Política Nacional de Saúde Bucal:uma análise da reorganização da atenção à saúde bucal no Estado do Rio de Janeiro frente aos incentivos federais

Esta dissertação foca o processo de reorganização das ações e serviços de saúde bucal no estado do Rio de Janeiro. Este processo, em tese, deve ser orientado pelas diretrizes da Política Nacional de Saúde Bucal (PNSB) que priorizam a atenção básica em saúde bucal através da Estratégia Saúde da Família e ampliam a atenção em saúde bucal na média e alta complexidades. O Ministério da Saúde lança mão de incentivos financeiros para induzir, sob condições específicas, a adesão às diretrizes formuladas pela Política Nacional de Saúde Bucal (PNSB) e assim promover um processo de reorganização da atenção à saúde bucal nas esferas subnacionais. O núcleo deste trabalho tem por base uma pesquisa que analisa um amplo espectro de dados sobre os serviços e as ações de saúde bucal realizadas pelo conjunto dos municípios do estado do Rio de Janeiro no período de janeiro de 1998 a dezembro de 2007. As principais conclusões da pesquisa apontam para o caráter inconcluso do processo de reorganização da atenção em saúde bucal na grande maioria dos municípios estudados e para a necessidade de uma ação conjunta entre as autoridades sanitárias das esferas federal, estadual e municipal orientada para promover uma efetiva melhoria das condições de saúde da população tal como é a proposta da PNSB.

Social disparity and oral health

There is a clear reported association between social disparity and oral health, for example, between dental caries and malnutrition in children. This fact is detected in several studies, and also found amongst the Brazilian population. However, several efforts have been made to improve the quality of life of the population and to achieve the 2015 Millennium Development Goals. Oral health is a branch to be improved among these goals. The Brazilian experience has been drawing the attention of authorities, insofar as there have been direct improvements in oral health through state oral health programs, and also indirect results by improving the quality of life of the population. Included within the Brazilian oral health programs are the Family Health Program and Smiling Brazil Program. The former is a global healthcare program which involves primary oral healthcare, while the latter is a specialized oral care program. Among the social programs that would indirectly improve oral health are Family Stipend and the Edmond and Lily Safra International Institute of Neuroscience of Natal (ELS-IINN). In conclusion, although oral health problems are related to socioeconomic factors, the implementation of primary oral health programs and programs to improve the population's quality of life may directly or indirectly improve the oral health scenario. This fact is being observed in Brazil, where the oral health policies have changed, and social programs have been implemented.

Self-rated oral health and associated factors in Brazilian elders

Objective: Self-rating provides a simple direct way of capturing perceptions of health. The objective of this study was to estimate the prevalence and associated factors of poor self-rated oral health among elders. Methods: National data from a cross-sectional population-based study with a multistage random sample of 4786 Brazilian older adults (aged 65-74) in 250 towns were analysed. Data collection included oral examinations (WHO 1997) and struct-ured interviews at elderly households. The outcome was measured by a single five-point-response-scale question dichotomized into `poor` (fair/poor/very poor) and `good` (good/very good) self-rated oral health. Data analyses used Poisson regression models stratified by sex. Results: The prevalence of poor self-rated oral health was 46.6% (95% CI: 45.2-48%) in the whole sample, 50.3% (48-52.5) in men and 44.2% (42.4-46) in women. Higher prevalence ratios (PR) were found in elders reporting unfavourable dental appearance (PR = 2.31; 95% CI: 2.02-2.65), poor chewing ability (PR = 1.64; CI: 1.48-1.8) and dental pain (PR = 1.44; CI: 1.04-1.23) in adjusted analysis. Poor self-perception was also associated with being men, black, unfavourable socioeconomic circumstances, unfavourable clinical oral health and with not using or needing a dental prosthesis. Conclusion: Assessment and understanding of self-rated oral health should take into account social factors, subjective and clinical oral symptoms.

