Artigos

Conteúdo (article):

Teorização sobre os limites à inserção da saúde bucal na Estratégia Saúde da Família
Theorization about the limits to the inclusion of oral health teams in the Family Health Strategy
Autores:
1. Elisa Lopes Pinheiro, Departamento de Odontologia Social e Preventiva, Faculdade de Odontologia, Universidade Federal de Minas Gerais, elisalp92@gmail.com, ORCID 0000-0002-3390-1062.
2. Mara Vasconcelos, Departamento de Odontologia Social e Preventiva, Faculdade de Odontologia, Universidade Federal de Minas Gerais, maravas@uol.com.br, ORCID 0000-0002-0316-4591.
3. Viviane Elisângela Gomes, Departamento de Odontologia Social e Preventiva, Faculdade de Odontologia, Universidade Federal de Minas Gerais, vivigomes74@gmail.com, ORCID 0000-0001-9637-1911.
4. Flávio de Freitas Mattos, Departamento de Odontologia Social e Preventiva, Faculdade de Odontologia, Universidade Federal de Minas Gerais, f.f.mattos@uol.com.br, ORCID 0000-0002-6052-2762.
5. Caroline Pereira Sutani Andrade, Departamento de Odontologia Social e Preventiva, Faculdade de Odontologia, Universidade Federal de Minas Gerais, carolinesutani@gmail.com, ORCID 0000-0003-4539-3517.
6. João Henrique Lara Amaral, Departamento de Odontologia Social e Preventiva, Faculdade de Odontologia, Universidade Federal de Minas Gerais, jhamaral1@gmail.com, ORCID 0000-0001-6900-7559.
RESUMO
Este estudo objetivou construir teorização a partir da concepção de atores sociais acerca das razões da não inserção da atenção à saúde bucal na Estratégia de Saúde da Família (ESF) no município de Juiz de Fora, Minas Gerais. Trata-se de um estudo qualitativo, fundamentado no referencial teórico construído com base na Política Nacional de Saúde Bucal e metodológico na Teoria Fundamentada nos Dados (GTD). Foram realizadas 11 entrevistas intensivas com atores sociais da gestão, do controle social e cirurgiões-dentistas do serviço público do município. Os dados foram categorizados segundo a GTD e a partir do processo de análise dos dados, construiu-se a teorização do estudo e obteve-se como categoria central “Consequência de uma concepção hegemônica doença-centrada da saúde para o modelo de atenção à saúde bucal”. A concepção de saúde dos atores sociais do município contribuiu para a não inserção da atenção à saúde bucal na ESF. A teorização permitiu a identificação da origem das condições do fenômeno estudado e poderá contribuir para tomada de decisões dos atores sociais em futuras ações políticas.
Palavras-chave: Saúde bucal; Estratégia Saúde da Família; Teoria Fundamentada; Políticas de Saúde.
ABSTRACT
This study aimed to theorize, by means of social actors’ conception, about the reasons for the non-inclusion of oral health in the Family Health Strategy (FHS) in the city of Juiz de Fora, Minas Gerais, Brazil. This is a qualitative, exploratory, descriptive, and analytical study based on the grounded theory methodology and the National Oral Health Policy. Eleven interviews were performed with public managers, delegates who participate in the municipal health council, and dental surgeons who belong to the public health service. The theorization of the study was created through the data analysis process, which resulted in “a consequence of the dominant disease-centered oral health care model" as the main category. Data were categorized according to a methodological framework. The health concept set forth by local social actors contributed to the non-inclusion of oral healthcare teams (OHTs) in the FHS. This theorization identified the origins of the studied phenomenon and can aid in future policy decision-making carried out by local social actors.
Keywords: Oral Health; Family Health Strategy; Grounded Theory; Health Policies.

INTRODUCTION
The Brazilian Unified Health System (SUS, in Portuguese) resulted from the Brazilian Sanitary Reform Movement (BSR) by overcoming the biomedical hegemonic care model1. The struggle for the universal right to health, the social determination of health, the concept of health through its social determinants, the decentralization of management, and the social control formulated the array of demands called for by the movement and led to their inclusion in the Brazilian constitution2,3. The development of health policies highlighted the prominence of Primary Health Care (PHC) and the adherence of Family Health in the restructuring of health care to tackle the population’s health needs1.
Despite the constitutional guarantee, SUS was not consolidated, its main challenge being political4. Since its creation, Brazilian public health has been conducted within a neoliberal perspective. Austerity measures have contributed to chronic under-funding, resulting in a non-universal SUS, which is restrictive and exclusionary. Constitutional Amendment 95 is a threat to the constitutional assumptions regarding SUS and implements a scenario of the de-funding of the system6. There are many obstacles and threats to SUS, stemming from an ideological, political, economic, cultural, and organizational nature4. Among these are: the reproduction of the hegemonic model of health care with a focus on disease and procedures, the difficulties in the construction of Healthcare Networks, the precariousness in the infrastructure of the services, “the devaluing of healthcare workers through outsourcing and work insecurity”4 and the privileging of the private healthcare sector by the State through subsidies, exonerations, and a lack of regulations2,4. These setbacks affect the health of the Brazilian population and the guarantee of their fundamental rights4,6.
