaboration and conflict that reflect an action space related to different perspectives of primary care delivery. They also unveiled the symbolic devices related to the participation of oral health technicians that represent a constraint to the implementation of oral health policy, thus reducing the potential of primary health care in Brazil.

Diferentes perspectivas sobre o papel dos trabalhadores de nível médio na atenção à saúde podem representar um gargalo para as políticas de saúde. Este estudo buscou investigar como diferentes agentes olham para a participação de técnicos em saúde bucal no desempenho de ações diretas, com o objetivo de compreender as disposições simbólicas associadas. Pressupostos teóricos relacionados à colaboração interprofissional e ao contexto conflitivo do campo da saúde foram usados para interpretação do material. Um pesquisador conduziu 24 entrevistas em profundidade com dentistas, técnicos em saúde bucal e gerentes de unidades de saúde. Conceitos de Pierre Bourdieu apoiaram a análise. Os resultados indicaram relações interprofissionais marcadas pela colaboração e conflito, que refletem um espaço de ação associado a diferentes perspectivas de cuidado primário e desvelam dispositivos simbólicos que representam restrições à implementação da política de saúde bucal, reduzindo o potencial da atenção primária à saúde no Brasil.

Diferentes puntos de vista sobre el papel de los trabajadores de nivel medio en la atención sanitaria pueden representar un obstáculo para las políticas de salud. Este estudio investigó cómo los diferentes agentes observan la participación de los técnicos de salud oral en la ejecución de acciones directas de asistencia odontológica, a fin de entender las disposiciones simbólicas asociadas. Los marcos teóricos relacionados con la colaboración interprofesional y el contexto conflictivo del campo de la salud se usaron en el análisis. Un investigador llevó a cabo 24 entrevistas en profundidad con dentistas, técnicos de salud oral y gerentes de salud. Los conceptos de Pierre Bourdieu han apoyado la interpretación de los datos. Los resultados indicaron relaciones interprofesionales que reflejan un espacio de acción, asociado a las diferentes perspectivas de la atención primaria y desplegaron disposiciones simbólicas, que representaron restricciones a la implementación de la política de salud oral, reduciendo el potencial de la atención primaria de salud en Brasil.

Percepção dos usuários do sus: expectativa e satisfação do atendimento na Estratégia de Saúde da Família / Perception of SUS users: expectation and satisfaction of care in the Family Health Strategy

OBJETIVO: este trabalho buscou analisar as percepções quanto à satisfação e expectativas dos usuários dos serviços de saúde de um território atendido pela Estratégia de Saúde da Família (ESF), do município de Bauru, Estado de São Paulo, e assim, promover um direcionamento no acolhimento e atenção dada aos indivíduos ali atendidos. MÉTODO: trata-se de uma pesquisa qualitativa que utilizou a análise do Discurso do Sujeito Coletivo. Fizeram parte da pesquisa 10 usuários da ESF selecionados por meio de amostragem oportunista. Foi utilizado um questionário semi-estruturado e as entrevistas foram gravadas em áudio para posterior análise do discurso. A referida pesquisa foi aprovada pelo Comitê de Ética em Pesquisa (CEP) da FOB/USP bem como pela Secretaria Municipal de Saúde, sob protocolo numero 167/2009.Para aprovação neste CEP, a pesquisa contou com o cadastro no Conselho Nacional de Saúde (CONEP), via Sistema Nacional de Ética em Pesquisa (SISNEP) RESULTADOS: verificou-se com os resultados obtidos que os usuários estão satisfeitos com o atendimento recebido. Além disso, notou-se a presença da participação popular quanto à divisão de responsabilidades no cuidado à saúde. No entanto, apresentaram queixas quanto à lentidão no referenciamento para a média e a alta complexidade. CONCLUSÃO: a Fonoaudiologia concentra parte das suas atividades na média e alta complexidade, níveis citados como insatisfação do usuário. Assim sendo, sugere-se o desenvolvimento desta pesquisa em locais cuja atuação fonoaudiológica esteja presente.

