Simone Rennó Junqueira

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.

Determinantes individuais e contextuais da prevalência de cárie dentária não tratada no Brasil

OBJETIVO: Descrever a prevalencia de carie dentaria nao tratada em adolescentes no Brasil e analisar a associacao da carie com fatores individuais e contextuais nos municipios onde esses adolescentes residem. METODOS: Utilizou-se um banco de dados gerado pelo Ministerio da Saude (projeto SB-Brasil) que inclui informacoes de 16 833 adolescentes (15 a 19 anos). A presenca de ao menos um dente permanente com carie nao tratada foi a variavel de estudo. As variaveis explicativas, em nivel individual, foram: sexo, grupo etnico, local de residencia e situacao escolar. As variaveis referentes ao municipio foram: indice de desenvolvimento humano municipal (IDH-M), proporcao de domicilios com ligacao de agua e presenca de fluor na agua de abastecimento ha 5 anos ou mais. Para ajustar o desfecho as condicoes individuais e municipais de interesse, foi realizada uma analise multinivel para estimacao em modelos multivariados de regressao logistica. RESULTADOS: Ser negro ou pardo (razao de chances ajustada, ORajust = 1,79; 1,68 a 1,92) e residir em area rural (ORajust = 1,31; 1,19 a 1,45) foram determinantes individuais de maior probabilidade de apresentar carie nao tratada. Ser estudante foi identificado como fator de protecao (ORajust = 0,67; 0,62 a 0,73). As variaveis de segundo nivel, IDH-M (coeficiente ajustado beta = -0,213), fluor na rede de agua (beta = -0,201) e proporcao de domicilios com ligacao de agua (beta = -0,197) foram identificadas como determinantes contextuais de carie. CONCLUSAO: Os resultados mostram que existe desigualdade na distribuicao dos servicos de saude nas diferentes regioes brasileiras e sugerem que pode haver desigualdade tambem na efetividade dos servicos prestados. Politicas de expansao do acesso a agua fluoretada e inclusao escolar podem contribuir para evitar a doenca carie em adolescentes.

City-level gender differentials in the prevalence of dental caries and restorative dental treatment

This study assesses gender differentials in the distribution of dental caries and restorative treatment at the city level in order to discuss gender inequities in health. We retrieved data for caries prevalence and dental service utilisation by 11- and 12-year-old girls and boys in 131 towns in the state of São Paulo, Brazil, 1998. We also gathered aggregate population data for these towns, and information already held by the health authority regarding the provision of dental services. Results of data analysis indicated that girls presented higher caries indices in permanent teeth than boys of the same age, concurrent with a higher utilisation of dental care. When studying aggregate data at the city level, we gathered evidence reinforcing the hypothesis that the higher prevalence of caries in girls is attributable to their earlier eruption of permanent teeth, with no significant association between this excess and indices of socio-economic status at the city level. However, indices assessing the discrepant incorporation of dental services between genders were higher in towns with a poorer profile of socio-economic status. We also observed that towns whose public health service was more effective in providing dental care presented a more equitable gender distribution of dental services. Public resources destined to dental assistance contributed to reducing inequities in oral health by allowing an incorporation of restorative dental treatment more equitably distributed between girls and boys.

Indicadores socioeconômicos e recursos odontológicos em Municípios do Estado de São Paulo, Brasil, no final do século XX

Resumo Sabendo-se que indicadores sociais influenciam o processo saude-doenca, buscou-se analisar se eles modularam os servicos publicos municipais odontologicos no Estado de Sao Paulo, no final do seculo XX. Caracteristicas socioeconomicas da populacao foram relacionadas aos recursos de gerenciamento dos servicos. As variaveis foram submetidas a analise bivariada e de regressao linear multipla. O numero de profissionais publicos revelou-se maior quanto piores mostraram-se os indicadores de renda e analfabetismo e quanto maiores foram as receitas e despesas em saude. O numero de auxiliares de odontologia manteve-se inadequado para o trabalho em equipe. O numero de equipamentos equivaleu ao de cirurgioesdentistas, indicando ociosidade da capacidade instalada; e esteve relacionado com a menor renda media e melhor receita municipal. Os cirurgioes-dentistas inscritos no Conselho Regional de Odontologia de Sao Paulo (CRO/SP) acompanharam as melhores condicoes socioeconomicas da populacao. Tem havido, no setor publico, o direcionamento dos recursos humanos e materiais de acordo com as necessidades da populacao, caracterizando-se a equidade do sistema de saude brasileiro. Palavras-chave: indicadores sociais; saude bucal; servicos de atendimento. Summary Socio-economic characteristics of the population were related to the resources of oral health services in the cities of Sao Paulo State, Brazil, at the end of the 20th century. The variables were submitted to a multiple linear regression analysis. The number of professionals in the public oral health system increases as the indicators of income and illiteracy get worse and expenditures in health increase. The number of dental attendants is still inadequate to introduce a new practice of team work in the heath system. In public services, the amount of dental equipment is equivalent to the number of dentists, which can indicate idleness of installed capacity. This variable is related to the lowest average income rate of the population and high income of the city. Dentists registered at the CRO/SP (responsible for the legalization of all oral health professionals in Sao Paulo State) are provided with the best socio-economic conditions. Public policy of oral health services is conducted according to the population needs and these resources are proportionally higher in cities presenting low socio-economic indicators.

