Artigos

INTRODUCTION
Dental radiology is the specialty dedicated to the study and practice of complementary diagnostic methods through imaging exams of the orofacial region1. The Brazilian Unified Health System (acronym in Portuguese, SUS) provides dental radiology services through the Centers of Dental Specialties (acronym in Portuguese, CEO), whose implementation was standardized by the National Oral Health Policy (acronym in Portuguese, PNSB) – “Brasil Sorridente”, in 20042,3. Dental radiography is rarely performed in primary healthcare4; however, there was an increase in the use of periapical and interproximal radiographs in SUS between 2000 and 2016, indicating greater availability of this service following the implementation of the PNSB and CEOs5 .
PNSB facilitated improvements in the accessibility and coverage of oral health care, emphasizing the imperative to extend access to comprehensive oral health services, encompassing promotion, prevention, and health recovery, incorporating procedures and services of high and medium complexity 6. Consequently, there was a substantial increase in funding from the Ministry of Health (MH) of Brazil during that period. However, in recent years, this funding has been diminished, posing challenges to the advancement of dentistry within SUS2,3,6-8. Moreover, austerity measures have been identified as a threat to the principles of universality and comprehensiveness of health care in Brazil10.
CEO are specialized clinics that offer medium-complexity care to the population, serving as reference health units for the oral health teams in primary care, which are responsible for initial care, coordination of treatment, and longitudinal follow-up of users. The functioning of a CEO should be planned according to the local epidemiological reality9,11,12. To assess access to health services within the SUS, the MH established the Program for the Improvement of Access and Quality (PMAQ) of Primary Care in 2011. This program aims to assess and enhance health service quality and was the largest health service evaluation initiative in Brazil, and globally significant for improving primary health care performance13-16. It identified improvements and challenges in infrastructure, work processes, and user perception of service quality14.
In 2013, PMAQ expanded to CEO (Program for the Improvement of Access and Quality - PMAQ-CEO), aiming to enhance access and quality in specialized oral health care17,18. Freire et al.5 observed increased use of radiography in SUS from 2000 to 2016, indicating improved access post-PNSB. However, data limitations in Outpatient Information System of SUS, indicating improved access post-PNSB. However, data limitations in SIA/SUS hindered assessing action quality and infrastructure for services. Martins et al.8 showed that dental radiology as the fourth most frequent specialty referred to in SUS dental services.
Up until now, there has been a lack of studies that analyze the impact of policies on the use of imaging for diagnostic purposes or on specialized dental clinical procedures. Therefore, it is necessary to evaluate and monitor health services to assess the impact of health policies and actions8,13. The objective of this study was to analyze the structure of dental radiology services available in CEOs across Brazil, by Federative Unit (UF), identifying potential advancements and challenges between 2014 and 2018. Our hypothesis is that there was an improvement in the structure of dental radiology in Brazil during this period.
Methodology
Study Design and Study Location
This is an ecological study19,20 using data on dental radiology obtained from the analysis of the structure of CEOs. The data were collected during the external evaluation of the first and second cycles of the PMAQ-CEO conducted in 2014 and 2018 in Brazil. Brazil is divided into 26 states, one Federal District, and five regions: North, Northeast, Central-West, South, and Southeast.
Population
All health establishments registered as CEOs participated in the external evaluation. For the 1st Cycle of PMAQ/CEO, a census was conducted in the 932 CEO facilities established in the country, and for the 2nd cycle, in the 1,097 CEO facilities. For this study, all CEO units that participated in both the 1st and 2nd cycles of PMAQ-CEO were selected (n=889).
