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Conteúdo (article):

THE USE OF DENTAL SERVICES IN THE PAST YEAR IN THE BRAZILIAN POPULATION: A SYSTEMATIC REVIEW WITH META-ANALYSIS.
Cinthia Nara Gadelha Teixeira - Universidade de Fortaleza
cinthia_n80@yahoo.com.br
ORCID: 0000-0003-0762-6121
Sângela Maria da Silva Pereira - Universidade Federal do Maranhão
sangelamaria@live.com
ORCID: 0000-0003-0287-7714
Juliana Balbinot Hilgert - Universidade Federal do Rio Grande do Sul
jhilgert@gmail.com
ORCID: 000-0002-2204-1634
Neurinéia Margarida Alves de Oliveira - Universidade Federal do Maranhão
oliveira.neury@gmail.com
ORCID: 0000-0002-5553-4988
Cecília Cláudia Costa Ribeiro - Universidade Federal do Maranhão
cecilia_ribeiro@hotmail.com
ORCID: 0000-0001-9126-1836
Matheus Neves - Universidade Federal do Rio Grande do Sul
matineves@gmail.com
ORCID: 0000-0002-7336-8987
Erika Bárbara Abreu Fonseca Thomaz - Universidade Federal do Maranhão
ebthomaz@gmail.com
ORCID: 0000-0003-4156-4067
Fernando Neves Hugo - Universidade Federal do Rio Grande do Sul
fernandoneveshugo@gmail.com
ORCID: 0000-0003-2222-7719
Cláudia Maria Coelho Alves - Universidade Federal do Maranhão
cmcoelhoa@gmail.com
ORCID: 00000-0003-4705-4914

Abstract:
The aim of this study was to analyze the factors associated with the use of dental services in Brazil. The review strategy included PubMed, SciELO, LILACS, BBO, EMBASE, Scopus, WOS and Google Scholar, in addition to repositories and databases of dissertations and theses. Studies were ed using the PEO (Population/Exposure/Outcomes) strategy. The outcome of this study was the use of dental services in the last year, by the Brazilian population, treated as dichotomous variables for the analyses: ≤1 year and >1 year. A Mantel-Haenszel random effect meta-analysis was performed, estimating Prevalence Ratios (PR) and 95% confidence intervals (95%CI). 94 studies were ed. The majority (98%) had a cross-sectional design, with 63% comingprimary data. For the meta-analysis, 25 studies were included. The use of oral health services in the last year was associated with higher education (≥8 years of schooling) (PR=0.49, (95%CI:0.39-0.60)); higher family income (≥2 minimum wages) (RP=0.79, (95%CI:0.74-0.84)); and reside in the urban area (RP=0.79, (95%CI:0.64-0.97)). The offer of dental services in the Unified Health System needs to be expanded among people with lower income, less education and those living in rural areas.

Keywords:
Access to Health Services. Equity in Health. Systematic Review. Oral Health. Dental care


Introduction
Access is one of the main priorities of health policies, being one of the most significant challenges to health systems, although there needs to be a consensus definition1-2. It is a diffuse concept, often used imprecisely, changing over time and context-dependent3. Donabedian4 refers to access to health services as accessibility, namely, the ability to produce services and respond to the health needs of a given population. It can be the use, which refers to entering health services and the continuity of treatment5. Another author6 considers it multidimensional, composed of multiple elements, such as the access provided.
Access is achieved with the use of health services7. The interaction between supply and demand influences the use of health services, occurring when health services are offered and users seek this service³. The use of health services results from a complex interaction between users, availability, and access to services. Some individual characteristics influence it. It is the perception of health status and needs; contextual factors, such as social inequalities; and the organization of health services8-10.
The use and use frequency of Brazilian dental services are influenced by variables such as schooling11-16 and socioeconomic conditions11,12,16,17. Other characteristics associated with greater use of dental services include being female13,14,18, white13, and having a health plan/insurance13,18. Contextual factors are also associated: urbanity (living in an urban area)19 and coverage by the Family Health Strategy (ESF)13.
Admittedly, the use of dental services is influenced by the supply and demand for services20. There are also access barriers, financial and physical, which can prevent or hinder the ability of people to use these services21 – these impact access to services, especially among vulnerable populations22. Despite the changes and evolution in the Brazilian health system, the use of dental services is sometimes low23,24 and still occurs unequally11,25.
Thus, given the gap in the literature and the importance of synthesizing the available evidence, this study aimed to analyze the factors associated with the use of dental services in the last year in the Brazilian population, considering the different macro-regions.