In 2004, the National Oral Health Policy (PNSB, in Portuguese) rearranged the oral healthcare model, incorporating the expanded concept of health, the social component of the health-disease process, the strengthening of SUS, and the principles of the integrality and promotion of health care7,8,9. In the restructuring of the model, the oral health teams (OHTs) were included in the Family Health Strategy (FHS). Funding was allocated to oral health actions, incentives for health education, the use of epidemiological indicators, the establishment of a care network through the Dental Specialty Centers (DSCs), and the creation of Regional Laboratories for Dental Prostheses (RLDP)7,9. In the years following 2004, despite the financial incentives, the continuity and maintenance of the sustainability of the policy were affected by the lack of funding and by limits in the political and managerial coordination, as well as in governability at the local and state levels10. The traditional dental practice has continued to be predominantly marked by conflicts and contradictions11,12. Moreover, dental professionals have not taken on the PNSB as their own, relinquishing themselves from the responsibility of effectively implementing dental practices within health care13.
Between 2015 and 2017, there was a restrictive political scenario concerning oral health actions, with a reduction in the inclusion of OHTs in the FHS, growth in the supply of private dental services, restriction in public funding, a decline in oral health indicators14, and difficulties in the implementation of the PNSB within municipalities8,12,15. The process of the implementation of public policies in oral health has been the object of study for many authors11,15,16. However, studies on the comprehension of the subjects involved in the implementation of oral health policies in different political contexts are scarce.
The restructuring of the oral healthcare model and its inclusion within the FHS7 has not occurred in many Brazilian municipalities18, calling for further investigation on the underlying motives. The present study aimed to construct a theorization about the non-inclusion of oral health care in the FHS in a Brazilian municipality, through the understanding of social actors: health managers, dental surgeons (DS) inserted in the municipal SUS, and members of the Municipal Health Council (MHC). The uniqueness of this study lies in the theorization concerning the phenomenon of the non-inclusion of oral health in the FHS through the understanding of social actors, as its comprehension is essential for the development of health policies. Theorization can contribute to decision-making by public health managers regarding improvements in oral health care in consonance with the principles of the PNSB and for the strengthening of oral health within SUS.

METHOD
Study design
This work consists of a qualitative study conducted by means of methodological references from the Grounded Theory based on Data (GTD)19. GTD aims to generate a theoretical explanation for a process, an action, or an interaction through the understandings that the participants express about a studied phenomenon20. It can contain an exploratory character, when little is known about the object of study, as it has the capacity to generate a theory heavily based on the local reality 20 and focuses on the interpretive comprehension of the meanings and experiences of the participants19. The subsequent result is a high-level theorization20. This study, as it is derived from data, provides a better discernment and understanding of the phenomenon19.
The theoretical reference was developed based on a critical and systematic analysis of the PNSB, forming a basic policy axis for the restructuring of the care model within micropolitics7. Stemming from the field of collective oral health13,21, it seeks to break from the operational biomedical paradigm through the incorporation of epidemiology, of the promotion of health, in defense of citizenship, and of oral health as a right. The qualification of basic care is presented as an essential assumption for the restructuring of this model, with the incorporation of oral health in the FHS, as well as the establishment of the coordination of care and of the Oral Healthcare Network. The DSCs represent the secondary care and must be used as a reference by the OHTs. The PNSB established that the work of the OHTs should not merely be limited to the field of dental technicians, but should also be included in the expanded concept of health focused on care, as well as on the prevention and promotion of health. It should guide the construction of sanitary awareness among SUS professionals and users, understanding that oral health is a citizenship right. The management of oral health services should democratically define the policy, guaranteeing the participation of both the population, through Health Councils, and workers, given that this would serve to better identify the problems and produce a more effective design of actions strategies that would answer to the true health needs of the population7,9,12,13,15.
Study location
This study was conducted in the municipality of Juiz de Fora (JF), Minas Gerais, a region in the Southeast of Brazil. JF has an estimated population of 573,285 inhabitants, and a Human Development Index of 0.77822. It is a regional pole for the rendering of services that are essential in the area of health, education, commerce, and industry23. The municipality is the headquarters of the state´s Southeast Macroregion of Health, with an extensive network of high-density technological, outpatient, and hospital services24.