Data Collection and Variables
The data were obtained from databases provided by the MH. These databases contained information related to the external evaluation of PMAQ-CEO, conducted in 2014 and 2018 nationwide. The external evaluation involved on-site observations of CEO infrastructure (module 1), interviews, and document verification with the manager and a dentist to assess the work process (module 2), and user interviews to assess satisfaction levels (module 3). The evaluation process analyzed access and quality conditions through a structured questionnaire provided by the MH¹?. For this study, variables from module 1 were considered, focusing on the structure of dental radiology services in CEOs. The following variables (V) were created after analyzing the questions from the research instruments assessed in both cycles. They were dichotomized as yes or no:
V1: Least one radiologist dentist
V2: Radiology room in usable condition
V3: Least one panoramic X-ray machine in usable condition
V4: Least one periapical X-ray machine in usable condition
V5: Least one lead apron in usable condition
V6: Least one darkroom box in usable condition
V7: Least one negatoscope in usable condition
V8: Adequate quantity of X-ray request forms
Data Analysis
Latent Transition Analysis (LTA) was employed to explore patterns across the two cycles of the PMAQ-CEO, identifying classes representing dental radiology structure and modeling transitions between these classes over time. LTA is a statistical approach to identify subgroups in a population with similar characteristics, relying on observed categorical variables21. LTA enables observing different subgroups within populations, called latent classes or statuses. LTA recognizes that units of analysis can transition between latent classes over time, estimating probabilities of unit characteristics belonging to a class, prevalence at each time point, and transition probabilities between latent classes over time22-24.
To identify patterns for the structure of CEO concerning dental radiology, among the five constructed models, the model with 3 latent statuses (LS) was selected as it showed the best theoretical plausibility, good conceptual interpretability and acceptable model fit parameters, considering the likelihood ratio, p-values, degrees of freedom (df), Akaike Information Criterion (AIC), Bayesian Information Criterion (BIC) and entropy. The analyses were conducted using the MPlus®.
The absolute and percentage frequencies of each study variable in the two censuses were measured using the STATA®. A choropleth map was created to represent the percentage of CEO facilities that showed improvement in LTA, using the QGis®.
Ethical Considerations
PMAQ-CEO received approval from the Federal University of Pernambuco Research Ethics Committee on 08/06/2014 and 01/30/2018 (CAAE 23458213.0.0000.5208).
RESULTS
889 CEOs were evaluated. The majority were located in the northeast region (n=340; 38.25%), followed in descending order by the southeast (n=323; 36.33%), south (n=112; 12.6%), central-west (n=57; 6.41%), and north (n=57; 6.41%). São Paulo had the highest number of CEOs (n=173) in the country, while Roraima, with only 1, had the lowest. Table 1 presents the proportion and number of CEOs for the 8 variables (V1 to V8) related to the radiology services' structure, by UF, macro-region, and in Brazil in the two cycles, 2014 and 2018, respectively.
In cycle 1 (c1), 20.25% of CEOs had a dentist radiologist (V1), and in cycle 2, 10.35%, being the only variable that showed a decline over time. The North region was the only one not to have a specialist in dental radiology in most of its states in both cycles. 3.82% had panoramic radiography equipment (V3) in c1 and in c2, this availability increased to 5.29%. The South region was the only region where all states had panoramic radiography equipment in both evaluated periods.
In c1, 47.58% of CEOs had an exclusive room for radiology (V2) and in c2, this frequency increased to 51.86%. The majority had, in both cycles, at least 1 periapical radiography device (V4) (c1: 96.51% and c2: 97.98%), 1 lead apron with thyroid protector (V5) (c1: 87.74% and c2: 95.61%), 1 darkroom (V6) (c1: 98.09% and c2: 98.0%), and 1 negatoscope (V7) (c1: 86.39% and c2: 91%) in usable condition. The darkroom was the item found most frequently in all macro-regions in both periods.
In c1, 62.77% of CEOs had a sufficient supply of X-ray request forms (V8) available, and 73.12% in c2. The Southeast and Central-West regions had the highest frequencies in both c1 and c2, while the North and Northeast regions had the lowest. In this variable, from one cycle to the other, the North and Central-West regions showed a decline.