PURPOSE: this study aimed to evaluate users' health care satisfaction and expectations, of Family Health Strategy (FHS), in Bauru, State of São Paulo, and thus, promote the receptivity and attention direction given for the attended people. METHOD: this is a qualitative study that used the collective subject discourse analysis. It was approved by the FOB/USP Research Ethics Committee and the Municipal Health Department, case number 167/2009. Ten users of FHS were selected through opportunistic sampling. A semi-structured questionnaire was used in the interview and was recorded for discourse analysis. RESULTS: it was observed by the results of the interviews that the users are satisfied with the service they get. We also noted that the presence of popular participation on the division of responsibilities in health care. However, they were not satisfied with the waiting time for referring to medium and high complexity procedures. CONCLUSION: the Speech-Language and Hearing Pathology focuses its actions in secondary and high complexity levels, whereas such levels are cited as user's dissatisfaction. Therefore, we suggest the development of this research in such locations where Speech-Language and Hearing professionals are present.

Programmatic actions in oral health: coping with social inequities.

Inequities are health imbalances that are avoidable, unfair and unnecessary. Studies on health inequities address the need for emergency care related to oral-dental lesions from external causes, toothache or prevalence of oral lesions, taking into account the differences between individuals and/or populations in terms of risk conditions to acquiring disease or access to health services. Inequities may be caused by the health service itself, because diseases affect socially deprived individuals more frequently and severely, especially because of multimorbidity. In the current Brazilian public health situation, programmatic actions are based on technological knowledge, especially epidemiology, focused on specific pathologies or disease risk groups, and relate closely to the organization of programmed demand. Moreover, programmatic actions should strategically use technological devices, without disregarding technical and policy flexibility, and should be closely related to inter-subjectivity and ethics, in order to develop emancipating capabilities. An action having this structure could make it easier to achieve Universality, Equity and Integrality.

Programmatic actions in oral health: coping with social inequities

Inequities are health imbalances that are avoidable, unfair and unnecessary. Studies on health inequities address the need for emergency care related to oral-dental lesions from external causes, toothache or prevalence of oral lesions, taking into account the differences between individuals and/or populations in terms of risk conditions to acquiring disease or access to health services. Inequities may be caused by the health service itself, because diseases affect socially deprived individuals more frequently and severely, especially because of multimorbidity. In the current Brazilian public health situation, programmatic actions are based on technological knowledge, especially epidemiology, focused on specific pathologies or disease risk groups, and relate closely to the organization of programmed demand. Moreover, programmatic actions should strategically use technological devices, without disregarding technical and policy flexibility, and should be closely related to inter-subjectivity and ethics, in order to develop emancipating capabilities. An action having this structure could make it easier to achieve Universality, Equity and Integrality.

[Spatial risk and factors associated with edentulism among elderly persons in Southeast Brazil]. / O risco espacial e fatores associados ao edentulismo em idosos em município do Sudeste do Brasil.

This study aimed to identify factors associated with edentulism and spatial risk of tooth loss in the elderly. A cross-sectional study was conducted using a random sample (n = 372) of individuals 60 years and older in Botucatu, São Paulo State, Southeast Brazil, in 2005. Crude and adjusted prevalence ratios were estimated by Poisson regression with robust variance. Spatial analysis was performed using Kernel intensity estimation. Prevalence of edentulism was 63.17%. Socio-demographic factors associated with edentulism according to multiple regression were low schooling, household crowding, not owning a car, older age, lack of a regular dentist, and the last dental visit three previously or longer. Spatial analysis showed greater risk of edentulism in the peripheral areas of the city. The results help understand the high prevalence of tooth loss among the elderly, thus providing essential information for planning oral health interventions.

O risco espacial e fatores associados ao edentulismo em idosos em município do Sudeste do Brasil / Spatial risk and factors associated with edentulism among elderly persons in Southeast Brazil

Objetivou-se identificar fatores associados ao edentulismo e o seu risco espacial em idosos. Foi realizado um estudo transversal em uma amostra de 372 indivíduos de 60 anos e mais, no Município de Botucatu, São Paulo, Brasil, em 2005. Razões de prevalência brutas e ajustadas foram estimadas por meio de regressão de Poisson, com estimativa robusta da variância e procedimentos de modelagem hierárquica. A análise espacial foi realizada por estimativas de densidade de Kernel. A prevalência de edentulismo foi de 63,17 por cento. Os fatores sociodemográficos associados ao edentulismo foram a baixa escolaridade, o aumento do número de pessoas por cômodo, não possuir automóvel e idade mais avançada, presença de comorbidades, ausência de um cirurgião-dentista regular e ter realizado a última consulta há três anos ou mais. A análise espacial mostrou maior risco nas áreas periféricas. Obteve-se uma melhor compreensão da perda dentária entre os idosos, subsidiando o planejamento de ações em saúde coletiva.