Validation of the Brazilian versions of two inventories for measuring oral health-related quality of life of edentulous subjects

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Reliability and validation of a Brazilian version of the Oral Health Impact Profile for assessing edentulous subjects

The aims of this study were to evaluate the reliability and to validate a Brazilian version of Oral Health Impact Profile for assessing edentulous subjects (OHIP-EDENT), an inventory for measuring oral health-related quality of life of edentulous subjects. The sample comprised 65 complete denture wearers (23 men, mean age of 69.1 +/- 10.3 years). The translated OHIP-EDENT was applied on two occasions with a washout period of 3 months. Reliability was assessed by an internal consistency analysis and a test-retest approach. A preliminary validation process was conducted by a qualitative approach/interview. Results of internal consistency showed a Cronbach's alpha of 0.86 or 0.90 for the first or second appointment respectively. Through the test-retest analysis, an intra-class correlation coefficient of 0.57 was found, and individual answers reflected a broad range of agreement. Interviewed volunteers (n = 6) comprehended most questions well. In conclusion, the Brazilian version of OHIP-EDENT is adequate for assessing the oral health-related quality of life for edentulous subjects.

Caries and its association with infant feeding and oral health-related behaviours in 3-4-year-old Brazilian children

Objectives: To investigate the relationships between socio-demographic factors, infant feeding habits, oral hygiene and the prevalence and patterns of caries in Brazilian 3-4-year-olds. Methods: Systematic random sampling was used to select children enrolled in municipal nurseries in Araraquara, Brazil, in 1998. Clinical examinations were carried out by one examiner using dmft and dmfs indices and WHO criteria. Questionnaires for information related to the socio-demographic background, oral hygiene and dietary history of the children were completed by their mothers. Results: Caries was seen in 46% of the children; 17% of them had the more extensive pattern involving molars and incisors. Social class, mother's education, and age at which breast-feeding terminated showed statistically significant associations with caries. Feeding bottles with added sugars were still being given to 80% of the children. When the significant variables were taken into account only age at which breast-feeding terminated showed a significant relationship to the pattern of disease. Children who were never breast-fed or were breast-fed beyond the age of 24 months had a higher prevalence of the more extensive pattern of caries. Conclusions: The association between the length of time a mother breast-feeds and extensive caries should be a consideration in any local infant feeding policies or health promotion strategies. The duration for appropriate breast- or bottle-feeding should be emphasised.

Correlation between oral health perception and clinical factors in a Brazilian community

Objective: The aim of this study was to analyse associations between self-perception of oral health and relevant clinical, personal and socio-demographic factors in a Brazilian community. Material And Methods: Urban adults living in a city in southern Brazil were interviewerd and examined. Individuals with acute pain and who needed multiple extractions of teeth were excluded. Self-perception and the Oral Health Impact Profile (OHIP-14) were applied to measure the impact of oral conditions on the quality of life. Socio-demographic and clinical indicators were also analysed. Results: The clinical examination revealed a high dental caries experience (DMFT = 18.9) and a high prevalence of periodontal disease. Oral condition was considered normal by 42% of respondents. The variables associated with the OHIP-14 were: education, age, self-assessment, dental caries and the DMFT index. Conclusions: Self-perception of oral health was associated with OHIP-14 and the clinical indicators had low influence in the self-perception. Therefore, the development of educational initiatives and preventive strategies for the adult population is recommended. © BASCD 2011.

Oral impacts on the daily performance of Brazilians assessed using a sociodental approach: analyses of national data

The aim of this study was to analyze the relationship between oral diseases and their impact on the daily performance of adult and elderly Brazilians, verify the association of oral diseases with socioeconomic and demographic features, and compare the standard estimate of need with the sociodental assessment of these same needs. The authors evaluated data from 17,398 Brazilians aged between 35-44 years and 65-74 years, taken from the cross-sectional Brazilian Oral Health Survey (Saúde Bucal Brasil - SBBrasil). Regression models were applied to assess associations among impacts on daily performance and income, schooling, gender, region, use of dental services, health perception and dental disease status. McNemar’s test was applied to compare standard versus impact-related estimates of need. The prevalence ratio of these impacts was associated with the sociodemographic versus health perceptions (p < 0.001) of adults and the elderly. Adults also had impacts associated with loss of periodontal attachment (p < 0.001). The prevalence of normative needs was 95.39% for adults and 99.76% for the elderly, whereas the impact-related estimate of need was 50.92% and 43.71%, respectively. The impacted-related approach had a statistically significant association with the normative estimate of need (p < 0.001). This study showed a relationship between oral impact on daily performance of adults and educational level. Sociodemographic features were also related to the impacts on both adults and the elderly, and to health perception. The impacts among the adults were related to the loss of periodontal attachment. In addition, the authors found a sizable difference between the standard versus the sociodental approach, in that the sociodental assessment needs were lower than the needs identified by the standard estimate of need.