Table 2 displays the descriptive variables used for latent class analysis. Table 3 compiles the model fit information for selecting the latent classes in this study. Six latent class models were computed, with the selection based on the best theoretical plausibility, conceptual interpretability, and acceptable model fit parameters. The chosen model consists of 3 latent classes, named as follows: LS1 - Best Dental Radiology Structure (DRS) (n=377; 42.4%); LS2 - Intermediate DRS (n=379; 42.6%) and LS3 - Worst DRS (n=133; 15%).
Table 4 displays LSs. The first, "Better DRS" is marked by the highest rates for variables like dentist radiologist presence (V1, 24.2%), an exclusive radiology room (V2, 94.1%) and panoramic radiography equipment (V3, 10%), alongside good rates for other factors. The second, "Intermediate DRS" include CEOs with a 100% rate of periapical radiography equipment (V4) and darkroom box availability (V6); and a 99.1% rate of lead apron availability (V5). However, it has the lowest rates for variables like dentist radiologist presence (V1, 7%) and an exclusive radiology room (V2, 15%), maintaining acceptable rates for other aspects. The third, "Worst DRS" comprise CEOs with the lowest rates in six of eight analyzed variables (V3-V8) in addition to proportions below 50% for the other variables (V1-V2), indicating inferior performance in radiographic examination equipment and supplies. The predominant status in both cycles was LS2.
The analysis of latent class transition showed that no CEO from LS1 migrated to another latent status, meaning that no CEO deteriorated between 2014 and 2018. 95.7% of CEOs from the LS2 remained in this status, and there was no migration to the LS3. 4.3% of CEOs in the LS2 and 16.6% of LS3 transitioned to LS1 between the cycles, while 66.3% of CEOs moved from the "worst" to the "intermediate DRS" status, demonstrating a higher tendency for improvement. Figure 1 represents the distribution by percentage of CEO facilities that improved regarding dental radiology infrastructure between cycles in each state of Brazil. It was observed that the Northern and Northeastern macroregions had the highest quantities of CEO facilities that experienced changes to a better latent class.
DISCUSSION
This innovative study compares the provision of dental radiology services by SUS through the two national censuses of PMAQ-CEO, using dentists as evaluators. Robust statistical methods, including LTA, were employed to assess structural changes in dental radiology. Utilizing nationwide data in a longitudinal approach, spatial analysis enhances the evaluation of variables' distribution across the national territory in both cycles, contributing to the formulation of effective public projects and policies. Given its focus on dental radiology service structures, the study's significance for health management and planning at all levels is noteworthy. Our findings support the hypothesis that the dental radiology structure has improved between cycles, indicating a concerted effort by the CEOs to enhance the quality of dental imaging diagnostic services provided by SUS.
LTA revealed a satisfactory trend between 2014 and 2018, with no deterioration observed in CEOs categorized as "best DRS" or "intermediate DRS". Notably, 4.3% of CEOs with an intermediate DRS and 16.6% with the worst structure transitioned to the best structural status. Additionally, 66.3% of CEOs moved from the "worst" to the "intermediate DRS," indicating an overall improvement. This positive trend may be attributed to the implementation of PMAQ-CEO, where health administrations prioritized maintaining or enhancing service quality and availability. The financial return provided by the program may have acted as a significant incentive for CEOs to seek improvements in their structure. This reward mechanism, based on performance evaluation, may have motivated managers and teams to improve the services provided, aiming for better external evaluations and, consequently, higher financial transfers25. No deterioration was identified in any CEO category, contributing to the provision of dental radiology services in other specialties reliant on it.
The majority of CEOs fell under the category of "intermediate DRS", exhibiting deficiencies in building structure, human resources (dentist radiologist) and panoramic radiography machine. LTA indicated no regression in the structure of CEOs with better and intermediate classifications. It revealed an enhancement in CEOs with the worst structure, as a majority transitioned to better-classified categories, signifying progress in dental radiology structure in secondary care.
