Eleven-Year Analysis (2010 to 2020) of Dental Implant Procedures in the Unified Health System (SUS)ABSTRACT
Objective: To analyze the number of dental implants performed at dental specialty centers of the Unified Health System (SUS) between 2010 and 2020, in the Brazilian macro-regions.
Material and Methods: A retrospective, quantitative, longitudinal study was conducted using publicly available data from the DATASUS/TABNET platform. The total number of annual dental implants was calculated by macro-region. The Kruskal-Wallis and Mann-Whitney nonparametric tests were applied, with 95% confidence intervals and a significance level of 5%.
Results: A total of 146,875 dental implant procedures were performed from 2010 to 2020. When comparing regions, the South performed 88,034 (59.94%) procedures, while the North performed 1,173 (0.80%; p < 0.0001). The South region showed statistical significance compared with Central-West (p = 0.0019), Northeast (p = 0.041), and Southeast regions (p = 0.0006). Annual comparisons of total procedures between regions indicated a statistical significance (p < 0.05) for dental implants. Also, statistical significances were observed between 2010 vs. 2016 (p = 0.0476), 2010 vs. 2017 and 2010 vs. 2018 (p = 0.0079), 2010 vs. 2019 and 2010 vs. 2020 (p = 0.0476), 2011 vs. 2017 (p = 0.0159), and 2012 vs. 2017 and 2017 vs. 2020 (p = 0.0317).
Conclusion: Therefore, differences in the number of dental implants across regions may be associated with barriers to access or the unavailability of services.
Keywords:
Surgery; Oral; Periodontal Diseases; Dental Implants; Public Health Dentistry.
Introduction
The Brasil Sorridente program was incorporated into the Brazilian Unified Health System (SUS) in 2004 [1-6] and, from 2010, implemented dental implant procedures in Dental Specialty Centers (Centros de Especialidades Odontologicas - CEO) [7]. The Department of Informatics of the SUS (DATASUS) [8] monitors these procedures, allowing the development and design of new policies for attention and prevention [4,9]. Also, this program is essential, as oral diseases are considered a global health problem [10,11] that negatively impacts human health [11-13] and requires integration into health systems [14,15].
Although the Brasil Sorridente program for oral health care is universal, integral, and free [16,17], its territorial dimension and regional differences highlight the complexity of health practices [18]. Thus, considering the need to expand healthcare centered on basic care [3-5,12,13], the presence of the CEO is an effort to extend coverage in specialized care [17,19-22], which was monitored by the Program for Improving Access and Quality of CEO (PMAQ-CEO) [23-25].
In this context, dental implant procedures performed by the CEO represent a significant achievement for oral health in Brazil, and access to information on data monitoring is essential to developing and expanding this specialized care. Thus, this study analyzed the number of dental implants performed in the SUS from 2010 to 2020.
Material and Methods
The study was reported following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.
Design and Context
A retrospective, quantitative longitudinal study was conducted to analyze dental implant procedures performed at the CEO of the SUS from 2010 to 2020. The Brazilian Unified Health System began offering dental implant procedures in 2010 through the CEO, marking a significant advancement in oral health care. Considering the benefits of this service, analyzing the number of dental implants and specialized centers allows us to assess the progress of treatment coverage to develop new oral health policies.
Variables
The following variables were included: dental procedures performed from January 2010 to December 2020; dental implants performed from January 2010 to December 2020; the number of CEO between 2014 and 2018; the number of specialists between 2014 and 2018; and macro-regions (Central-West, North, Northeast, South, and Southeast). The results from the two PMAQ-CEO cycles (2014 and 2018) were also used to support the analysis.
Data Source
The number of dental implants performed in the SUS was collected from the TABNET/DATASUS public database [10] on June 20, 2021, while the numbers of CEOs and specialists were collected from the PMAQ-CEO.
Data Analysis
The collected data were exported and plotted in an Excel (version 2013) spreadsheet, and statistical analysis was conducted using Prism (version 9; GraphPad Software, La Jolla, CA, USA), including time-series analysis. Data from DATASUS showed non-normal distributions (Shapiro-Wilk test) for the procedure, year, and region variables; the Kruskal-Wallis and Mann-Whitney nonparametric tests were applied, with 95% confidence intervals and a significance level of 5%.
Results
A total of 146,875 dental implant procedures were performed from 2010 to 2020. When comparing regions, the South performed 88,034 (59.94%) procedures, while the North performed 1,173 (0.80%; p < 0.0001). The South region showed statistical significance compared with Central-West (11.35%, p = 0.0019), Northeast (21.18%, p = 0.041), and Southeast regions (6.74%, p = 0.0006) (Table 1).
