COVID-19 Pandemic impact on Brazil's Public Dental System

Chisini, Luiz Alexandre; Costa, Francine dos Santos; Sartori, Leticia Regina Morello; Corrêa, Marcos Britto; D’Avila, Otávio Pereira; Demarco, Flávio Fernando

doi:10.1590/1807-3107bor-2021.vol35.0082

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Sumário

Original Research, Social/Community Dentistry • Braz. oral. res. 35 • 2021 • https://doi.org/10.1590/1807-3107bor-2021.vol35.0082 copy

COVID-19 Pandemic impact on Brazil's Public Dental System

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract:

The present study aimed to estimate the impact of the COVID-19 pandemic on dental care procedures in the Public Health System in Brazil. A retrospective, ecological study was carried out, comprising 5,564 Brazilian municipalities. The number of dental procedures (per 100,000 inhabitants) performed in the Brazilian Public Health System (SUS) was the outcome. The impact of the pandemic was estimated by comparing the rate of procedures for each month of 2020 with the rates observed in the equivalent months in 2019, considering the period from March to August. Regulatory legislation regarding restrictions on dental care, issued by the state governments of 27 Brazilian federative units, was used for mediation analysis. A 55% reduction was observed in March for all procedures (IRR = 0.45, 95%CI 0.39–0.51), while in the other months, the rate of reduction remained ≥ 88%. The biggest decrease was observed in collective preventive procedures (reduction ≥99%) between April and August. Procedures that were less likely to generate aerosols (tooth extraction and prosthetic) and emergencies showed the smallest reduction. The reduction was not mediated by the restrictions imposed by state governments (p>0.05). The impact of the COVID-19 pandemic was noteworthy in terms of the decrease in the number of dental procedures carried out in the Brazilian Public Dental Service. The lack of access, the delay of elective procedures and the lack of preventive collective procedures could result in an overburdened system, post-Pandemic.

Keywords:
COVID-19; Epidemiology; Health Services Research; Public Health Dentistry

Attention level	Procedures group	SUS - Procedure codes	Procedure
Basic	Access	301010153	First programmatic dental consultation
	Restorative	307010023	Primary tooth restoration
		307010031	Anterior permanent tooth restoration
		307010040	Posterior permanent tooth restoration
		307010015	Pulp Capping
		307020070	Pulpotomy
		101020090	Temporary cavity sealing
	Tooth extraction	414020120	Primary tooth extraction
		414020138	Permanent tooth extraction
		414020146	Multiple extraction with alveoloplasty by sextant
	Preventive procedures	101020074	Individual fluoride topical application per session
		101020058	Tooth cariostatic application
		101020066	Tooth sealant application
		307030040	Prophylaxy/ bacterial plaque removal
		101020082	Bacterial plaque disclosure
	Collective procedures	101020031	Collective action of supervised tooth brushing
		101020015	Collective action of fluoride gel topical application
		101020023	Collective action of fluorinated mouthwash
		101020040	Collective action of oral examination with epidemiological purpose
	Periodontics	307030016	Supragingival scraping, smoothing and polishing (by sextant)
	Periodontics	307030059	Supragingival scraping, smoothing and polishing (by sextant)
Basic/Specialized	Urgency	307020010	Access to dental pulp and medication (by tooth)
		404020054	Abscess drainage from the mouth and attachments
		414020383	Alveolitis treatment
		414020340	Surgical treatment of intraoral and/or extraoral fistula
		414020359	Surgical treatment of oral-dental hemorrhage
		414020391	Emergency treatment for reduction of tooth socket fracture
Specialized	Prosthetics	701070099	Removable partial mandibular denture
		701070102	Removable partial maxillary denture
		701070110	Temporary denture
		701070129	Mandibular complete denture
		701070137	Maxillary complete denture
		701070145	Fixed / adhesive intraradicular coronary prostheses by tooth
		701080027	Dental implant prosthesis
	Endodontics	307020088	Endodontic retreatment in permanent biradicular tooth
		307020096	Endodontic retreatment in permanent tooth with three or more roots
		307020053	Endodontic retreatment in permanent uniradicular tooth
		307020045	Permanent biradicular tooth filling
		307020053	Permanent tooth filling with three or more roots
		307020061	Permanent uniradicular tooth filling
		307020037	Primary tooth filling
	Periodontics	307030024	Subgingival scraping and smoothing (by sextant)
		307030032	Coronoradicular scraping (by sextant)
		414020375	Surgical periodontal therapy (by sextant)