The MH report after Brazil's 2nd PMAQ-CEO Cycle in 2021 highlights a general improvement in quality across structure, process, and outcomes. Reduced service interruptions from structural issues and material shortages were observed, along with improvements in environmental aspects and the availability of resources, instruments, and equipment. Regional disparities in CEOs persisted, impacting service delivery, particularly in the Northern region, mirroring the findings on oral cancer care in CEOs26 as well as care offered to people with disabilities27. Access to care showed slight improvement, including expanded appointment scheduling, absenteeism control, and appointments at Basic Health Units28. Our analysis revealed an improvement in specialized dental radiology services provision, likely contributing to enhanced access.
Investments made through the Brazilian PNSB and effective local management may have also influenced the improvement in dental radiology. This policy played a significant role in expanding and improving oral health services, increasing the effectiveness of actions, supporting dental care in primary health care and establishing specialized dental services, such as CEO7-9. Therefore, the creation and effective operation of these services created conditions for the improvement of dental radiology services in CEOs.
Some Basic Health Units in Brazil are equipped with X-ray machines, allowing diagnostic imaging in primary care settings. However, dental radiography is still rarely performed in primary healthcare, often requiring patients to be referred to specialized services4. A study in which they observed a trend of increased use of periapical/interproximal radiography in the Brazilian public healthcare system from 2000 to 2016, presumably due to increased access of the population to oral healthcare services provided after PNSB5. PNSB is implemented in different ways in Brazilian capitals, and how its guidelines are followed in each capital facilitates the evolution of oral healthcare service provision 29. PNSB plays a crucial role in expanding access to basic and specialized dental care for the population13.
Our study identified, in the assessment cycles of PMAQ-CEO in 2014 and 2018, a deficiency throughout the Brazilian territory in dental radiology specialists and the availability of panoramic radiography equipment, more pronounced in the Northern region. The most populous macro-regions of the country, the Northeast and Southeast, have the highest number of CEOs. In Brazil, there was an increase in the availability of exclusive rooms for radiology in CEOs between one cycle and another. In both cycles, the majority had at least one periapical radiography machine, lead apron with thyroid protector, darkroom box, and negatoscope in usable conditions. There is still a need to improve the availability of requisition forms, as their absence can hinder the workflow in CEO since they serve both for internal X-ray requests and for feedback to the primary health care oral health teams. Overall, the structure of CEOs for the provision of dental radiology services improved between the cycles.
From one cycle to another, there was a decrease in the availability of a specialist in dental radiology (c1=17.54% and c2=10.53%), being the only studied variable that showed a negative variation. The presence of a dentist specialized in dental radiology is crucial for improving the accuracy of dental diagnoses, as studies have demonstrated that specialists are more effective in identifying certain dental conditions, such as caries on proximal surfaces of premolars and molars30. Additionally, the likelihood of users accessing oral radiology services is higher when these services are available in the public health system and provided by dentists with postgraduate qualifications in dental radiology31.
The absence of a dentist specialized in radiology working in CEOs can be justified by the limited availability of this specialist throughout the Brazilian territory, as out of 383,047 dentists registered with the Federal Council of Dentistry, 131,385 (34.30%) have some registered specialty, and of these, 5,479 (4.17%) are specialists in dental radiology and imaging. As there is no career plan and incentives for professionals to work and stay in the public network, many prioritize the private sector. There are chronic problems in the SUS regarding the availability of health professionals in general, resulting from SUS underfunding, health expenditure freezing, service deterioration, and workforce precariousness, which have been further exacerbated by the covid-19 pandemic32. This job precariousness and low remuneration lead many professionals to have more than one job to meet their needs.
The availability of an exclusive room for radiology showed a slight growth and may be associated with the improvements implemented in the CEOs that participated in both cycles and adapted for better evaluation in the second cycle. It is important to have a room with isolation and lead walls when using a panoramic device. When analyzing the low availability of an exclusive room and panoramic radiography equipment, we can infer that one may be related to the other, as providing this service requires building adaptation to provide an exclusive room and follow all radiation protection recommendations.