Annual comparisons of total procedures between regions indicated a statistical significance (p < 0.05) for dental implants (Table 1). Also, statistical significances were observed between 2010 versus 2016 (p = 0.0476), 2010 versus 2017 and 2010 versus 2018 (p = 0.0079), 2010 versus 2019 and 2010 versus 2020 (p = 0.0476), 2011 versus 2017 (p = 0.0159), and 2012 versus 2017 and 2017 versus 2020 (p = 0.0317).
Considering the CEO as places to perform dental procedures and the number of specialists, the first and second PMAQ-CEO cycles were used as references. During the first cycle, 932 types I, II, and III CEO with 10,153 specialists in several areas were active in Brazil. In the second cycle, the number of types I, II, and III CEO increased to 1,060, while the number of specialists in the same areas decreased to 6,249. The comparison between both cycles showed an increase in CEO and a decrease of 3,904 specialists (Table 2).
In the first cycle, 27 implant specialists were identified, increasing to 34 in the second cycle. Regarding CEO distribution and specialists per region, the 34 implant specialists (second cycle) were allocated to 27% of the total CEO performing dental implants in the macro-regions. The South region had 9% (12) of its total CEOs performing dental implants, while the Southeast region had 91% (249), the Central-West had 8% (6), the Northeast had 3% (14), and the North had 2% (1) (Table 3).
Number and percentage of CEO, CEO performing implants, implant specialists, and implants performed in 2018 by macro-region.
Discussion
Despite broad coverage and integration of public oral health services, disparities in provision were observed across regions [1]. Also, a low representation of dental implants was observed when considering the general framework of dental procedures performed in the SUS [26].
Although dental implant procedures began in 2010, they were recorded only from 2011, totaling 146,875 implants during the studied period. The South region presented the highest number of implants (59.94%, 88,034), followed by the Northeast (21.18%, 31,102), Central-West (11.35%, 16,671), Southeast (6.74%, 9,895), and North (0.80%, 1,173) (Table 1).
The North region had records of dental implants only between 2017 and 2018 (806 and 367 implants, respectively). The Northeast increased the number of implants from 2015 to 2017, but decreased in 2018 to the same number as in 2014. Simultaneously, the Southeast region maintained a standard level of implant provision during the studied period. Also, the COVID-19 pandemic may have contributed to the decrease in procedures in 2020, as it temporarily disrupted dental care services [27].
The South region concentrated most of the implant procedures performed during the timeframe. However, its records were audited by the Brazilian Ministry of Health between 2015 and 2019 due to potential irregularities related to the high number of procedures in municipalities with low population density, which may influence the results by increasing the number of procedures in this region [28].
When associating the number of dental implants with the CEO offering the procedures, 282 centers were identified (2010 to 2020) [25] of the 932 CEO in the first cycle and 1,060 in the second cycle of the PMAQ-CEO, with 27 implant specialists in 2014 and 34 in 2018, highlighting the low productivity related to total procedures. However, outsourced services not registered in the PMAQ-CEO and difficulty in accessing the CEO performing the procedures by the population may have influenced the number of specialists [24].
Although all CEOs who meet the minimum mandatory criteria (i.e., oral diagnosis, specialized periodontics, minor surgeries, endodontics, and care for patients with special needs) can perform dental implants, challenges persist in providing services involving rehabilitation with prosthesis over implants. Such challenges may occur because rehabilitation treatment is a priority for patients with complete edentulism and insufficient alveolar ridges, which impair the use of a total dental prosthesis, with a transfer value of R$ 260.00 for the surgical phase per implant and R$ 300.00 for the prosthesis, regardless of the number of implants [17].
The financial incentive to the CEO as a strategy to improve management may influence the number of specialized procedures [29]. However, the PMAQ-CEO, conducted between 2014 and 2018, was discontinued and replaced by a new evaluation method, Previne Brasil, without a new survey, limiting data comparison across new periods [30]. When using public data, the reliability of the results depends on the responsibility of each specialist within the CEO and healthcare units, and mechanisms for verification should be incorporated to enhance this reliability [8].
Conclusion
The difference in the number of dental implant procedures across Brazilian regions may be associated with barriers to access or service unavailability, increasing the discrepancy among regions.
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Financial Support
None.
Data Availability
The data used to support the findings of this study can be made available upon request to the corresponding author.
References
- [1] Brasil. Constituição da República Federativa do Brasil de 1988. Brasília. DF: Presidência da República; 2016. [In Portuguese].
-
[2] Brasil. Lei 8.080 de 19 de Setembro de 1990. Dispõe sobre as condições para a promoção, proteção e recuperação da saúde, a organização e o funcionamento dos serviços correspondentes e dá outras providências. Diário Oficial da União, 1990. Available from: https://www.planalto.gov.br/ccivil_03/leis/l8080.htm [Accessed on November 05, 2022]. [In Portuguese].