This study aimed to identify factors associated with edentulism and spatial risk of tooth loss in the elderly. A cross-sectional study was conducted using a random sample (n = 372) of individuals 60 years and older in Botucatu, São Paulo State, Southeast Brazil, in 2005. Crude and adjusted prevalence ratios were estimated by Poisson regression with robust variance. Spatial analysis was performed using Kernel intensity estimation. Prevalence of edentulism was 63.17 percent. Socio-demographic factors associated with edentulism according to multiple regression were low schooling, household crowding, not owning a car, older age, lack of a regular dentist, and the last dental visit three previously or longer. Spatial analysis showed greater risk of edentulism in the peripheral areas of the city. The results help understand the high prevalence of tooth loss among the elderly, thus providing essential information for planning oral health interventions.

[Epidemiologic aspects of dental fluorosis in Brazil: research in the period 1993-2006]. / Aspectos epidemiológicos da fluorose dentária no Brasil: pesquisas no período 1993-2006.

The epidemiology of dental fluorosis derives from surveys carried out in recent years, as a result of a better comprehension of metabolic aspects of fluoride in the human organism and oral health concerns. This reflection aims at presenting studies carried out on fluorosis between 1993 and 2006. The period of 1993-2004 delimits the interval between the 2nd and the 3rd National Conferences on Oral Health, and, in the period of 2005-2006, the search of primary data presented in scientific meetings confirmed the findings in the literature, showing that the Brazilian scientific agenda was not substantially influenced by the discussions engaged during the 3rd National Conference on Oral Health. Most studies concentrate on urban areas and the predominance, in Brazil, of 'very mild' and 'mild' levels of fluorosis shows that there is no compromising in terms of functional order. The low perception of fluorosis by the population, along with its low prevalence, evokes the necessary debate on public health issues, in the country. Since the national scientific production constitutes an important source of knowledge to subsidize the elaboration of public policies for the health sector, the successive and punctual studies analyzed show that, as far as fluorosis is concerned, the epidemiological diagnosis reaffirms the need, importance and safety of the fluoridation of public water supplies, as a public health measure.

Aspectos epidemiológicos da fluorose dentária no Brasil: pesquisas no período 1993-2006 / Epidemiologic aspects of dental fluorosis in Brazil: research in the period 1993-2006

A epidemiologia da fluorose dentária resulta de inquéritos realizados recentemente, em decorrência da melhor compreensão de aspectos metabólicos dos fluoretos no organismo humano e de preocupações no âmbito da saúde coletiva. Objetiva-se apresentar os estudos realizados sobre a fluorose entre 1993 e 2006. O período 1993-2004 demarca o intervalo entre a 2ªe a 3ª Conferência Nacional de Saúde Bucal. Em 2005-2006, a busca de dados primários apresentados em reuniões científicas confirmou os achados existentes na literatura, mostrando que a agenda científica brasileira não foi substancialmente influenciada pelas discussões travadas durante a 3ª Conferência. A maioria dos estudos concentra-se em áreas urbanas e a predominância no Brasil dos graus "muito leve" e "leve" de fluorose mostra não haver comprometimentos de ordem funcional. A baixa percepção da fluorose pela população, aliada à sua baixa prevalência, evoca o necessário debate sobre as questões de saúde coletiva no país. Visto que a produção científica nacional constitui uma importante fonte de conhecimentos para subsidiar a elaboração de políticas públicas para o setor da saúde, os sucessivos e pontuais estudos analisados mostram que, no que diz respeito à fluorose, o diagnóstico epidemiológico reafirma a necessidade, a importância e a segurança da fluoretação das águas de abastecimento público como medida de saúde coletiva.