Avaliação dos procedimentos coletivos em saúde bucal: percepção de adolescentes de Embu, SP

The decline in tooth decay in the children of the State of Sao Paulo is explained by fluoridation of the water supply, the use of fluoridated toothpaste and access to collective actions promoting oral health, such as the “collective procedures” (CPs). CPs are educational and preventive annual programs developed in public schools by the Brazilian public health system. It is expected that the participants will acquire and maintain healthy oral hygiene practices. The purpose of this study was to investigate perception, knowledge and practices/behavior related to oral health, as well as the evaluation of the educational and preventive activities of 219 students of the 1 grade of high school in the city of Embu, Sao Paulo, in 2005. The first group of students had received the CPs in elementary public school from grades 1 to 4; the second group had received them from grades 1 to 8; and the third one had not received the CPs. The students were interviewed after consent had been obtained. Analyses were performed using the Chi-square test. No significant differences were found between groups. The majority of the students believe it is important to speak about oral health at school. The ones who had not participated in the CPs said that they had received some instructions at school, which strengthens the theory according to which oral health is influenced by other factors. In this study, children’s participation in the CPs did not seem to have an impact on oral health care/practices in adolescence.

Conditional factors for untreated caries in 12-year-old children in the city of Sao Paulo

The aim of the study was to analyze what sociodemographic and economic variables were associated with the presence of untreated caries in 12-year-old children in the city of São Paulo. This cross-sectional study had a complex sample design. It was based on secondary data generated by the Levantamento epidemiológico em saúde bucal (Epidemiological Oral Health Survey) in the city of São Paulo, conducted in 2008, whose sample comprised 4,246 12-year-old children from the public and private schools of all the administrative districts of the city. A questionnaire was applied and an epidemiological exam was performed in accordance with the World Health Organizations (WHO) recommendations. The variables of interest were categorized into a dependent variable of untreated dental caries (carious component of the DMFT index that corresponds to carious, missing and filled teeth) and independent variables related to the socioeconomic and demographic conditions of the children and their families, and to their access to dental services. The EPI-INFO 06 and STATA 10 programs were used for the analysis; the prevalence ratio and a confidence interval of 95% were applied to the population parameters. The Poisson regression model was used, adjusted for sampling of the complex type. Caries was associated with ethnicity (higher rate in black people, p=0.042), attending public school (p=0.000), lower average family income (p=0.002), overcrowded dwellings (p=0.000) and presence of pain (p=0.000). Caries is a multifactorial disease influenced by social health determinants that intensify its risk.

Saúde bucal e uso dos serviços odontológicos em função do Índice de Necessidades em Saúde: São Paulo, 2008

The Health Department of Sao Paulo, Brazil, has developed a Health Necessities Index (HNI) to identify priority areas for providing health assistance. In 2008, a survey of the status of oral health was conducted. The objective of this ecological study was to analyze the status of oral health in relation to the HNI. The variables, stratified by the age of 5, 12 and 15 years old were: percentage of individuals with difficulty of access to dental care services; DMFT and DMFS; prevalence of the need for tooth extraction and treatment of dental caries. Data were analyzed for the 25 Health Technical Supervision Units (HTS). The Statistical Covariance Test was used as well as the Pearson correlation coefficient and linear regression model. A positive correlation was observed between high scores of the HNI and difficulty of access to services. In the HTS with high scores of HNI a higher incidence of dental caries was observed, a greater need for tooth extractions and low caries-free incidence. In order to improve health conditions of the population it is mandatory to prioritize actions in areas of social deprivation.