Groups	Intercept	SE	p-value	Linear Slope	SE	p-value	Quadratic slope	SE	p-value	AIC	BIC	Sample Adjusted BIC
1 (null)	-0.20768	0.02384	< 0.001	-0.44201	0.01111	< 0.001	0.02695	0.00097	< 0.001	34619	34636.3	34622.8
2	-8.034.461	4.902.128	0.9869	777.357	4155.44	0.9851	-192.069	85.740.843	0.9821	26426.7	26458.3	26449.9
2	0.67163	0.02479	< 0.001	-0.42235	0.01138	< 0.001	0.02625	0.00098	< 0.001
3	-9.022.451	6.173.122	0.9883	858.212	5144.50	0.9867	-207.815	1025.29	0.9838	24306.5	2456.1	24342.9
	276.339	0.09742	< 0.001	-179.337	0.10187	< 0.001	0.05992	0.02043	< 0.003
	0.01939	0.03236	0.5490	-0.10597	0.01323	< 0.001	0.00460	0.00110	< 0.001
4	-627.808	0.24690	< 0.001	574.888	0.24039	<.001	-144.101	0.05828	< 0.001	24276.4	24344.1	24326.1
	-4.366.213	251.305	0.9999	962.606	130.200	0.9999	-127.704	16607.0	0.9999
	2.558.695	7.487.299	0.9727	-262.216	817.600	0.9773	200.046	7.024.339	0.9993
	0.01708	0.03216	0.5955	-0.10364	0.01313	< 0.001	0.00446	0.00110	< 0.001
5	-2.434.956	5.336.692	0.9964	-0.19804	1390.91	0.9999	0.04783	8.787.121	0.9996	24511.6	24597.31	24574.53
	3.638.095	46328.49	0.9994	-379.010	49705.8	0.9994	288.578	49705.84	0.9994
	-653.206	0.27455	< 0.001	596.536	0.26285	< 0.001	-149.466	0.06395	< 0.001
	-229.278	0.08160	< 0.001	0.41794	0.02531	< 0.001	-0.01836	0.00182	< 0.001
	0.42390	0.04223	< 0.001	0.10344	0.02237	< 0.001	-0.04428	0.00246	< 0.001

Variables	Mean	SD	Minimum	Median	Maximum
Family health strategy coverage in % of inhabitants, 2020 (SIAB)	89.4	21.2	0	100	100
IDH of Brazilian municipalities 2010 (UNDP)	0.66	0.07	0.41	0.66	0.86
Gini index of Brazilian municipalities 2010 (UNDP)	0.50	0.07	0.28	0.50	0.80
The trajectory of states with always social isolation in %	25.1	–	–	–	–

Procedures	March to August 2019		March to August 2020
Procedures	Mean Rate	95%CI	Mean Rate	95%CI
Total of procedure	88,081.0	(87,203.8–88,924.2)	3,605.8	(3,479.0–3,733.1)
First dental visit	2,651.2	(2,535.3–2,769.1)	33.0	(19.2–51.1)
Emergency	275.9	(235.5–323.3)	143.3	(114.2–178.6)
Restoration	31,271.1	(30,005.5–32,509.2)	946.7	(871.5–1,027.1)
Tooth Extraction	3,798.1	(3,669.8–3,926.6)	1,303.2	(1,215.6–1,394.3)
Endodontics	61.0	(42.3–85.3)	23.1	(12.5–39.9)
Individual preventives	70,747.8	(69,525.4–71,933.8)	628.6	(566.5–696.1)
Collective preventives	10,597.6	(9,806.7–11,442.6)	675.4	(611.2–744.9)
Basic periodontal	1,234.3	(1,149.9–1,324.0)	368.6	(320.5–421.3)
Prosthetics	448.4	(394.7–505.2)	138.0	(109.3–172.6)
Surgical periodontal	919.4	(845.5–999.2)	326.8	(281.9–377.3)