Methods
Protocol and Register
This study was registered in PROSPERO (CRD42020189716). A systematic review of observational studies with meta-analysis was performed. The work was carried out according to the guidelines of the Meta-analysis Of Observational Study in Epidemiology (MOOSE)26.
Eligibility Criteria
The PEO strategy (Population/Population, Exposure/Exposure, and Outcome/Outcome) was used to search for studies. The item population (P) included ethnic groups, African descent groups, rural and urban populations, groups with native ancestors from the American continent, South American Indians, risk groups, older adults, children, and adults. Exposure (E) involved socioeconomic factors, household income, social class, schooling, and maternal and paternal schooling. The outcome (O) included access to health services, health assessment, quality of health care, equity in health, equity in access to health services, patient acceptance of health care, oral health, health services, oral hygiene, dental care, and the needs and demand for health services.
The research encompassed studies carried out until 2020, conducted in the Brazilian population, such as articles, dissertations, and theses, without restrictions on languages and date of realization. All analytical observational studies (cohort, case-control, and cross-sectional) that investigated factors associated with the use of dental services in the last 12 months were included. Exclusion criteria: literature reviews and studies that did not address the “use of dental services” as an outcome, even if they referred to other dimensions of access. For the meta-analysis, studies with no results with absolute values were also excluded.
Sources of information
Databases and depositories used: PubMed, Scientific Electronic Library Online (SciELO), Latin American and Caribbean Health Sciences Literature (LILACS), Bibliografia Brasileira de Odontologia (BBO), Excerpta Medica DataBASE (EMBASE), Scopus, Web of Science Core Collection (WOS), and Google Scholar. Studies were also identified in repositories and bases of dissertations and theses. The data search occurred in May 2020.
Search
The descriptors used in this study were identified according to the Health Sciences Descriptors (DECs) and the Medical Subject Headings (MeSH), with the following combinations of descriptors, in English and Portuguese: ((((((((((((Ethnic groups) OR African continental ancestry group) OR (((Rural population) OR Rural community) OR Rural communities)) OR ((Urban population) OR Urban populations)) OR American native continental ancestry group) OR Indians, South American) OR ((((Vulnerable groups) OR Vulnerable communities) OR At-risk groups) OR At-risk communities)) OR ((Aged) OR Elderly)) OR ((Child) OR Children)) OR ((Adult) OR Adults))) AND ((((((Socioeconomic Factors) OR ((Income) OR Family income)) OR Social class) OR Educational status) OR Maternal educational status) OR Paternal educational status)) AND (((((((((((((((((((Health services accessibility) OR Accessibility of health services) OR Access to health care) OR Health services geographic accessibility) OR Health services availability) OR Availability of health services) OR Accessibility, health services) OR Program accessibility) OR Accessibility, program)) OR Health evaluation) OR ((Quality of Health Care) OR (Health care quality, access and evaluation))) OR ((Health equity) OR Equity in health)) OR ((Equity in access to health services) OR Equity in access)) OR Patient acceptance of health care) OR Oral Health) OR Dental Health Services) OR Dental care) OR ((Health services needs and Demand))).
We opted to expand the items that make up the PEO search strategy, as a more restricted search or delimiting the place of publication yielded few results. Moreover, “access to health services” can have different interpretations, concepts, and meanings, increasing our possibility of capturing more studies.
Data collection
Studies initially selected for inclusion based on their titles and abstracts were read by two independent reviewers. They were classified as “included”, “excluded”, or “unclear”, according to the eligibility criteria. After reading the abstracts, studies not conducted on the Brazilian population were excluded. Discrepant results were discussed, and records of the reasons for any exclusions were kept. When there was no consensus, a third evaluator reviewed some studies. Two researchers read all selected manuscripts.
Data list
Information was extracted on authors, year of publication, title, objective, sample size, age (years), place of affiliation of the principal author of the studies, study design, sampling design strategy, data collection place, primary and secondary exposure, and main results. Data were recorded in a Table (Appendix 1).
Risk of Bias Assessment
The risk of bias for each study was assessed using a quality assessment instrument specific to observational studies, consisting of 14 items. For each item, the response options were as follows: yes; and no, cannot be determined, not applicable, or not reported. Studies with a “yes” answer to items 7 to 11, 14 (most important), and those with adequate responses to at least ten items were considered to have a low risk of bias 27. This classification was performed by two independent evaluators (Appendix 2).
Summary Measures
Variables such as gender, schooling, income, urbanity, and dental service type used by dental service users in Brazil were recorded to calculate the association measures. For the meta-analysis, studies that considered a regular visit to the dentist, defined as at least one visit in the last year (≤1 year), were included. For studies with different categories of use of dental services, when possible, the total number of users was calculated and recategorized into the frequency of use ≤1 year and >1 year.
A random Mantel-Haenszel effect meta-analysis was performed using Review Manager software version 5.3.528, which estimates the variation between studies. The Prevalence Ratio (PR), with an interval of 95%, was used as a measure of association.
Summary of Results
Methodological heterogeneity was assessed considering the disparities between the studies. Statistical heterogeneity was evaluated based on the estimation of the p-value of the Cochran Q test and the Inconsistency Index (I²). Forest plots and funnel plots were also evaluated. Statistical heterogeneity was observed if p<0.10 for the Q test, I²≥50%, with a 95% CI, so that the studies did not overlap in the forest plots and whether there was asymmetry in the measurements of the studies in the funnel plots.
Additional Analysis
Subgroup analyses were performed according to the study’s macro-region whenever there were significant heterogeneities.
Subgroup analyses were conducted by region: Brazil, for national studies, and by macro-regions (South, Southeast, North, Northeast, and Midwest), as they were less heterogeneous, and the results are presented as such. The meta-analysis did not analyze the North macro-region due to the small number of studies. These studies and those unable to group at least two subgroups by macro-region were allocated to the “Other” group.