Validation of the Brazilian versions of two inventories for measuring oral health-related quality of life of edentulous subjects

'Objectives: To analyse the validity of the Brazilian versions of OHIP-EDENT and GOHAI as assessment tools of edentulous subjects' OHRQoL. Background: Inventories for measuring oral health-related quality of life (OHRQoL) are important in clinical studies regarding oral rehabilitation. However, there is a need for comprehensive validation after translation into different cultural settings. Materials and methods: The sample comprised of 100 complete denture wearers (29 men, 71 women, mean age of 65.2 +/- 9.9 years). The associations between each OHRQoL inventory and other variables served as measurements of construct validity. Data analysis comprised the Spearman correlation test as well as multiple regression using the OHRQoL inventories as dependent variables and the other scales as determinants. Results: Both OHRQoL inventories showed good correlation with denture satisfaction, whereas lower correlation coefficients were found among the inventories and the HAD subscales. Denture satisfaction alone explained 48% and 39% of the variance found for the OHIP-EDENT and GOHAI, respectively, as assessed by multiple regression. A smaller effect was found for OHIP-EDENT. Conclusion: Both OHIP-EDENT and GOHAI showed good construct validity for measurement of OHRQoL of edentulous subjects.

Responsiveness to change for the Brazilian Scale of Oral Health Outcomes for 5-year-old children (SOHO-5)

Abstract Background The responsiveness of oral health-related quality of life (OHRQoL) instruments has become relevant, given the increasing tendency to use OHRQoL measures as outcomes in clinical trials and evaluations studies. The purpose of this study was to assess the responsiveness of the Brazilian Scale of Oral Health Outcomes for 5-year-old children (SOHO-5) to dental treatment. Methods One hundred and fifty-four children and their parents completed the child self- and parental’ reports of the SOHO-5 prior to treatment and 7 to 14 days after the completion of treatment. The post-treatment questionnaire also included a global transition judgment that assessed subject’s perceptions of change in their oral health following treatment. Change scores were calculated by subtracting post-treatment SOHO-5 scores from pre-treatment scores. Longitudinal construct validity was assessed by using one-way analysis of variance to examine the association between change scores and the global transition judgments. Measures of responsiveness included standardized effect sizes (ES) and standardized response mean (SRM). Results The improvement of children’s oral health after treatment are reflected in mean pre- and post-treatment SOHO-5 scores that declined from 2.67 to 0.61 (p < 0.001) for the child-self reports, and 4.04 to 0.71 (p < 0.001) for the parental reports. Mean change scores showed a gradient in the expected direction across categories of the global transition judgment, and there were significant differences in the pre- and post-treatment scores of those who reported improving a little (p < 0.05) and those who reported improving a lot (p < 0.001). For both versions, the ES and SRM based on change scores mean for total scores and for categories of global transitions judgments were moderate to large. Conclusions The Brazilian SOHO-5 is responsive to change and can be used as an outcome indicator in future clinical trials. Both the parental and the child versions presented satisfactory results.

Cross-cultural adaptation and psychometric properties of the Brazilian version of the scale of oral health outcomes for 5-year-old children (SOHO-5)

Abstract Background Most of the instruments available to measure the oral health-related quality of life (OHRQoL) in paediatric populations focus on older children, whereas parental reports are used for very young children. The scale of oral health outcomes for 5-year-old children (SOHO-5) assesses the OHRQoL of very young children through self-reports and parental proxy reports. We aimed to cross-culturally adapt the SOHO-5 to the Brazilian Portuguese language and to assess its reliability and validity. Findings We tested the quality of the cross-cultural adaptation in 2 pilot studies with 40 children aged 5–6 years and their parents. The measurement was tested for reliability and validity on 193 children that attended the paediatric dental screening program at the University of São Paulo. The children were also clinically examined for dental caries. The internal consistency was demonstrated by a Cronbach's alpha coefficient of 0.90 for the children’s self-reports and 0.77 for the parental proxy reports. The test-retest reliability results, which were based on repeated administrations on 159 children, were excellent; the intraclass correlation coefficient was 0.98 for parental and 0.92 for child reports. In general, the construct validity was satisfactory and demonstrated consistent and strong associations between the SOHO-5 and different subjective global ratings of oral health, perceived dental treatment need and overall well-being in both the parental and children’s versions (p < 0.001). The SOHO-5 was also able to clearly discriminate between children with and without a history of dental caries (mean scores: 5.8 and 1.1, respectively; p < 0.001). Conclusion The present study demonstrated that the SOHO-5 exhibits satisfactory psychometric properties and is applicable to 5- to 6-year-old children in Brazil.