Group of procedures Ref. No pandemic	Impact of COVID 19 monthly compared
	March		April		May		June		July		August
	IRR (95%CI)	p-value	IRR (95%CI)	p-value	IRR (95%CI)	p-value	IRR (95%CI)	p-value	IRR (95%CI)	p-value	IRR (95%CI)	p-value
Total of procedure	0.45 (0.39–0.51)	< 0.001	0.06 (0.06–0.07)	< 0.001	0.07 (0.06–0.08)	< 0.001	0.09 (0.07–0.10)	< 0.001	0.12 (0.10 0.14)	< 0.001	0.09 (0.07–0.10)	< 0.001
First dental visit	0.52 (0.43–0.63)	< 0.001	0.08 (0.07–0.10)	<.001	0.10 (0.08–0.12)	< 0.001	0.14 (0.11–0.17)	< 0.001	0.15 (0.12–0.19)	< 0.001	0.09 (0.07–0.12)	< 0.001
Emergency	0.58 (0.49–0.68)	< 0.001	0.22 (0.18–0.27)	< 0.001	0.25 (0.21–0.30)	< 0.001	0.32 (0.27–0.39)	< 0.001	0.34 (0.28–0.40)	< 0.001	0.28 (0.23–0.34)	< 0.001
Restoration	0.49 (0.41–0.57)	< 0.001	0.08 (0.01–0.10)	< 0.001	0.10 (0.08–0.12)	< 0.001	0.13 (0.11–0.16)	< 0.001	0.12 (0.10–0.15)	< 0.001	0.06 (0.05–0.07)	< 0.001
Tooth Extraction	0.48 (0.41–0.56)	< 0.001	0.06 (0.05–0.07)	< 0.001	0.14 (0.11–0.17)	< 0.001	0.14 (0.12–0.16)	< 0.001	0.22 (0.19–0.27)	< 0.001	0.17 (0.14–0.21)	< 0.001
Endodontics	0.60 (0.53–0.69)	< 0.001	0.14 (0.01–0.20)	< 0.001	0.02 (0.01–0.03)	< 0.001	0.04 (0.03–0.05)	< 0.001	0.06 (0.05–0.09)	< 0.001	0.17 (0.12–0.24)	< 0.001
Individual preventives	0.45 (0.38–0.53)	< 0.001	0.01 (0.00–0.01)	< 0.001	0.01 (0.01–0.02)	< 0.001	0.02 (0.01–0.02)	< 0.001	0.03 (0.02–0.03)	< 0.001	0.05 (0.04–0.06)	< 0.001
Collective preventives	0.24 (0.17–0.14)	< 0.001	0.00 (0.00–0.01)	< 0.001	0.00 (0.00–0.01)	< 0.001	0.00 (0.00–0.01)	< 0.001	0.00 (0.00–0.01)	< 0.001	0.00 (0.00–0.01)	< 0.001
Basic periodontal	0.55 (0.44–0.67)	< 0.001	0.01 (0.01–0.02)	< 0.001	0.01 (0.01–0.02)	< 0.001	0.01 (0.01–0.02)	< 0.001	0.04 (0.03–0.06)	< 0.001	0.05 (0.04–0.06)	< 0.001
Prosthetics	0.66 (0.53–0.81)	< 0.001	0.29 (0.23–0.37)	< 0.001	0.29 (0.23–0.38)	< 0.001	0.33 (0.26–0.42)	< 0.001	0.41 (0.32–0.51)	< 0.001	0.32 (0.25–0.40)	< 0.001
Surgical periodontal	0.50 (0.42–0.60)	< 0.001	0.03 (0.02–0.04)	< 0.001	0.03 (0.02–0.04)	< 0.001	0.05 (0.04–0.06)	< 0.001	0.06 (0.05–0.08)	< 0.001	0.07 (0.06–0.10)	< 0.001