Results
A total of 50,088 articles were identified, and of these, 3,137 were found in PubMed, 262 in SciELO, 1,666 in LILACS, 293 in BBO, 835 in Embase, 24,048 in Scopus, and 19,847 in WOS. Google Scholar and dissertation and theses websites provided 6,699 files, including articles, dissertations, and theses. Thus, 56,787 files were selected. Nine articles were captured from other sources. A total of 49,232 studies were selected for reading titles and abstracts, and then 156 for full-text reading, 62 of which were excluded. Ninety-four studies were indicated, 80 of which were scientific articles, eight dissertations, and six theses (Figure 1).
The sample size ranged from 50 to 775,024 participants. Their age ranged from 0 to ≥80 years. Most studies (98%) had an observational, cross-sectional design, with 63% coming from primary data.
The selected studies were published between 2001 and 2020, with an increase in the last decade (2001-2010: 25; 2011-2020: 69). They were carried out in 13 Brazilian states, one in the North region (Amazonas: 1); 16 in the Northeast region (Bahia: 2; Ceará: 2; Maranhão: 1; Pernambuco: 5; Paraíba: 6); 26 in the Southeast region (Espírito Santo: 1; Minas Gerais: 8; Rio de Janeiro: 2; São Paulo: 15); 28 in the South region (Paraná: 6; Rio Grande do Sul: 19; Santa Catarina: 3). The other studies (23) were conducted with data from national surveys, and most of these were published in Portuguese (70%).
Appendix 1 presents the assessment of the quality of the selected studies and the risk of bias. Of the 14 items used, at least 10 (71.4%) were adequately present in 37 (39.3%) studies, considered to have a lower risk of bias.
Twenty-five studies were included in the meta-analysis. The summarized estimate of the meta-analysis showed an association of the variables gender, schooling, income, urbanity, and type of oral health service, with the use of dental services (Figures 2-5).
The use of dental services in the last year was associated with higher education (≥8 years of schooling) (PR=0.49, (95%CI:0.39-0.60)) (Figure 3); higher family income (≥2 minimum wages) (PR=0.79, (95%CI:0.74-0.84)) (Figure 4); and urbanity (PR=0.79, (95%CI:0.64-0.97)) (Figure 5).
The studies showed heterogeneity (I²>50%, p<0.10), and subgroup analyses were performed to minimize this heterogeneity, listing the studies in the following groups: Brazil, referring to national studies; and by macro-region, Northeast, South, Southeast, and Midwest (Figures 2-5). Despite the heterogeneity, it did not impact the weighted estimates of the association between the use of dental services in the last year with the following variables: schooling in the South region, urbanity in the Northeast region, and type of oral health service in the Midwest region.
In the Southeast region, the use of dental services in the last year was associated with males (PR=1.19, (95%CI: 1.02-1.38)) (Figure 2), higher education, in national studies (Brazil) (PR=0.43, (95%CI:0.33-0.57)), in the South region (PR=0.77, (95%CI:0. 72-0.82)), and Midwest (PR=0.49, (95%CI:0.39-0.60)) (Figure 3), higher income in national studies (Brazil) (PR=0.75, (95%CI:0.70-0.80)) (Figure 4), and private dental services in the South region (PR= 0.69, (95%CI:0.61-0.77)).
Discussion
This systematic review, a pioneer in the use of Brazilian dental services, showed that this access is unequal and less frequent among people with lower education and income and who live in rural areas. One of the hypotheses to justify this result is the non-consolidation of dental services in the country, and this implementation was carried out only 20 years ago113, even though the expansion of oral health in Primary Health Care has been significant since the publication of the National Oral Health Policy114. Another hypothesis that justifies this finding is the evident social and regional inequalities in the use of dental services. Barriers to their use are an example of these inequalities115, even when considering individual conditions of social vulnerability116.
The use of dental services in the last year in Brazil was more frequent among people with higher education, corroborating the literature117. Higher education is a proxy for better material conditions and, therefore, greater use of health services, including dental services. Furthermore, schooling represents the level of understanding/awareness about diseases and oral care11, which may also justify this result.
Higher family income was associated with greater use of dental services in the last year in Brazil. This finding corroborates the literature, as there is a higher probability of lack of access to dental services among individuals with a per capita household income “less than a minimum wage”118. If there are no accessible public dental services, many Brazilians will not pay to access them. Moreover, families with different incomes use dental services differently, and the frequency of use is directly proportional to income. Thus, socioeconomic status differences indicate inequality in dental services’ use119.
