Paulo Capel Narvai

Cárie dentária no Brasil: declínio, polarização, iniqüidade e exclusão social

OBJETIVO: Analisar a evolucao da experiencia de carie dentaria entre escolares brasileiros no periodo de 1980 a 2003 e determinar a distribuicao da carie e o acesso dessa populacao ao tratamento da doenca. METODO: Foram utilizados dados secundarios produzidos no periodo de 1980 a 2003, empregando o indice dentes permanentes cariados, perdidos e restaurados (CPOD). Os estudos que deram origem aos dados variaram quanto ao tipo de investigacao, delineamento, plano amostral e criterio diagnostico para a doenca, mas produziram estimativas nacionais consideradas validas para os valores do indice CPOD, admitindo-se como possivel a presente analise de tendencia. RESULTADOS: Os valores de CPOD indicaram um nivel alto de carie dentaria nos anos 1980, declinando para um nivel moderado nos anos 1990. Em 2003, o valor do CPOD ainda era moderado (2,8). Entre 1980 e 2003, o declinio nos valores do CPOD foi de 61,7%. A porcentagem de escolares com CPOD igual a zero aumentou de 3,7% em 1986 para 31,1% em 2003. Por outro lado, enquanto no segmento menos atingido pela doenca (CPOD de 1 a 3), o indice de cuidados aumentou de 26,3% em 1986 para 34,7% em 2003, no segmento com CPOD de 4 a 5 o indice de cuidados caiu de 50,2% em 1986 para 39,3% em 2003. No segmento com CPOD de 6 ou mais, o indice de cuidados se manteve estavel (28.0%). Aproximadamente 20% da populacao passou a concentrar cerca de 60% da carga de doenca. CONCLUSAO: Um declinio relevante do CPOD foi observado no periodo do estudo, sendo a hipotese explicativa mais plausivel a elevacao no acesso a agua e creme dental fluorados e as mudancas nos programas de saude bucal coletiva. A despeito da melhora, a distribuicao da carie ainda e desigual. Os dentes atingidos por carie passaram a se concentrar numa proporcao menor de individuos. Ademais, nao se alterou a proporcao de dentes cariados nao tratados. A reducao das disparidades socioeconomicas e medidas de saude publica dirigidas aos grupos mais vulneraveis permanecem como um desafio para todos os que formulam e implementam as politicas publicas no Brasil.

Cárie dentária e flúor: uma relação do século XX

No inicio do seculo XX a carie dentaria era um problema de saude publica, na maior parte do planeta. As populacoes conviviam com infeccao, dor, sofrimento e mutilacao. A descoberta do efeito preventivo do fluor o transformou, ao longo do seculo, no principal agente utilizado no enfrentamento da doenca em todo o mundo. Em varios paises e tambem no Brasil produtos fluorados tem sido apontados como os principais responsaveis pelo declinio observado na prevalencia da carie. No Brasil, estudos pioneiros realizados nos anos 50 e 60 corroboraram a eficacia preventiva da fluoretacao das aguas. No periodo 1986-1996, com 42% da populacao recebendo agua fluoretada, a queda na prevalencia da carie entre criancas de 12 anos de idade foi de 53%. Alem da agua fluoretada tambem os dentifricios sao, no presente, amplamente utilizados como veiculos para uso do fluor em saude publica. Neste artigo sao abordados aspectos historicos do emprego de fluor, algumas caracteristicas epidemiologicas da carie dentaria no Brasil, e as perspectivas da continuidade do uso de produtos fluorados nas proximas decadas.