The epidemiology of dental fluorosis derives from surveys carried out in recent years, as a result of a better comprehension of metabolic aspects of fluoride in the human organism and oral health concerns. This reflection aims at presenting studies carried out on fluorosis between 1993 and 2006. The period of 1993-2004 delimits the interval between the 2nd and the 3rd National Conferences on Oral Health, and, in the period of 2005-2006, the search of primary data presented in scientific meetings confirmed the findings in the literature, showing that the Brazilian scientific agenda was not substantially influenced by the discussions engaged during the 3rd National Conference on Oral Health. Most studies concentrate on urban areas and the predominance, in Brazil, of "very mild" and "mild" levels of fluorosis shows that there is no compromising in terms of functional order. The low perception of fluorosis by the population, along with its low prevalence, evokes the necessary debate on public health issues, in the country. Since the national scientific production constitutes an important source of knowledge to subsidize the elaboration of public policies for the health sector, the successive and punctual studies analyzed show that, as far as fluorosis is concerned, the epidemiological diagnosis reaffirms the need, importance and safety of the fluoridation of public water supplies, as a public health measure.

Oral health conditions among the elderly in Southeastern São Paulo State

Objective: This study aimed to asses oral health conditions in a population aged 60 years and over living in Botucatu, Southeastern Brazil. A cross-sectional population-based study was carried out using a random sample (N=372) of the urban population aged 60 years and over from the city of Botucatu, in 2005. World Health Organization criteria and codes for oral health epidemiological surveys were used. Re-examination was carried out in 10% of individuals aiming to evaluate intra-examiner agreement. Statisticalanalysis was performed by one-way ANOVA or Kruskal-Wallis ANOVA, as applicable. Also, the t-test was used in the absence of homoscedasticity. Fisher’s exact test was used for situations where the categories with less than five units were observed. Adjusted residuals and multiple-comparison analysis were conducted to identify associations between variable categories and subgroups. The intra-examiner agreement was 98% and Kappa statistics result was 0.95. Loss component represented 90.68% of DMF-T index, which was 29.85. The prevalence of edentulism was 63.17%. Upper and lower dentures were found in 80% and 58% respectively, with complete denture as the most commonly used. In those studied, 15% required upper and 38% lower dentures. There was more need for complete denture in both jaws. Approximately 20% had soft tissue alterations. For periodontal conditions, most sextants were excluded (81.81%). Periodontal pockets (4 – 5 mm) were seen in 11.29% of the examined individuals. The oral health status of the elderly population in Botucatu is poor, as well as in other Brazilian cities. The results of this study may help planning collective health actions, giving an accurate description of the oral problems among the elderly.

Oral health conditions among the elderly in Southeastern São Paulo State.

OBJECTIVE: This study aimed to asses oral health conditions in a population aged 60 years and over living in Botucatu, Southeastern Brazil. A cross-sectional population-based study was carried out using a random sample (N=372) of the urban population aged 60 years and over from the city of Botucatu, in 2005. World Health Organization criteria and codes for oral health epidemiological surveys were used. Re-examination was carried out in 10% of individuals aiming to evaluate intra-examiner agreement. Statistical analysis was performed by one-way ANOVA or Kruskal-Wallis ANOVA, as applicable. Also, the t-test was used in the absence of homoscedasticity. Fisher's exact test was used for situations where the categories with less than five units were observed. Adjusted residuals and multiple-comparison analysis were conducted to identify associations between variable categories and subgroups. The intra-examiner agreement was 98% and Kappa statistics result was 0.95. Loss component represented 90.68% of DMF-T index, which was 29.85. The prevalence of edentulism was 63.17%. Upper and lower dentures were found in 80% and 58% respectively, with complete denture as the most commonly used. In those studied, 15% required upper and 38% lower dentures. There was more need for complete denture in both jaws. Approximately 20% had soft tissue alterations. For periodontal conditions, most sextants were excluded (81.81%). Periodontal pockets (4 - 5 mm) were seen in 11.29% of the examined individuals. The oral health status of the elderly population in Botucatu is poor, as well as in other Brazilian cities. The results of this study may help planning collective health actions, giving an accurate description of the oral problems among the elderly.