Less use of dental services in the last year occurred by those who lived in rural areas, evidenced by some factors: human capital, quality of life, markets, and social infrastructure, among others120, which tends to concentrate dentists (CD) in large centers. This last hypothesis is corroborated by a study that revealed Brazil as the country that, despite having the highest number of DCs per inhabitant in the world (20%), has an unequal distribution of these in its territory, where 57% of professionals were concentrated in the states of São Paulo, Minas Gerais, and Rio de Janeiro121.
In the Southeast region, we identified greater use of dental services in the last year by males. However, the magnitude found in this result was negligible. More studies can clarify this issue.
In the South region, the most significant use of dental services in the last year occurred in the private sphere, perhaps justified by the socioeconomic characteristics of this region. It has the highest Human Development Index in Brazil122 and the country’s third-highest per capita Gross Domestic Product. It is the region where most of the population is literate and has the lowest incidence of poverty123. Furthermore, until June 2021, the exclusively dental plans reached 14.4% of the Brazilian population, with greater coverage in the states of the Southeast and South regions (capitals and metropolitan regions)124, which can be justified by the greater purchasing power of the population. Data from the SB Brazil 2010 show that the use of dental services in the SUS, in the South region, was the lowest among the regions, with 37.2% of individuals using such services125. This finding reflects the reality of the public dental service, with gaps in the relationship between supply and demand, which allows for greater demand for private services by the general population.
Studies on the use of dental services in Brazil have increased in the last decade, as observed in this research. This growth has been helped both by the increase in the ESB in the ESF and by the performance of the last two epidemiological surveys on Brazilian oral health125,126. Thus, investigating this topic is fundamental since all should ideally access dental services.
The studies included in the meta-analysis were cross-sectional, which hindered the monitoring of the use of dental services over time. Users of different age groups participated in them, from teenagers to older adults, perhaps a reflection of everyone’s need to effectively use dental services. Data collection focused more on the household, most of which came from secondary sources, increasing the possibility of selection bias.
This study’s strengths are that it is an unprecedented work, as it analyzed the use of dental services in Brazil through a systematic review, followed by a meta-analysis. Moreover, the analysis by subgroups per Brazilian macro-region helped to portray how dental services are used in these regions. Thus, it can help professionals, managers, and researchers to glimpse access to dental services concerning use in the last year. As a result, different strategies can be enhanced, such as a better spatial distribution of oral health teams and dentists. The study, however, has limitations, such as the difficulty in analyzing other variables, such as age and ethnicity/skin color, due to significant data heterogeneity; the risk of selection bias in the allocation of meta-analysis studies; and the quality of the selected studies, which required a methodological adjustment for the meta-analysis.
Future studies suggest standardizing variables, such as age, income, and education, based on recommendations from bodies such as the World Health Organization, the Brazilian Institute of Geography and Statistics, and others.
According to the different definitions of this term, gaps regarding the investigation of access to dental services must still be elucidated. Furthermore, more in-depth investigations of this outcome by sex and Brazilian macro-region must also be analyzed in depth as they would give greater robustness to future studies on this topic.
We can conclude by saying that the use of Brazilian dental services is unequal and must be expanded among people with lower income, less education, and rural residents, reinforcing the need for public policies and programs that promote access and use by these groups.

Funding
The Foundation for Support to Research and Scientific and Technological Development of Maranhão (FAPEMA/MA) – National Internship Notice-07805/17 and Doctoral Scholarship BD-00142/17 and Coordination for the Improvement of Higher Education Personnel (CAPES), finance code 001.

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