In December 2020, the municipality presented an estimated 11.35% oral health coverage of the population within basic care services, with no OHT included in the FHS. JF has five DSCs distributed throughout the health regions of the center, west, north, and south, with 183 dentists working in SUS. Regarding the population’s oral health conditions, no representative epidemiological data were found.


Study participants
The participants are social actors who are members of the MHC, municipal and state health managers, and DS included in SUS. Our study chose informants capable of providing relevant information, based on their understandings and lived experiences20,25 in the process of the non-inclusion of oral health care within the FHS. One key informant recommended participants who could contribute. As these participants were contacted, the interviews began to indicate new informants who worked with the theme. The inclusion of these participants was carried out in an intentional manner through decisions made by the research group. This technique was adequate, considering that the object of the study implies private sensitive and vague questions, requiring specific knowledge from the members of the group involved in the context of the pehnomenon25,26.
The characterization of the participants was elaborated in such a way as to preserve the identity and guarantee the confidentiality of the participants. Thirteen invitations were made. Two subjects refused to participate: one due to disease in the family and the other because the subject felt his experience would not contribute to the research. In the end, 11 subjects were interviewed. There was no loss of data. Some of the participants worked as managers and service providers, other as workers in health and social control. The municipal management of oral health was represented by 7 participants – state-level managers, social control, and service providers – 2 each.

Data collection
Data was collected by means of intensive interviews20, from November 2020 to May 2021, remotely, through the Google Meet platform, meeting the demands of social distancing imposed because of the COVID-19 pandemic27. One main researcher conducted the interviews and another provided technical support. One of the participants requested that the interview be in person, outside of the normal working hours, on the grounds of the Municipal Health Secretariat (MHS). The request was granted, considering the relevance of the participant´s contribution. In this case, biosafety measures recommended due to COVID-19 were adopted. The interviews were scheduled at times that were comfortable for the participants. The interview lasted 40 minutes on average.
The initial impressions and insights were recorded immediately after the end of the interviews through intuitive memoranda in order to allow for successive comparisons and not forgo any notable facts20,26. The interviews were recorded on the computer, using the application Open Broadcaster Software and transcribed in Word (Microsoft Office®).
The research group produced a guiding script based on information from the public domain about the studied phenomenon and on the knowledge of prior concepts on the theme19,20. The interview was divided into three moments: initial open questions focused on the professional career of the participants; intermediary, seeking to understand the functioning, features, and organization of public health and oral health care within the municipality and the participants’ conception concerning the non-inclusion of oral health care within the FHS; and final questions, related to the expectations of the inclusion of oral health within the FHS, in addition to a moment in which the subjects were open to explore their own perceptions about the interview and if they had anything to add. During the interviews and their subsequent analysis, new questions arising from the data and that were considered necessary for the understanding of the phenomenon were included19,20. The study guiding script is available in a supplementary file (https://doi.org/10.48331/scielodata.5DRGF9).

Data analysis
Data analysis and collection were performed concomitantly, as was the drafting of the successive memoranda19. The analysis took place in a free and creative manner, using systematized analytical tools and procedures from the method, enabling the merging of categories, codes, and concepts19,20. The literature review was conducted throughout the study, and the researchers kept an “open mind” as regards the data and their meanings19.
After the transcription, the process of dynamic and fluid analysis was begun by coding. The comparative method of intuitive analysis was used, marked by the comparison among the data, codes, and categories19. The coding was carried out in three stages: open coding, axial coding, and selective coding. These stages aim to find the concept and categorization of the data that represent the phenomenon19. Examples of data analysis during the open coding stage and of a memo for axial coding are available in a supplementary file (https://doi.org/10.48331/scielodata.5DRGF9)
The main study category was developed and discussed by the researchers in such a way as to refine the theorization19,20. The formulation of the theorization about the non-inclusion of the oral health care in the FHS was ordered and integrated through theoretical connections among the categories. The main category explains how the problem of this study is treated.
Recommendations from Decree 466, of 2012, from the National Health Council were respected. The project was approved by the Research Ethics Committee of Universidade Federal de Minas Gerais (UFMG) (logged under protocol number 35791320.2.0000.5149), and all participants signed a Free and Informed Consent Form.

RESULTS
The GTD resulted in the main category: Consequence of a hegemonic disease-centered concept of health for oral healthcare model. The following categories are related to this concept: 1) biomedical hegemonic care model; 2) care model defended by the management focused on dental clinics; 3) different concepts of the oral healthcare model; 4) loss of a window of opportunity provided by the PNSB (Chart 1)

Chart 1
The Biomedical Hegemonic Care Model refers to the organization of the rendering of healthcare services, the availability of healthcare units and equipment, the concept of health, and care actions focused on the production of procedures. The following subcategories were also associated: a) care model historically focused on high and medium complexity; b) municipal funding for health compromised by high and medium complexity; and c) most Basic Health Units (BHUs) have an inadequate infrastructure.