Diagnóstico da cárie dentária: comparação dos resultados de três levantamentos epidemiológicos numa mesma população

INTRODUCAO: Os indices mais utilizados para medir a frequencia da carie dentaria em populacoes sao o CPO-D, para dentes permanentes, e o ceo-d, para dentes temporarios. A Organizacao Mundial da Saude vem estabelecendo, desde os anos 60, padroes para os levantamentos de carie dentaria, a fim de melhorar a validade e a confiabilidade dos dados. Tem havido questionamentos, porem, quanto a validade e a confiabilidade de dados obtidos com essas diferentes padronizacoes da metodologia, quando sao introduzidas mudancas nos criterios utilizados para definir o que e carie dentaria. OBJETIVO: Comparar os dados obtidos de uma mesma populacao de referencia, empregando diferentes padronizacoes dos indices CPO-D e ceo-d, com a finalidade de verificar se essas diferencas nos criterios alteram significativamente as estimativas. METODOLOGIA: Foram utilizados dados secundarios, obtidos em levantamentos epidemiologicos realizados no municipio de Sao Paulo, em 1996 e 1998. Analisaram-se as medias e a distribuicao dos valores dos indices CPO-D e ceo-d, em escolares de 6 a 12 anos de idade, comparando-se estatisticamente medias e proporcoes. Admite-se que outros aspectos metodologicos, como os planos amostrais e os treinamentos de calibracao, tambem poderiam alterar os resultados. RESULTADOS: Nao se observou diferenca estatisticamente significativa entre as medias. Houve diferencas significativas nas porcentagens de individuos livres de carie na denticao permanente; o mesmo nao aconteceu com os dentes deciduos. CONCLUSAO: Os diferentes criterios empregados para definir carie dentaria nao levaram a obtencao de medias e porcentagens estatisticamente diferentes nos tres levantamentos.

O ensino de bioética: avaliação discente por meio de fóruns de discussão na Internet

Bioethics learning has mainly being developed in classroom activities. Without pretending to substitute this classical face to face model, bioethics discipline, taught to first year students at day and night courses in Dentistry Department of Sao Paulo University, has been complemented by supervised visits to Department Clinics, as well as on line studies using Moodle platform. In this study students’ records of discussion forums in Moodle platform in 2008 were evaluated to verify their perception about the proposal of supervised visits to clinical practice during their learning process. 71 of 100 students who published comments in discussion forums accepted to participate in the study. This is a qualitative study carried out by thematic content analysis. Students’ perceptions about clinical practice allow professors to enhance their practice as pedagogical strategy for future classes and this may serve as model for other institutions.

Educação pelo trabalho: reorientando a formação de profissionais da saúde

O trabalho se propos a avaliar o Programa de Educacao pelo Trabalho para a Saude (PET-Saude) instituido na Universidade de Sao Paulo, Brasil. Os sujeitos do estudo foram preceptores e alunos de odontologia que integraram a proposta entre os anos de 2009 e 2012. Foi utilizada uma abordagem qualitativa, sendo os dados coletados por grupos focais e analisados por analise de conteudo tematica. Os resultados evidenciam que a educacao pelo trabalho e capaz de auxiliar no processo formativo, ampliar o olhar do estudante em direcao ao processo saude/doenca e despertar para atuacao futura no âmbito do Sistema Unico de Saude (SUS). Uma das vantagens apontadas consiste no estabelecimento da interdisciplinaridade no processo formador. Os resultados do estudo traduzem o programa como um poderoso instrumento de inducao de mudancas nas concepcoes dos profissionais de saude.O trabalho se propos a avaliar o Programa de Educacao pelo Trabalho para a Saude (PET-Saude) instituido na Universidade de Sao Paulo, Brasil. Os sujeitos do estudo foram preceptores e alunos de odontologia que integraram a proposta entre os anos de 2009 e 2012. Foi utilizada uma abordagem qualitativa, sendo os dados coletados por grupos focais e analisados por analise de conteudo tematica. Os resultados evidenciam que a educacao pelo trabalho e capaz de auxiliar no processo formativo, ampliar o olhar do estudante em direcao ao processo saude/doenca e despertar para atuacao futura no âmbito do Sistema Unico de Saude (SUS). Uma das vantagens apontadas consiste no estabelecimento da interdisciplinaridade no processo formador. Os resultados do estudo traduzem o programa como um poderoso instrumento de inducao de mudancas nas concepcoes dos profissionais de saude.