Similar to the findings of this study, which indicated that most CEOs had only periapical X-ray machines in working condition, it was observed that, in Sweden's public service, interproximal radiography, which uses the periapical X-ray machine, was the most common for children and adolescents33. Data collected in the PMAQ-AB in 2012 showed that radiology was one of the specialties with the highest referral frequency and the shortest waiting time for patients after referral to specialized services in SUS11. In Finland, radiographs were identified as the third most performed procedure in the public sector, with a statistically significant growth over time34. Furthermore, a trend of increased use of periapical and interproximal radiographs in SUS between 2000 and 2016 was identified, reflecting greater access to oral health services after the implementation of the PNSB and CEOs5.
Periods of economic recessions and associated austerity measures impact healthcare expenditures and, consequently, the provision of services35-37. Brazil has a complex public and private healthcare system, and the last economic recession brought significant cost-containment measures to balance budgets and enhance productivity. Signs indicate that the balance among the macrocomponents of its healthcare system has shifted in response to the recession and associated austerity measures. Despite Brazil's economic recession in the last decade, the dental radiology of CEOs managed to maintain or improve its parameters during the evaluated period, possibly justified by the implementation of PMAQ-CEO, thus fulfilling the goal of promoting improvements in the centers.
While more countries move toward achieving universal healthcare many struggles to ensure the sustainability of their healthcare systems amid competing patient demands, constant medical advancements, and limited healthcare budgets23. Underfunding of public health in Brazil is one of the structural challenges of SUS. This worsened with the establishment of Constitutional Amendment 95 in 2016, which set ceilings for public health expenditures. Expanding the supply of services and professionals, incorporating technologies, and democratizing access to resources depend on greater investments. Therefore, to guarantee and expand access and the effectiveness of healthcare, it is necessary to allocate resources. Considering the role played by SUS in healthcare, it is crucial to seek improvements in its financing38.
Disparities in access to and use of oral health services in Brazil highlight the persistence of inequities, even with the expansion of these services in recent years. Populations of black race/color, residing in the North and Northeast regions, with lower socioeconomic status and education levels, are disproportionately affected, showing higher chances of irregular dental follow-up or never having accessed dental consultations6. Furthermore, management and human resource factors in CEOs are directly associated with the performance of dental care, especially for patients with special healthcare needs, emphasizing the heterogeneity and low performance in some regions39. The implementation of strategies such as the active use of health ombudsman services has proven effective in reducing racial inequities in access and bonding with specialized services, suggesting that planning tools based on social participation can improve equity in CEOs40. These findings underscore the urgency of equitable public policies that promote universal and adequate access to oral health services, reducing regional and social disparities with a focus on the specific needs of the most vulnerable subgroups6.
Studies on services offered by CEOs, such as those developed by the PMAQ-CEO, can contribute to the planning and management of healthcare services. Additionally, they help identify weaknesses in the healthcare network to ensure that public policies are implemented to advance healthcare attention8. PMAQ-CEO was a program of great importance for the evaluation and improvement of services in CEOs throughout Brazil. Its extinction could lead to setbacks and an increase in disparities in service provision across the Brazilian territory. Future government administrations need to invest in monitoring and evaluation programs to observe the current state of service offerings in CEOs25.
Furthermore, it is important to reflect on the need for digitization in public health, representing significant advancements in dental radiology services, as digitals radiographs offer greater ease and quality in processing and sharing among healthcare professionals. Studies demonstrate that digitization enhances the healthcare system, making it more efficient, secure, and cost-effective. Digital technologies enable these benefits due to their customization and precision, automation, prediction, data analysis, and interaction41,42. The use of digital technologies in public health has the potential to enhance health promotion and disease prevention through efficient recording, storage, and processing of large volumes of health data43.