According to the participants of this study, historically, the municipality played the role of the technological health pole, providing, even today, many high and medium complexity services. The “inheritance of municipalization” is presented by the participants as one of the conditions responsible for the maintenance of the biomedical model, focused on high and medium complexity. Municipal funding for health responds to these priorities, leaving insufficient resources for Primary Health Care (PHC). For this reason, basic care witnessed a minimal growth over time and presented an inadequate infrastructure in the majority of UBSs, making it difficult to organize oral health care within the FHS. In PHC, oral health care is precarious and is described as costly and difficult to maintain.
The second category, Care model defended by the management focused on dental clinics, is referent to the management process and to decision-making regarding oral health services. The subcategories that explain this category are: a) oral healthcare model in PHC organized according to regional poles; b) verticalized and unconnected oral health management; and c) the proposal of the inclusion of OHT within the FHS, defended by the health management not seeking to restructure the care model.
In the oral healthcare model, the offer of dental services within basic health was organized in regional poles with Regional Dental Units (RDUs), located in the physical spaces of the DSCs. The justification for this decision was to take advantage of the spaces with good infrastructure, with the allotment of additional resources. These service production units, from the point of view of some management actors, guarantee the integral and continued care, together with the expansion of population access for areas of the municipality that are not covered by basic health care. The organization of regional poles positioned itself in opposition to the expectations of some health and MHC managers regarding the inclusion of oral health within the FHS.
The proposal to include oral health care within the FHS is given as a possibility, given the management initiatives, such as studies conducted on financial impacts and in the bureaucracy. However, it does not seek to surpass the model, since it is in need of a universal perspective and maintains the centrality of care within dental clinics.
With the theorization, it was possible to justify that the oral health management within the MHS is verticalized and disconnected. Secondary and tertiary care are the responsibility of the Oral Health Department (OHD), while primary care was submitted to the Primary Healthcare Management of the Under-Secretary of Health Care. Communication problems were detected between sectors and levels of management as regards the proposal and follow-up of programs and actions.
The category, Different understandings of the oral healthcare model, shows the willingness present in the MHC to include oral health within the FHS and their critical position in relation to the implementation of regional poles. The category presents three subcategories: a) the concept of the MHC care model is counter-hegemonic; b) the expectation of the MHC to include the OHTs in the FHS is not supported by the general population and among the DS of the FHS; and c) the oral healthcare model meets the professional profile and the expectations of the DS of the FHS.
The results indicate that the MHC has an understanding of the care model focused on the principle of the integrality of care and the defense of the strengthening of oral health in PHC. This concept is counter-hegemonic and opposes the organization of regional poles, which has led to clashes with city hall. Nevertheless, there are doubts about the true position of the MHS on the issue. The position would not be of the MHC, but rather of some representatives who work for the Council, in conjunction with the Brazilian Dental Association.
The proposal to include oral health within the FHS, presented by the MHC in 2001, has remained in effect for 20 years under the national Budgetary Guidelines Law, under the Annual Budget Law, and within the Annual Health Planning. In 2016, the city council approved the inclusion of oral health care within the FHS and the extension of DS working hours to 40 hours/week. In 2019, a study was conducted regarding the budget impact on the implementation of some OHTs within the FHS, which did not result in an effective movement of the health management sector in favor of changing the model. The non-existence of records in relation to oral health in the municipal ombudsman would indicate the absence of a demand for improvements and changes in oral health services.
There is no mobilization among DSs for the inclusion of oral health within the FHS, which shows a certain accommodation among the professionals who choose not to engage in changes in oral health care. This understanding is reinforced by the fact that these professionals have achieved a reduction in weekly working hours from 20 hours to 12 hours and 30 minutes, without a loss in salary.
The category, Loss of the window of opportunity provided by the PNSB, presents internal factors of the municipality that resulted in the loss of opportunities to strengthen oral health in PHC and funding to implement health policies. It also presents external factors related to the macropolitical and economic scenario of the country, such as factors that hinder the process of the inclusion of oral health within the FHS. The situation of recent de-funding was the most heavily impacting because of the lack of investment at previous moments. The following subcategories were associated with this category: a) choice of management concerning the application of resources coming from the PNSB and b) Constitutional Amendment 95: from the chronic under-funding to the de-funding of health.
The PNSB allowed the municipality to buy dental equipment and inputs, as well as implement new DSCs. Despite the greater allocation of financial resources from the federal government, the proposal to include oral health in the FHS did not progress due to municipal costs with inputs and the professional work force. Brazilian Constitutional Amendment 95 imposed a reduction in health funding, even further hindering the project to include oral health within the FHS, which is under debate in the municipal administration.