Políticas de saúde bucal no Brasil e seu impacto sobre as desigualdades em saúde

This text systematizes available knowledge about the main dental health policies in Brazil in regards to their current degree of implementation and their impact on health inequalities. Although the fluoridation of publicly distributed water is legally mandated in Brazil, its implementation has been subject to marked regional inequalities. Data are presented about the extent of implementation for the intervention, and studies are reviewed that evaluate the interventions impact upon increasing inequality in the experience of dental caries. The provision of public dental services, which expanded considerably after the implementation of the National Unified Health Care System, is also discussed in relation to service provision and its impact on reducing inequality in access to dental treatment. The discussion of the differential effect of these interventions allowed for the proposal of targeted strategies (directing fluoridation to areas of greater need), aiming to reduce inequalities in the experience of dental caries in Brazil.Sistematiza-se o conhecimento disponivel sobre o estagio atual de efetivacao das principais politicas de saude bucal no Brasil e seu impacto sobre as desigualdades em saude. Embora a fluoretacao da agua de abastecimento publico no Brasil seja uma determinacao legal, sua implantacao tem sofrido marcantes desigualdades regionais. Sao apresentados dados sobre o grau de efetivacao da medida e sao revisados estudos que avaliaram seu impacto sobre a ampliacao da desigualdade na experiencia de carie dentaria. A oferta de atendimento publico odontologico, ampliada consideravelmente apos a implantacao do Sistema Unico de Saude, tambem e discutida em relacao a provisao do servico e seu impacto sobre a reducao da desigualdade no acesso a tratamento dentario. A discussao do efeito diferencial dessas medidas propiciou a proposicao de estrategias focais (direcionar a fluoretacao para as areas com maiores necessidades), visando a reduzir a desigualdade na experiencia de carie no Pais.

Aspectos metodológicos do Projeto SBBrasil 2010 de interesse para inquéritos nacionais de saúde

The SBBrasil 2010 Project (SBB10) was designed as a nationwide oral health epidemiological survey within a health surveillance strategy. This article discusses methodological aspects of the SBB10 Project that can potentially help expand and develop knowledge in the health field. This was a nationwide survey with stratified multi-stage cluster sampling. The sample domains were 27 State capitals and 150 rural municipalities (counties) from the countrys five major geographic regions. The sampling units were census tracts and households for the State capitals and municipalities, census tracts, and households for the rural areas. Thirty census tracts were selected in the State capitals and 30 municipalities in the countryside. The precision considered the demographic domains grouped by density of the overall population and the internal variability of oral health indices. The study evaluated dental caries, periodontal disease, malocclusion, fluorosis, tooth loss, and dental trauma in five age groups (5, 12, 15-19, 35-44, and 65-74 years).

Trends and spatial distribution of oral cancer mortality in São Paulo, Brazil, 1980–1998

We assessed oral cancer mortality data in São Paulo to study trends of the disease and its distribution by areas of the city. We standardized death rates by gender and age group, and also supplied complementary information regarding oral cancer incidence. Oral cancer mortality remained stationary at high levels during the study period. Site-specific death rates revealed high figures for two categories of site: tongue and unspecified parts of mouth. Gum cancer death rates--the most easily diagnosed site-specific oral cancer at a routine dental examination--fell sharply, possibly as a consequence of the recent expansion in community dental health services in the city. In spite of this observation, the increase of death rates related to unspecified parts of the mouth points to the deficiencies of health services in detecting most of oral cancer cases early. Spatial data analysis enabled indication of areas and socio-economic factors associated with poorer profile in oral cancer mortality, important information for the targeting of health resources directed to the screening, prevention and education in oral cancer.

The association between socioeconomic development at the town level and the distribution of dental caries in Brazilian children