This study presented limitations, including the use of secondary data, which prevented us from evaluating information about the work process related to dental radiology in CEOs due to a lack of available data. Some information was collected during the PMAQ-CEO cycle 1 but not in cycle 2. Therefore, we did not include these data, resulting in a slight loss of information about the structure of the CEOs. The study assessed the available structure but did not evaluate demand or whether the supply was sufficient for the demand. Work processes were also not considered. The external evaluation instrument in cycles 1 and 2 of PMAQ-CEO differed in some questions, limiting the determination and analysis of variables for those that repeated in both instances. Not all CEO units in Brazil participated in both evaluation cycles, either due to refusals geographic barriers that made access to the CEO impossible (floods especially in the Amazon region, damaged bridges or roads especially in the North and Northeast), or the closure of others. In the first cycle, 932 units participated, and in the second cycle, 1,097 units participated. Of these, 889 were evaluated in both cycles, representing a small sample loss (less than 5%).
CONCLUSION
Improvements in dental radiology infrastructure were observed in CEO facilities across Brazil between 2014 and 2018. However, there is a shortage of panoramic radiography equipment and specialized professionals within these healthcare facilities, indicating a reduction in specialized human resources or polarization of these professionals in large urban centers. The structure of these services in CEO facilities is uneven among the Brazilian macroregions. It is recommended to restructure policies aimed at the appreciation of work and healthcare workers within the SUS.
ACKNOWLEDGMENTS
To the Coordination for the Improvement of Higher Education Personnel (Capes), the National Council for Scientific and Technological Development (CNPq, processes 306592/2018-5 and 308917/2021-9), he Brazilian Ministry of Health for funding PMAQ-CEO's external evaluation, the Federal University of Pernambuco, and other participating universities, including the Dentistry Postgraduate Program at the Federal University of Maranhão.
FINANCING
CAPES Code 001

REFERENCES
1. Fenyo-Pereira M. Radiologia odontológica e imaginologia. 2ª ed. São Paulo: Santos; 2013. 408 p.
2. Narvai PC. O caso do ‘Brasil Sorridente’ e perspectivas da Política Nacional de Saúde Bucal em meados do século XXI. Tempus – Actas de Saúde Coletiva. 2020 Jul 3;14(1):175-187.
3. Pucca Junior GA, Gabriel M, Almeida Carrer FC de, Paludetto Junior M, Lucena EH G de, Melo NS de. Acesso e cobertura populacional à saúde bucal após a implementação da Política Nacional de Saúde Bucal “Brasil Sorridente”. Tempus – Actas De Saúde Coletiva. 2020;14(1):29-43.
4. Gonçalves AJG, Pereira PHS, Monteiro V, Silva Junior MF, Baldani MH. Estrutura dos serviços de saúde bucal ofertados na Atenção Básica no Brasil: diferenças regionais. Saúde debate [Internet]. 2020Jul;44(126):725–38.
5. Freire DB de L, Celeste RK, Arús NA, Vizzotto MB, Silveira HLD da. Procedimentos de imagem em Odontologia no Sistema Único de Saúde e a expansão da atenção secundária: série entre 2000-2016. Ciênc saúde coletiva [Internet]. 2021Oct;26(10):4727–36.
6. Galvão MHR, Roncalli AG. “Does the implementation of a national oral health policy reduce inequalities in oral health services utilization? The Brazilian experience.” BMC public health. 2021; 21(1): 541.

7. Casotti E, Contarato PC, Fonseca ABM, Borges PKO, Baldani MHA. Atenção em Saúde Bucal no Brasil: uma análise a partir da Avaliação Externa do PMAQ-AB. Saúde Debate. 2014 Oct;38(Especial):140-157.
8. Martins RC, Reis CMR, Machado ATGM, Amaral JHL, Werneck MAF, Abreu MHN G. Relationship between Primary and Secondary Dental Care in Public Health Services in Brazil. PLoS ONE. 2016 Oct;11(10):e0164986.
9. Silva HEC, Gottems LBD. Interface entre a Atenção Primária e a Secundária em odontologia no Sistema Único de Saúde: uma revisão sistemática integrativa. Ciência & Saúde Coletiva. 2017;22(8):2645-2657.
10. Lima AMF de S, Lyra L de S, Guimarães LLV, Teixeira MP, Rossi TRA, Chaves SCL. Oral Health in universal health systems: comparative analysis of Brazil and the United Kingdom. Research, Society and Development. 2021;10(10):e185101018444.