It becomes clear that, during the studied period (2001-2020), changes occurred in the MHS organization, and the sectors related to oral health and PHC changed in nomenclature and in position within the administrative framework. The flow chart (Fig. 1), constructed according to the data, present oral health care within the organizational structure of the MHS.

Figure 1

DISCUSSION
The emerging theorization allowed for the understanding of the phenomenon of the non-inclusion of oral health care within the FHS in the municipality studied here. The elements that enabled this theorization were identified through the concept of social agents who spearheaded conflicting relations in the processes of the organization of oral health care within the municipality over the past 21 years. The non-inclusion of the oral health service within the FHS runs in opposition to that established by the PNSB7, bearing in mind that Family Health is a strategy for the qualification and reorganization of basic care. The difficulty in this adherence is also shared by other Brazilian municipalities8,13,17,18.
Mid and large-scale municipalities, which composed regionalized poles of the care system from the National Social Security Institute for Medical Care (INAMPS, in Portuguese), with an apparatus of medium and high-complexity services28 and contracting with private initiatives29, passed through the process of municipalization with no change in the health services model28. The municipality studied here is an INAMPS pole, remains as a reference in the rendering of public and private health services of middle and high complexity, and shares with other Brazilian municipalities the hegemonic experience of reproducing of biomedical model practices. Not overcoming this paradigm has consequences for the organization of the services and the practice of health professionals12,13,15.
The reproduction of the biomedical care model takes place due to the interaction among the economic, political, and social conditions that favor their maintenance15. To break with this hegemony it is necessary to strengthen the role of the State and the political project that restructures the organization of the system in favor of the population’s health needs30. The starting point for change is to adopt the expanded concept and the promotion of health within the restructuring of the model of adherence to the FHS7,12,13,15,31.
In the municipality, the biomedical care model is reproduced in oral health care, in misalignment with what was originally proposed in the PNSB guidelines. According to the PNSB7, the concept of care and the expanded conception of health should be the foundation of health care, with protection and promotion actions geared toward the quality of life.
Oral health care in the municipality is organized primarily in regional poles of clinical care in RDUs located in the spaces occupied by the DSCs, and the OHTs are present in less than half of the BHUs. Oral health care should assume a commitment with the qualification of basic health and guarantee the principle of integrality, interlinking individual care with collective care. It should also defend the promotion, prevention, treatment, and recovery of health within Brazil7. The organization, according to regional poles, concentrates dental clinical care in equipment that is distant from the communities. Thus, the qualification of PHC is not promoted due to the lack of bonds and presence in the territory, the lack of a multidisciplinary team, and the lack of intersectoral actions. In the regional poles, oral health care is reduced to dental care focused on clinics. Oral health care should not only be limited to clinical care, but it should also consider the health needs, community work, and preventive and educational actions within health care32. The heavy focus on the dental clinic indicates that the hegemonic biomedical model and the concept of health focused on disease and procedures have not been overcome13,15.
In the municipality, the implementation of DSCs was a priority for the municipal administration; however, there was not a corresponding effort to include oral health within the FHS. Chaves et al.33, in the state of Bahia, verified that in municipalities that have an FHS, there is a greater possibility of guaranteeing the integrality of care. In this sense, it is clear that there is a need for primary care in oral health to precede the implementation of DSCs.
The municipalities, proportionally, have greater expenses within the three spheres of government36. The chronic under-funding of SUS impacts the maintenance of the providing of health care where dental professionals’ salaries are included4, with a significant reduction in the perspectives of the expansion of oral health services throughout the country6,33,34. The scenario of the insecurity of the BHU infrastructure is present throughout Brazil35 and hinders the expansion of oral health care in PHC.
With the PNSB7, the municipality’s oral health management had the opportunity to obtain financial incentives to implement and expand their oral health services8,9,36. While many Brazilian municipalities included oral health within the FHS with qualifications in basic care9,10,16,36, the municipality under study here allocated resources for the strengthening and implementation of DSCs and the consolidation of RDUs, even though there was a proposal from the OHD, backed by the MHC, for the inclusion of oral health within the FHS.
In the municipality, there is no clear mobilization of the DSs linked to the service for the inclusion of oral health within the FHS. The professionals seem to be in consensus regarding the care model established by the municipal administration. This posture may well be associated with the professional education marked by specialization, where curative and technocare practices prevail12,5,8,37. In this sense, the DS can represent a low adherence to the public service, as this occupation would not respond to the expectations of professional achievements39. It is important to provide an education that is based on the foundational principles of the FHS and on the production of medical care, in which the core focus in the clinic is on the user12,38. Chaves and Silva39 point out that the hegemony of the private sector seems to influence the practice of DSs in the public sector. The reduction in the weekly work hours conceded in 2016 to the DSs in the municipality may well indicate a predilection for a professional career in the private clinics, which is in accordance with the modus operandi of dental practices in Brazil12,14,37 and worldwide13, where the providing of market services and the heavy influence of the liberal model in Dentistry is still predominant13,15.