Oral Health among Young Adults and the Middle-aged in Iran

The aim of the present study was to assess oral health and treatment needs among adult Iranians according to socio-demographic status, smoking, and oral hygiene, and to investigate the relationships between these determinants and oral health. Data for 4448 young adult (aged 18) and 8301 middle-aged (aged 35 to 44) Iranians were collected in 2002 as part of a national survey using the World Health Organization (WHO) criteria for sampling and clinical diagnoses, across 28 provinces by 33 calibrated examiners. Gender, age, place of residence, and level of education served as socio-demographic information, smoking as behavioural and modified plaque index (PI) as the biological risk indicator for oral hygiene. Number of teeth, decayed teeth (DT), filled teeth (FT), decayed, missing, filled teeth (DMFT), community periodontal index (CPI), and prosthodontic rehabilitation served as outcome variables of oral health. Mean number of DMFT was 4.3 (Standard deviation (SD) = 3.7) in young adults and 11.0 (SD = 6.4) among middle-aged individuals. Among young adults the D-component (DT = 70%), and among middle-aged individuals the M-component (60%) dominated in the DMFT index. Among young adults, visible plaque was found in nearly all subjects. Maximum (max) PI was associated with higher mean number of DT, and higher periodontal treatment needs. A healthy periodontium was a rare condition, with 8% of young adults and 1% of middle-aged individuals having a max CPI = 0. The majority of the CPI findings among young adults consisted of calculus (48%) and deepened periodontal pockets (21%). Respective values for middle-aged individuals were 40% and 53%. Having a deep pocket (max CPI = 4) was more likely among young adults with a low level of education (Odds ratio (OR) = 2.7, 95% Confidence interval (CI) = 1.9–4.0) than it was among well-educated individuals. Among middle-aged individuals, having calculus or a periodontal pocket was more likely in men (OR = 1.8, 95% CI = 1.6–2.0) and in illiterate subjects (OR = 6.3, 95% CI = 5.1–7.8) than it was for their counterparts. Among young adults, having 28 teeth was more (p < 0.05) prevalent among men (72% vs. 68% for women), urban residents (71% vs. 67% for rural residents), and those with a high level of education (73% vs. 60% for those with a low level). Among middle-aged individuals, having a functional dentition was associated with younger age (OR = 2.0, 95% CI = 1.7−2.5) and higher level of education (OR = 1.8, 95% CI = 1.6−2.1). Of middle-aged individuals, 2% of 35- to 39-year-olds and 5% of those aged 40 to 44 were edentulous. Among the dentate subjects (n = 7,925), prosthodontic rehabilitation was more prevalent (p < 0.001) among women, urban residents, and those with a high level of education than it was among their counterparts. Among those having 1 to 19 teeth, a removable denture was the most common type of prosthodontic rehabilitation. Middle-aged individuals lacking a functional dentition were more likely (OR = 6.0, 95% CI = 4.8−7.6) to have prosthodontic rehabilitation than were those having a functional dentition. In total, 81% of all reported being non-smokers, and 32% of men and 5% of women were current smokers. Heavy smokers were the most likely to have deepened periodontal pockets (max CPI ≥ 3, OR = 2.9, 95% CI = 1.8−4.7) and to have less than 20 teeth (OR = 2.3, 95% CI = 1.5−3.6). The findings indicate impaired oral health status in adult Iranians, particularly those of low socio-economic status and educational level. The high prevalence of dental plaque and calculus and considerable unmet treatment needs call for a preventive population strategy with special emphasis on the improvement of oral self-care and smoking cessation to tackle the underlying risk factors for oral diseases in the Iranian adult population.