11. Lucena EH G, Lucena CDR, Goes PSA, Sousa MF. Condições associadas a atividade de planejamento nos centros de especialidades odontológicas. Univ Odontol. 2019 Jan-Jun;38(80).
12. Condessa AM, Lucena EH G, Figueiredo N, Goes PSA, Hilgert JB. Atenção odontológica para pessoas com deficiência no Brasil. Epidemiol. Serv. Saude. 2020;29(5):e2018154.
13. Galvão MHR, Roncalli AG. Desempenho dos municípios brasileiros quanto à oferta de serviços especializados em saúde bucal. Cad. Saúde Pública. 2021 Jan;37(1).
14. Macinko J, Harris MJ, Rocha MG. Introduction to the Special Edition on the Brazilian National Program to Improve Primary Care Access and Quality (PMAQ). J Ambul Care Manage. 2017 Apr;40(2 Suppl):S1–S3.
15. Macinko J, Harris MJ, Rocha MG. Brazil's National Program for Improving Primary Care Access and Quality (PMAQ): Fulfilling the Potential of the World's Largest Payment for Performance System in Primary Care. J Ambul Care Manage. 2017 Apr;40(2 Suppl):S4–S11.
16. Scalzo MTA, Matta-Machado AT G, Abreu MHN G, Martins RC. Braz Oral Res. 2021;35:e023.
17. Goes PSA, Figueiredo N, Martelli PJL, Luvison IR, Werneck MAF, Ribeiro MAB, et al. Theoretical and Methodological Aspects of the External Evaluation of the Improvement, Access and Quality of Centers for Dental Specialties Program. Pesq Bras Odontoped Clin Integr. 2018;18(1):1-11.
18. Goes PSA, Biazevic MGH, Celeste RK, Moyses S. Secondary dental care quality in Brazil: What we are talking about? Community Dent Oral Epidemiol. 2022;50(1):1-3.
19. Lash, TL; VanderWeele, TJ; Haneuse, S; Rothman KJ. Modern Epidemiology. 4th ed. Philadelphia: Wolters Kluwer, 2021. 1250 p.
20. Almeida Filho, N; Barreto, ML. Epidemiologia & saúde: fundamentos, métodos, aplicações. 1ª edição. Rio de Janeiro: Guanabara Koogan, 2012, 728 p.
21. Leão RCH, Silva VL, Moreira RS. Análise de Classes Latentes: um novo olhar sobre o fenômeno depressão em homens idosos no nordeste do Brasil. Rev. Bras. Geriatr. Gerontol. 2017.
22. Collins LM, Lanza ST. Latent class and latent transition analysis: with applications in the social behavioral, and health sciences. Hoboken, N.J: Wiley; 2010.
23. Weale A, Kieslich K, Littlejohns P, et al. Introduction: priority setting, equitable access and public involvement in health care. J Health Organ Manag. 2016;30(5):736-750.
24. Guo B, Aveyard P, Fielding A, Sutton S. Using latent class and latent transition analysis to examine the transtheoretical model staging algorithm and sequential stage transition in adolescent smoking. Substance Use & Misuse. 2009;44(14):2028-2042.
25. 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.
26. Thomaz EBAF, Costa EM, Queiroz RCDS, Emmi DT, Ribeiro AGA, Silva NCD, Hugo FN, Figueiredo N. Advances and weaknesses of the work process of the oral cancer care network in Brazil: A latent class transition analysis. Community Dent Oral Epidemiol. 2022;50:38–47.
27. Queiroz RCDS, Oliveira ICV, Silva NC, Borges TS, Nunes AMM, Figueiredo N, Thomaz EBAF. Oral health care for people with disabilities in Brazil: Transition from the specialized dental services between 2014 and 2018. Community Dent Oral Epidemiol, 2022,50:48-57.