The municipal administration’s proposal for the inclusion of oral health care within the FHS restricts the OHTs in BHUs of neighborhoods of greater social and peripheral vulnerability, with the maintenance of dental care in the regional poles, is dissonant with the principle of the universality of healthcare7, and the manner in which it is proposed reinforces the oral healthcare model focused on the dental clinic. Its understanding harkens back to the discussion about the selective PHC presented by Mendes40 as a specific program focused on and geared toward poor populations and regions, offering a group of simple and low-cost technologies. The concept of PHC must surpass this restrictive concept to become the chief space for a healthcare network 40. This project, developed in 2001, is still being debated with the MHC, demonstrating the sluggishness in the decision-making process. In part, this can be explained by the disconnection between the oral health management sectors of the municipality. The fact that oral health care is managed by two sectors within the municipal administration hinder the planning, surveillance, and assessment processes. The qualification of the PHC, as part of the PNSB, requires strong engagement and decision-making on the part of the managers and the professionals of the team8,15.
The verticalized management, in addition to jeopardizing the participative and democratic proposal of public policies7, can also cause demotivation, a lack of commitment among professionals, and flaws in the rendering of services41. In the municipality, in addition to the management being conducted in a centralized and disconnected manner, there is also the distancing in relation to social control. This condition hinders the population’s participation in the management of SUS, effective answers to health problems, and the definition of care and management models according to social demands and health needs8.
The participative culture and the councils, as innovation in health governance in Brazil2,4, present challenges in relation to their representativeness and to the communication between actors and institutions42,43. In the municipality, the crystallization of the positions of city councilmen impedes the disclosure of the interests of the population. This fragile link between representatives and the represented weakens the defense of common interests and hinders a collective construction of a social and political project42.
The institutional positioning of the MHC is contrary to the oral healthcare model focused on the dental clinic and defended by the municipal administration. This positioning could fortify the positions favorable to the inclusion of oral health within the FHS7. Nonetheless, the consensus of this position in the MHC is rather uncertain and fragile. The inclusion of oral health within the FHS is defended by one of the members of social control and is shared by professionals linked to the Brazilian Dental Association. Magalhães and Xavier44 found, as a critical point in the work of the MHC of JF, the discursive asymmetry between actors of social control and the need for greater societal engagement in their true interests.
In the municipality, there is no record of popular initiatives to call for changes in oral health services, which points to the need to expand the debate surrounding the appreciation of oral health as a right to be demanded together with the public service’s structures of governance45. Further studies are needed, which indicate strategies to sustain the reproduction of the existing oral healthcare model, to engage in municipal governance with advice from the PNSB, and to exercise participative management. In this same sense, the strengthening of social control geared toward the recognition of oral health as a right represents a major challenge.
This study highlighted the need to establish the Oral Healthcare Network40, since the implementation of the OHTs within the FHS should not be bureaucratic, but rather result from a group of initiative in the fulfillment of the PNSB. Although the scenario of federal de-funding for health2,6,4 harms the maintenance and expansion of oral health services34, the municipality must set priorities to guarantee high-quality health care. Mobilizing social actors and strengthening social control geared toward a sanitary awareness is essential in order to exercise citizenship, to combat iniquities and inequalities, and to maintain health as a right.

CONCLUSION
Theorization enabled the identification of the origin of the conditions of the studied phenomenon and can contribute to social actors’ decision-making in future policy actions. The disease-centered hegemonic concept of social actors of the municipality contributed to the non-inclusion of oral health care within the FHS. The consequences of this concept are observed in the advice from the oral healthcare model, which is in historical misalignment with that established by the national health policies before the approval of Constitutional Amendment 95.
This study points out the modus operandi reproduction of the technicist practice that hegemonically mirrors the clinic and the liberal model of observed dentistry, even in countries that have universal systems and treat health as a right. In this light, it is clearly necessary for the PNSB to become a policy of the State in order to consolidate the healthcare model included in the defense of life and of social determinants, and oral health should be understood as a social right for the entire population, within a high-quality universal public system. What is needed is a policy that opposes the de-funding of health and the dismantling of SUS. Collective oral health care must be a guiding principle in the processes of professional education, with teamwork, integral care, the guidance established in the expansion of health, and the promotion of health being absolutely indispensable.

REFERENCES
1. Paim J, Travassos C, Almeida C, Bahia L, Macinko J. The Brazilian health system: history, advances, and challenges. Lancet 2011;377(9779):1778-97.
2. Castro MC, Massuda A, Almeida G, Menezes-Filho NA, Andrade MV, de Souza Noronha KVM, Rocha R, Macinko J, Hone T, Tasca R, Giovanella L, Malik AM, Werneck H, Fachini LA, Atun R. Brazil’s unified health system: the first 30 years and prospects for the future. Lancet 2019;394(10195):345-356.