Variable		G-computation estimate (Coef.)	Bootstrap std. err.	p-value	95%CI (OR)
Total procedures
	TCE	-0.23	0.0069	< 0.001	-0.24– −0.21
	NDE	-0.23	0.0061	< 0.001	-0.24– −0.22
	NIE	0.00	0.0023	0.858	-0.00– 0.01
	CDE	-0.22	0.0058	< 0.001	-0.23– −0.22
Dentistry Access
	TCE	-0.15	0.0058	< 0.001	-0.16– −0.14
	NDE	−0.15	0.0060	< 0.001	−0.16– −0.14
	NIE	0.00	0.0020	0.324	−0.00– 0.00
	CDE	−0.10	0.0037	< 0.001	−0.11– −0.09
Emergency
	TCE	−0.16	0.0070	< 0.001	−0.17– −0.14
	NDE	−0.16	0.0069	< 0.001	−0.16– −0.15
	NIE	0.00	0.0019	0.222	−0.00– 0.01
	CDE	−0.12	0.0052	< 0.001	−0.14– −0.11
Restoration
	TCE	−0.16	0.0071	< 0.001	−0.17– −0.14
	NDE	−0.16	0.0072	< 0.001	−0.17– −0.14
	NIE	0.00	0.0021	0.245	−0.00– 0.01
	CDE	−0.14	0.0059	< 0.001	−0.15– −0.13
Tooth extraction
	TCE	−0.17	0.0070	< 0.001	−0.18– −0.16
	NDE	−0.17	0.0070	< 0.001	−0.18– −0.16
	NIE	0.00	0.0021	0.679	−0.00– 0.00
	CDE	−0.15	0.0058	< 0.001	−0.16– −0.14
Endodontics
	TCE	−0.14	0.0037	< 0.001	−0.15– −0.13
	NDE	−0.14	0.0039	< 0.001	−0.15– −0.14
	NIE	0.00	0.0009	0.568	−0.00– 0.00
	CDE	−0.15	0.0046	< 0.001	−0.16– −0.14
Individual preventives
	TCE	−0.23	0.0063	< 0.001	−0.24– −0.21
	NDE	−0.22	0.0063	< 0.001	−0.24– −0.21
	NIE	0.00	0.0018	0.815	−0.00– 0.00
	CDE	−0.18	0.0050	< 0.001	−0.19– −0.18
Collective preventives
	TCE	−0.13	0.0043	< 0.001	−0.14– −0.12
	NDE	−0.13	0.0042	< 0.001	−0.14– −0.13
	NIE	0.00	0.0011	0.661	−0.00– 0.00
	CDE	−0.07	0.0026	<0.001	−0.08 – −0.06
Basic periodontal
	TCE	−0.17	0.0049	<0.001	−0.18 – −0.16
	NDE	−0.17	0.0049	<0.001	−0.19 – −0.16
	NIE	0.00	0.0015	0.913	−0.00 – 0.00
	CDE	−0.11	0.0032	<0.001	−0.11 – −0.10
Prosthetic
	TCE	−0.19	0.0039	<0.001	−0.19 – −0.18
	NDE	−0.18	0.0039	<0.001	−0.19 – −0.18
	NIE	0.00	0.0012	0.766	−0.00 – 0.00
	CDE	−0.19	0.0046	<0.001	−0.20 – −0.18
Surgical periodontal
	TCE	−0.22	0.0054	<0.001	−0.23 – −0.21
	NDE	−0.21	0.0057	<0.001	−0.23 – −0.21
	NIE	0.00	0.0014	0.394	−0.00 – 0.00
	CDE	−0.18	0.0050	<0.001	−0.19 – −0.17

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[1] Corresponding Author: Flávio Fernando Demarco E-mail: ffdemarco@gmail.com