Características sociodemográficas da mortalidade por câncer de boca em Bauru, SP, no período de 1991 a 2001: uso de geoprocessamento / Sociodemographic characteristics of death by oral cancer in Bauru, SP, Brazil, in the 1991-2001 period: use of geoprocessing

O objetivo deste estudo foi avaliar as taxas de mortalidade por câncer de boca no período de 1991-2001, no município de Bauru-SP. A fonte de informação utilizada para o reconhecimento e seleção da população-alvo foram Certidões de Óbito dos Cartórios do município de Bauru com dados relativos ao período 1991-2001. Foram coletadas informações referentes a sexo, idade, localização da lesão e endereço. A coleta dos endereços visou à identificação no mapa do município de Bauru da localização geográfica do domicílio. Utilizando ferramentas do geoprocessamento, foi feita a inserção no mapa dos casos identificados. Foram registrados 67 casos de morte por câncer de boca na cidade de Bauru entre 1991 e 2001, com maiores taxas no sexo masculino e sexta década de vida. A análise da distribuição espacial mostra que a maioria dos casos encontra-se próxima à linha férrea que corta o município e foi responsável, em grande parte, pela ocupação territorial pela população, sendo esta também uma área que abrange os bairros mais antigos do município. O câncer de boca constitui importante causa de óbito no município, requerendo um planejamento de ações georreferenciadas pelo sistema local de saúde.

Principais mecanismos de atuação do álcool no desenvolvimento do câncer oral / Main alcohol performance mechanisms in the oral cancer development

O Efeito do álcool sem associação ao tabaco vem sendo estudado; contudo, os mecanismos pelos quais o álcool exerce o seu efeito carcinogênico não estão completamente esclarecidos. Evidências sugerem que o efeito do álcool esteja relacionado principalmente à exposição tópica, que altera membranas celulares e aumenta a permeabilidade ao tabaco. É proposto também que o efeito do álcool seja modulado por polimorfismos de genes que codificam enzimas para o metabolismo do etanol, do folato e reparo do DNA. O mecanismo de atuação do álcool também está realcionado a um efeito genotóxico do acetaldeído, o principal metabólito do etanol, alteração no metabolismo dos retinóides, deficiências nutricionais e efeitos sistêmicos. Porém, há uma grande dificuldade na avaliação do efeito do álcool, devido à falta de exatidão das histórias do consumo, dos tipos de bebidas, suas concentrações e quantidades, alterando os resultados dos estudos. Este trabalho se propõe a discutir os principais mecanismos de atuação do álcool que poderão promover o desenvolvimento do câncer oral, e nortear o cirurgião-dentista quanto à sua prevenção.

The chronic and excessive alcohol intake is associated with an increased risk for developing oran cancer, which has tobacco and alcohol as risks factors. Nevertheless, the sole effect of alcohol, not associated with tobacco has been related to the development of oral cancer. However, the exact mechanism by which alcohol may exert this effect is not clear. Evidence suggests that the effect of alcohol is related, mainly, to the topic exposure, which promotes modifications in cell membranes and increase in the permeability for carcinogenic agents, such as tobacco. It has also been suggested that the effect of alcohol is modulated by polymorphisms in genes encoding enzymes for ethanol metabolism, folate metabolism and DNA repair. The mechanism of alcohol performance is related to the existence of acetaldehyde genotoxic effect, changes in retinoid metabolism, nutritional deficiencies and systemic effects. Yet, there still exists a vast difficulty in evaluating the alcohol effect, mainly due to the lack of exactness description of alcohol consumption, type of alcoholic beverages, concentration and amount of alcohol, which, therefore, disturb the study data. This study aims at explaining the main mechanisms by which alcohol acts in developing oral cancer, and guiding the general dentist to prevent this cases.

[The relation between space and collective oral health: for a georeferenced epidemiology]. / A relação entre o espaço e a saúde bucal coletiva: por uma epidemiologia georreferenciada.

The influence of the environment on health is an ancient human concern. From the Hippocratic texts to today, the concept of space permitted and still permits different representations and forms of perception. Overcoming the natural conception of space as only an inert and passive environment, the idea of a socially constructed geographic space, both as a receiver of social processes as much as being its own activator in these processes, becomes ever more relevant in the comprehension of phenomena involved in the health-disease process. In this sense, epidemiology is presented as a privileged reference point in the articulation of place-time-people elements. This reflexive investigation seeks to explore the relations established between space (social and geographical) and Collective Oral Health, emphasizing the role of territory in the reproduction of iniquities in health and the necessity of developing studies that approach space as a constitutive element in the oral health-disease process. In what could be termed a georeferenced epidemiology, the spatial expression of events of oral health-disease and of the actors involved in this process strengthens the importance of territory (and its various significations) to Collective Oral Health.