» https://www.planalto.gov.br/ccivil_03/leis/l8080.htm - [3] Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Secretaria de Vigilância em Saúde. SB Brasil 2010: Pesquisa Nacional de Saúde Bucal: resultados principais. Brasília: Ministério da Saúde; 2012. [In Portuguese].
-
[4] Janakiram C, Dye BA. A public health approach for prevention of periodontal disease. Periodontol 2000 2020; 84(1):202-214. https://doi.org/10.1111/prd.12337
» https://doi.org/10.1111/prd.12337 -
[5] Chisini LA, Martin ASS, Pires ALC, Noronha TG, Demarco FF, Conde MCM, et al. A 19-years study of the dental procedures performed in the Brazilian Unified Health System. Cad Saúde Coletiva 2019; 27(3):345-353. https://doi.org/10.1590/1414-462X201900030215
» https://doi.org/10.1590/1414-462X201900030215 - [6] Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política Nacional de Atenção Básica Brasília. Brasília: Ministério da Saúde; 2012. [In Portuguese].
-
[7] Brasil. Portaria nº 718/SAS, de 20 de dezembro de 2010. Dispõe sobre a assistência aos pacientes com anomalia do crânio e região bucomaxilofacial. Diário Oficial da União, Brasília; 2010. Available from: https://bvsms.saude.gov.br/bvs/saudelegis/sas/2010/prt0718_20_12_2010.html [Accessed on November 05, 2022]. [In Portuguese].
» https://bvsms.saude.gov.br/bvs/saudelegis/sas/2010/prt0718_20_12_2010.html -
[8] Lopes FRL, Monteiro KS, Santos S. How data provided by the Brazilian information system of primary care have been used by researchers. Health Informatics J 2020; 26(3):1617-1630. https://doi.org/10.1177/1460458219882273
» https://doi.org/10.1177/1460458219882273 - [9] Pettres AA, Ros MA. A determinação Social da saúde e a promoção de saúde. Arq Catarin Med 2018; 47(3):183-196. [In Portuguese].
-
[10] Marcenes W, Kassebaum NJ, Bernabé E, Flaxman A, Naghavi M, Lopez A, et al. Global burden of oral conditions in 1990-2010: A systematic analysis. J Dent Res 2013; 92(7):592-597. https://doi.org/0.1177/0022034513490168
» https://doi.org/0.1177/0022034513490168 -
[11] Bawaskar HS, Bawaskar PH. Oral diseases: A global public health challenge. Lancet 2020; 395(10219):185-186. https://doi.org/10.1016/S0140-6736(19)33016-8
» https://doi.org/10.1016/S0140-6736(19)33016-8 -
[12] Kassebaum NJ, Smith AGC, Bernabé E, Fleming TD, Reynolds AE, Vos T, et al. Global, regional, and national prevalence, incidence, and disability-adjusted life years for oral conditions for 195 countries, 1990-2015: A systematic analysis for the global burden of diseases, injuries, and risk factors. J Dent Res 2017; 96(4):380-387. https://doi.org/10.1177/0022034517693566
» https://doi.org/10.1177/0022034517693566 -
[13] Jin LJ, Lamster IB, Greenspan JS, Pitts NB, Scully C, Warnakulasuriya S. Global burden of oral diseases: Emerging concepts, management and interplay with systemic health. Oral Dis 2016; 22(7):609-619. https://doi.org/10.1111/odi.12428
» https://doi.org/10.1111/odi.12428 -
[14] Singhal A, McKernan SC, Sohn W. Dental public health practice, infrastructure, and workforce in the United States. Dent Clin North Am 2018; 62(2):155-175. https://doi.org/10.1016/j.cden.2017.11.001
» https://doi.org/10.1016/j.cden.2017.11.001 -
[15] Lomazzi M, Wordley V, Bedi R. Dental public health capacity worldwide: Results of a global survey. J Public Health Policy 2016; 37(4):528-542. https://doi.org/10.1057/s41271-016-0029-9
» https://doi.org/10.1057/s41271-016-0029-9 -
[16] Reda SF, Reda SM, Thomson WM, Schwendicke F. Inequality in utilization of dental services: A systematic review and meta-analysis. Am J Public Health 2018; 108(2):e1-e7. https://doi.org/10.2105/AJPH.2017.304180
» https://doi.org/10.2105/AJPH.2017.304180 - [17] Kinalski MA, Pires ALC, Saporiti JM, MBF Santos. Dental implant therapy in the Brazilian Public System: An overview of the last decade. Braz J Oral Sci 2020;:19.