OBJECTIVE To investigate the association between dental caries among children in the state of São Paulo, Brazil, and town-level indices of socioeconomic development. METHODS We examined 15 385 oral-examination records from children aged 5 or 6 years old from 129 towns and cities in the state of São Paulo. We studied two outcomes: (1) the mean number of decayed, missing, and filled deciduous teeth (dmft index) and (2) the care index, which is the proportion of decayed teeth that have already been filled. The explanatory variables were the child development index, human development index, illiteracy rate among subjects older than 20 years, household income, Gini coefficient, insufficient income, fluoridated water supply, number of dentists per 10 000 inhabitants, number of dentists in the public service per 10 000 inhabitants, and number of weekly hours of dentist work in the public service per 10 000 inhabitants. Multiple linear regression models were fitted to the two outcome variables (dmft index and care index). RESULTS The multiple linear regression analysis showed that a higher dmft index was associated with a low child development index, a high illiteracy rate, and an unfluoridated water supply. The child development index was significantly associated with the care index, and the number of dentists in the public service per 10 000 inhabitants showed borderline statistical significance. CONCLUSIONS Our results indicate that town-level indices of socioeconomic status are significantly correlated with caries indices. Our results also emphasize the beneficial effect that fluoridating water has on reducing the prevalence of dental caries and the fact that strategies for treating and preventing oral diseases should be emphasized within the context of overall health promotion for children.

A fluorose dentária no Brasil: uma revisão crítica

This paper discusses dental fluorosis as a relevant public health problem, using a review of epidemiological studies published in the last 10 years on the diseases prevalence, severity, and risk factors. The results suggest that there are already more cases than expected, although few studies refer to major severity. Thus, measures are needed for the prevention and surveillance of dental fluorosis.

Cárie dentária e condições sócio-econômicas no Estado do Paraná, Brasil, 1996

The aim of this research was to determine the correlation between dental caries and socioeconomic conditions in the State of Parana, Brazil. Caries prevalence was estimated for each city in the State by gathering data on the DMFT index (in 12-year-old schoolchildren) supplied by the State Health Department. Official socioeconomic data for the municipalities were also presented. Ordinary least squares regression analysis was performed, and significant correlation coefficients were observed between the dental caries index and various social development indicators. Maps highlighting the overlapping areas with poor outcomes for most of these variables were presented. The results showed a significantly lower DMFT index in cities with fluoridated water supply and a negative correlation between the caries index and the proportion of households with running water in cities with fluoridated water supply. This observation highlights the importance of fluoridated drinking water for the prevention of dental caries and as a measure to reduce the impact of socioeconomic inequalities on the prevalence of tooth decay.

Saúde bucal coletiva: caminhos da odontologia sanitária à bucalidade

This essay focuses on the pioneer activities of public health dentistry in Brazil and its evolution in the 20th century with emphasis on the emergency of a landmark, the sanitary dentistry. Social and preventive dentistry and market dentistry, with reference to the main theoretical works representative of these trends, are presented. The essential characteristics of collective oral health (Brazilian variant of public health dentistry) and buccality are presented. The relationship between collective oral health and collective health as well as the implications of the buccality concept for the development of public health dentistry actions and new guidance of clinical practice in public services of the Brazilian Health System (SUS) are discussed. The key elements of an agenda for collective oral health based on proposals presented at the 3rd National Conference on Oral Health are addressed.

Prevalência de oclusopatia na dentição decídua e permanente de crianças na cidade de São Paulo, Brasil, 1996

O objetivo deste estudo foi estimar a prevalencia de oclusopatia na denticao decidua e permanente de criancas de escolas publicas e privadas do Municipio de Sao Paulo, SP, Brasil, em 1996. A condicao oclusal foi classificada em tres categorias: normal, leve e moderada/severa conforme os criterios da Organizacao Mundial da Saude. Os resultados referem-se a 985 exames em criancas de 5 e 12 anos de idade. A prevalencia das oclusopatias foi alta, aumentando de 48,97 ± 4,53% na denticao decidua a 71,31 ± 3,95% na denticao permanente, sendo que a proporcao de oclusopatia moderada/severa foi quase duas vezes maior na denticao permanente (OR = 1,87; IC95% = 1,43-2,45; p < 0,001). Quanto ao sexo e ao tipo de estabelecimento de ensino, nao foram observadas diferencas estatisticamente significativas nas idades estudadas. Diferencas estatisticas associadas aos grupos etnicos denotam a complexidade e diversidade da oclusao na populacao e sugerem que estudos longitudinais devem ser realizados.