3. Souto LRF, Oliveira MHB. Movimento da Reforma Sanitária Brasileira: um projeto civilizatório de globalização alternativa e construção de um pensamento pós-abissal. Saúde em Debate 2016;40(108):204-218.
4. Paim JS. Thirty years of the Unified Health System (SUS). Cien Saude Colet 2018;23(6):1723-1728.
5. Brasil. Presidência da República. Casa Civil. Subchefia para Assuntos Jurídicos. Emenda Constitucional nº 95, de 15 de dezembro de 2016. Disponível em: http://www.planalto.gov.br/ccivil_03/constituicao/emendas/emc/emc95.htm
6. Menezes APR, Moretti B, Reis AAC. O futuro do SUS: impactos das reformas neoliberais na saúde pública - austeridade versus universalidade. Saúde em Debate 2019;43(esp. 5):58-70.
7. Ministério da Saúde (Brasil), Secretaria de Atenção à Saúde, Departamento de Atenção Básica, Coordenação Nacional de Saúde Bucal. Diretrizes da Política Nacional de Saúde Bucal. Brasília: MS; 2004 [citado 10 ago. 2021]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/politica_nacional_brasil_sorridente.htm
8. Scherer CI, Scherer MD. Advances and challenges in oral health after a decade of the “Smiling Brazil” Program. Rev Saude Publica 2015;49:98.
9. Pucca GA Jr, Gabriel M, de Araujo ME, de Almeida FC. Ten years of a National Oral Health Policy in Brazil: innovation, boldness, and numerous challenges. J Dent Res 2015;94(10):1333-7.
10. Chaves SCL, Almeida AMFL, Rossi TRA, Santana SF, Barros SG, Santos CML. Oral health policy in Brazil between 2003 and 2014: scenarios, proposals, actions, and outcomes. Cien Saude Colet 2017;22(6):1791-1803.
11. Soares CL, Paim JS. Critical issues for implementing oral health policy in the city of Salvador, Bahia State, Brazil. Cad Saude Publica 2011;27(5):966-74.
12. Pires FS, Botazzo, C. Organização tecnológica do trabalho em saúde bucal no SUS: uma arqueologia da política nacional de saúde bucal. Saúde Soc 2015;24(11):273-284.
13. Nétto OBS, Chaves SCL, Colussi CF, Pimenta RMC, Bastos RS e Warmling CM. Diálogos bucaleiros. Reflexões em tempos pandêmicos. São Paulo: Editorial Pimenta, 2021. Disponível em: www.pimentacultural.com/livro/dialogos-bucaleiros
14. Chaves SCL, Almeida AMFL, Reis CS, Rossi TRA, Barros TRA. Política de Saúde Bucal no Brasil: as transformações no período 2015-2017. Saúde em Debate 2018;42(spe2):76-91.
15. Fertonani HP, de Pires DE, Biff D, Scherer MD. The health care model: concepts and challenges for primary health care in Brazil. Cien Saude Colet 2015;20(6):1869-78.
16. Aquilante AG, Aciole GG. Building a “Smiling Brazil”? Implementation of the Brazilian National Oral Health Policy in a health region in the State of São Paulo. Cad Saude Publica 2015;31(1):82-96.
17. Caldas AS, Cruz DN, Barros SG, Rossi TRA, Chaves SCL. The oral health policy in a municipality of Bahia: the agents of state bureaucracy. Saúde em Debate 2018;42(119):886-900, 2018.
18. Mattos GC, Ferreira EF, Leite IC, Greco RM. The inclusion of the oral health team in the Brazilian Family Health Strategy: barriers, advances and challenges. Cien Saude Colet 2014; 19(2):373-82.
19. Strauss A, Corbin J. Pesquisa qualitativa: técnicas e procedimentos para o desenvolvimento de teoria fundamentada. 2. ed. Porto Alegre: Artmed; 2008.
20. Charmaz K. A construção da teoria fundamentada: guia prático para análise qualitativa. São Paulo: Artmed; 2009.
21. Roncalli AG. Epidemiologia e saúde bucal coletiva: um caminhar compartilhado. Cien Saude Colet, 2006; 11(1):105-114.
22. Instituto Brasileiro de Geografia e Estatística (IBGE). População estimada: IBGE, Diretoria de Pesquisas, Coordenação de População e Indicadores Sociais, Estimativas da população residente. Rio de Janeiro: IBGE; 2020 [citado 11 fev. 2021]. Disponível em: https://cidades.ibge.gov.br/brasil/mg/juiz-de-fora/panorama.
23. Chaves ST. Estudo de caso a cidade de Juiz de Fora, MG: sua centralidade e problemas socioeconômicos. Rev. GEOMAE 2011;2(Esp. 1):155-70.