28. Ribeiro AGA, Martins, RFM, Vissoci JRN, Silva NCD, Rocha TAH, Queiroz RCDS, Tonello AS, Staton CA, Facchini LA, Thomaz EBAF. Progress and challenges in potential access to oral health primary care services in Brazil: A population-based panel study with latent transition analysis. PLoS One. 2021,16: e024710.
29. Souza GCA, Kusma SZ, Moysés S, Roncalli AG. Implantação da Política Nacional de Saúde Bucal e sua influência sobre a morbidade bucal em capitais brasileiras na primeira década do século XXI. Cad. Saúde Pública. 2021 Dec;37(12):e00320720.
30. Esmaeili EP, Pakkala T, Haukka J, Siukosaari P. Low reproducibility between oral radiologists and general dentists with regards to radiographic diagnosis of caries. Acta Odontologica Scandinavica. 2018.
31. Svenson B, Stahlnacke K, Karlsson R, Falt A. Dentists’ use of digital radiographic techniques: Part II – extraoral radiography: a questionnaire study of Swedish dentists Acta Odontologica Scandinavica. 2018.
32. Teixeira CFS, Soares CM, Souza EA, Lisboa ES, Pinto ICM, Andrade LR, Espiridião MA. The health of healthcare professionals coping with the Covid-19 pandemic. Cien Saude Colet. 2020;25(9):3465–3474.
33. Kieri CF, Twentman S, Stecksén-Blicks C. Use of radiography in public dental care for children and adolescents in northern Sweden. Swedish dental journal. 2009;33(3):141-148.
34. Linden J, Widström E, e Sinkkonen J. Adults’ dental treatment in 2001–2013 in Finnish public dental servisse. BMC Oral Health. 2020;20:121.
35. Jesus TS, Kondilis E, Filippon J, Russo G. Impact of economic recessions on healthcare workers and their crises' responses: study protocol for a systematic review of the qualitative and quantitative evidence for the development of an evidence-based conceptual framework. BMJ Open. 2019 Nov 19;9(11):e032972.
36. Andrietta LS, Levi ML, Scheffer MC, Britto e Alves MTSS, Oliveira BLCA, Russo G. The differential impact of economic recessions on health systems in middle-income settings: a comparative case study of unequal states in Brazil. BMJ Glob Health. 2020 Feb 28;5(2):e002122.
37. Russo G, Levi ML, Britto e Alves MTSS, Oliveira BLCA, Carvalho RHSBF, Andrietta LS, Filippon JG, Scheffer MC. How the 'plates' of a health system can shift, change and adjust during economic recessions: A qualitative interview study of public and private health providers in Brazil's São Paulo and Maranhão states. PLoS One. 2020 Oct 26;15(10):e0241017.
38. Viacava F, Oliveira RA D, Carvalho CC, Laguardia J, Bellido JG. SUS: oferta, acesso e utilização de serviços de saúde nos últimos 30 anos. Ciência & Saúde Coletiva. 2018;23(6):1751-1762.
39. Reis-Oliveira J, Costa BSF, Borges-Oliveira AC, de Abreu MHNG. Association between management, human resources, and care provided to patients with special healthcare needs in dental specialty centers in Brazil: A cross-sectional study. Spec Care Dentist. 2023 Sep-Oct;43(5):611-618.
40. Bomfim RA, da Cunha IP, Lacerda VRD. Health ombudsman and racial inequities in Dental Specialities Centers performance in Brazil: A multilevel analysis. Community Dent Oral Epidemiol. 2022; 50: 11–18.
41. Odone A, Buttigieg S, Ricciardi W, Azzopardi-Muscat N, Staines A. Public health digitalization in Europe [published correction appears in Eur J Public Health. 2021 Dec 1;31(6):e1]. Eur J Public Health. 2019;29(Supplement_3):28-35.
42. Wang J, Xu Y. Digitalization, income inequality, and public health: Evidence from developing countries. Technol Soc. 2023;73:102210.
43. Marckmann G. [Ethical implications of digital public health]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2020;63(2):199-205.