-
[18] Fonseca SGOD, Fonseca EPD, Meneghim MC. Factors associated with public dental service use by adults in the state of São Paulo, Brazil, 2016. Cien Saude Colet 2020; 25(1):365-374. https://doi.org/10.1590/1413-81232020251.04562018
» https://doi.org/10.1590/1413-81232020251.04562018 -
[19] Silva HECD, Gottems LBD. The interface between primary and secondary care in dentistry in the Unified Health System (SUS): An integrative systematic review. Cien Saude Colet 2017; 22(8):2645-2657. https://doi.org/10.1590/1413-81232017228.22432015
» https://doi.org/10.1590/1413-81232017228.22432015 -
[20] Billings M, Holtfreter B, Papapanou PN, Mitnik GL, Kocher T, Dye BA. Age-dependent distribution of periodontitis in two countries: Findings from NHANES 2009 to 2014 and SHIP-TREND 2008 to 2012. J Clin Periodontol 2018; 45(Suppl 20):S130-S148. https://doi.org/10.1111/jcpe.12944
» https://doi.org/10.1111/jcpe.12944 -
[21] GBD 2021 Diseases and Injuries Collaborators. Global incidence, prevalence, years lived with disability (YLDs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) for 371 diseases and injuries in 204 countries and territories and 811 subnational locations, 1990-2021: A systematic analysis for the Global Burden of Disease Study 2021. Lancet 2024; 403(10440):2133-2161. https://doi.org/10.1016/S0140-6736(24)00757-8
» https://doi.org/10.1016/S0140-6736(24)00757-8 -
[22] Schierz O, Baba K, Fueki K. Functional oral health-related quality of life impact: A systematic review in populations with tooth loss. J Oral Rehabil 2021; 48(3):256-270. https://doi.org/10.1111/joor.12984
» https://doi.org/10.1111/joor.12984 - [23] Brasil. Programa Nacional de Melhoria do Acesso e da Qualidade dos Centros de Especialidades odontológicas (PMAQ-CEO). Ministério da Saúde. Departamento de atenção básica. Brasília: Ministério da Saúde; 2013. [In Portuguese].
-
[24] Kimatura ES, Bastos RR, Palma PV, Leite ICG. Patient satisfaction evaluation at the Specialized Dental Centers in the Southeast Macro-region of Minas Gerais, Brazil, 2013. Epidemiol Serv Saúde 2016; 25(1):137-148. https://doi.org/10.5123/S1679-49742016000100014
» https://doi.org/10.5123/S1679-49742016000100014 -
[25] Goes PSA, Biazevic MG, Celeste RK, Moyses S. Secondary dental care quality in Brazil: What we are talking about?. Community Dent Oral Epidemiol 2022; 50(1):1-3. https://doi.org/10.1111/cdoe.12724
» https://doi.org/10.1111/cdoe.12724 - [26] Almeida AMR, Gurgel GSCA, Campos CG, Guimarães EAA. Access to dental implant osseointegrated in the Unified Health System (SUS): Description of the national panorama. Arq Odontol 2016; 52(3):145-153.
-
[27] Danigno JF, Echeverria MS, Tillmann TFF, Liskoski BV, Silveira MG de S e S, Fernandez M dos S, et al. Factors associated with the reduction of dental care in Primary Health Care in Brazil after the emergence of COVID-19: A cross-sectional study, 2020. Epidemiol Serv Saúde 2022; 31(1):e2021663. https://doi.org/10.1590/S1679-49742022000100015
» https://doi.org/10.1590/S1679-49742022000100015 -
[28] Brasil. Ofício Nº 856/2020/ASPAR/GM/MS. Brasília. Luiz Henrique Mandetta, 2020, 6p. Available from: https://www.camara.leg.br/proposicoesWeb/prop_mostrarintegra;jsessionid=3C04A5CF6C693CB3FFA56229D3414543.proposicoesWebExterno2?codteor=1864952&filename=Tramitacao-RIC+18/2020 [Accessed on November 05, 2022]. [In Portuguese].
» https://www.camara.leg.br/proposicoesWeb/prop_mostrarintegra;jsessionid=3C04A5CF6C693CB3FFA56229D3414543.proposicoesWebExterno2?codteor=1864952&filename=Tramitacao-RIC+18/2020 -
[29] Cabreira FDS, Hugo FN, Celeste RK. Pay-for-performance and dental procedures: A longitudinal analysis of the Brazilian Program for the Improvement of Access and Quality of Dental Specialities Centres. Community Dent Oral Epidemiol 2022; 50(1):4-10. https://doi.org/10.1111/cdoe.12717
» https://doi.org/10.1111/cdoe.12717 -
[30] Harzheim E. “Previne Brasil”: bases of the Primary Health Care Reform. Ciênc Saúde Colet 2020; 25(4):1189-1196. https://doi.org/10.1590/1413-81232020254.01552020
» https://doi.org/10.1590/1413-81232020254.01552020
Edited by
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Academic Editor:
Wilton Wilney Nascimento Padilha