24. Secretaria Municipal de Saúde (Juiz de Fora, MG). Plano de Saúde 2014-2017. Juiz de Fora: Prefeitura Juiz de Fora, 20 set. 2012 [citado 10 ago. 2021]. Disponível em: https://www.pjf.mg.gov.br/conselhos/cms/arquivos/plano_saude_2014_2017.pdf.
25. Flick U. Introdução à pesquisa qualitativa. 3ª ed. Porto Alegre: Artmed; 2009.
26. Moser A, Korstjens I. Series: Practical guidance to qualitative research. Part 3: Sampling, data collection and analysis. Eur J Gen Pract 2018;24(1):9-18.
27. Sah, LK, Singh, DR, Sah, RK. Conducting Qualitative Interviews using Virtual Communication Tools amid COVID-19 Pandemic: A Learning Opportunity for Future Research. Journal of Nepal Medical Association, 2020; 58(232):1103–1106.
28. Teixeira CF. Municipalização da saúde: os caminhos do labirinto. Rev Bras Enferm 1991;44(1):10-15.
29. Marques R. Notas exploratórias sobre as razões do subfinanciamento estrutural do SUS. PPP, 2017;(49).
30. Teixeira CF, Solla JP. Modelo de atenção à saúde: vigilância e saúde da família. Salvador: EDUFBA; 2006 [citado 10 ago. 2021]. Disponível em: https://static.scielo.org/scielobooks/f7/pdf/teixeira-8523204008.pdf.
31. Bezerra IMP, Sorpreso ICE. Concepts and movements in health promotion to guide educational practices. J Hum Growth Dev 2016;26(1):11-20.
32. Antunes JLF, Narvai PC. Políticas de saúde bucal no Brasil e seu impacto sobre as desigualdades em saúde. Rev Saúde Pública 2010;44(2):360-5.
33. Chaves SC, Barros SG, Cruz DN, Figueiredo AC, Moura BL, Cangussu MC. Brazilian Oral Health Policy: factors associated with comprehensiveness in health care. Rev Saude Publica. 2010 Dec;44(6):1005-13.
34. Rossi TRA, Lorena Sobrinho JE, Chaves SCL, Martelli PJL. Crise econômica, austeridade e seus efeitos sobre o financiamento e acesso a serviços públicos e privados de saúde bucal. Ciênc. Saúde Coletiva 2019;24(12):4427-4436.
35. Bousquat A, Giovanella L, Fausto MCR, Medina MG et al. A atenção primária em regiões de saúde: política, estrutura e organização. Cad Saude Publica, 2019; 35(2):e00099118.
36. Santos JLD, Ferreira RC, Amorim LP, Santos ARS, Chiari APG, Senna MIB. Oral health indicators and sociodemographic factors in Brazil from 2008 to 2015. Rev Saude Publica 2021;55:25.
37. Narvai PC. Collective oral health: ways from sanitary dentistry to buccality. Rev Saude Publica 2006;40(Spec no.):141-7.
38. Graff, VA, Ceriotti Toassi, RF. Produção do cuidado em saúde com foco na Clínica Ampliada: um debate necessário na formação em Odontologia. Revista Da ABENO 2018;17(4): 63–72.
39. Chaves, SC, Silva LMV. As práticas profissionais no campo público de atenção à saúde bucal: o caso de dois municípios da Bahia. Ciênc. Saúde Coletiva 2007;12(6):1697-1710.
40. Mendes EV. O cuidado das condições crônicas na atenção primária à saúde: o imperativo da consolidação da estratégia da saúde da família. Brasília: Organização Pan-Americana da Saúde; 2012.
41. Andraus SHC, Ferreira RC, Amaral JHL, Werneck MAF. Organization of oral health actions in primary care from the perspective of dental managers and dentists: process of work, planning and social control. Rev Gaúch Odontol 2017;65(4):335-343.
42. Paiva FS, Van Stralen, CJ, Costa PH. A. Participação social e saúde no Brasil: revisão sistemática sobre o tema. Ciênc Saúde Coletiva 2014;19(2):487-98.
43. Ventura CAA, Miwa MJ, Serapioni M, Jorge MS. Participatory culture: citizenship-building process in Brazil. Interface 2017;21(63):907-20.
44. Magalhães, F. G. G. P.; Xavier, S. X. Processo participativo no controle social: um estudo de caso do Conselho Municipal de Saúde de Juiz de Fora (MG). REAd 2019;25(1):179-212.
45. Godoi H, Castro RG, Santos JLGD, Moyses SJ, Mello ALSF. Obstacles to public governance and their influence on oral healthcare in the state of Santa Catarina, Brazil. Cad Saude Publica 2020;36(11):e00184719.