Abstract

Dental caries is an important Public Health issue. However, the treatment of this disease in tertiary dental care requires further investigation. Therefore, the objective of this study was to evaluate caries-related hospital morbidity in the Brazilian Unified Health System (SUS) from 2008 to 2022. An ecological study was conducted with secondary data on caries-related Hospital Admission Authorizations (AIH) and in-hospital dental procedures (IDP). Data were collected nationwide and statistical analysis was performed with a significance level (p) of 5%. In the last 15 years, 3,474 caries-related AIH and 63,657 IDP were approved within SUS. There was a significant upward trend in the number of caries-related AIH (p = 0.018) and a stationary trend in the number of caries-related IDP (p = 0.841). Moreover, from 2008 to 2022, R$ 1,160,843.09 was allocated for caries-related AIH. Hospital mortality was 0.29% (10 deaths), and 75.1% were elective inpatient admissions. Among SUS users, adults constituted the majority (49%), with a higher frequency of males (59.8%) and whites (46.2%). The most frequent type of caries-related IDP was restoration of permanent teeth (55.3%). Nonetheless, during the COVID-19 pandemic years, significant reductions in caries-related AIH and IDP within the SUS were observed (all p <0.05). Thus, within the SUS, caries-related tertiary dental care has shown a specific pattern over the last 15 years, including an increase in hospitalizations and a high number of in-hospital dental procedures, especially before the COVID-19 pandemic onset.

Dentistry; Dental Caries; Delivery of Health Care; Morbidity; Hospitalization

Introduction

Dental caries (DC) is considered a relevant Public Health issue. Nowadays, it is evident that different population profiles and unequal access to oral health services continue to cause disparities in DC prevention and treatment. ¹1. Sampaio FC, Bönecker M, Paiva SM, Martignon S, Ricomini Filho AP, Pozos-Guillen A, et al. Dental caries prevalence, prospects, and challenges for Latin America and Caribbean countries: a summary and final recommendations from a Regional Consensus. Braz Oral Res. 2021 May;35 suppl 01:e056. https://doi.org/10.1590/1807-3107bor-2021.vol35.0056
https://doi.org/10.1590/1807-3107bor-202... , ²2. Wen PY, Chen MX, Zhong YJ, Dong QQ, Wong HM. Global burden and inequality of dental caries, 1990 to 2019. J Dent Res. 2022 Apr;101(4):392-9. https://doi.org/10.1177/00220345211056247
https://doi.org/10.1177/0022034521105624... From this perspective, it is understood that access to timely DC treatment should consider the implementation of public policies and the structuring of health systems. ³3. Martignon S, Roncalli AG, Alvarez E, Aránguiz V, Feldens CA, Buzalaf MA. Risk factors for dental caries in Latin American and Caribbean countries. Braz Oral Res. 2021 May;35 suppl 01:e053. https://doi.org/10.1590/1807-3107bor-2021.vol35.0053
https://doi.org/10.1590/1807-3107bor-202... In fact, the availability of public oral health services can influence the caries experience, highlighting the importance of Public Health settings in addressing this disease. ⁴4. Moraes RB, Menegazzo GR, Knorst JK, Ardenghi TM. Availability of public dental care service and dental caries increment in children: a cohort study. J Public Health Dent. 2021 Dec;81(1):57-64. https://doi.org/10.1111/jphd.12401
https://doi.org/10.1111/jphd.12401...

DC treatment and oral health services are primarily provided on an outpatient level. However, there are instances when dentists recommend hospitalization to access resources unavailable in outpatient dental services, ⁵5. Schulz-Weidner N, Schlenz MA, Jung LG, Uebereck CF, Nehls A, Krämer N. Dental treatment under general anesthesia in pre-school children and schoolchildren with special healthcare needs: a comparative retrospective study. J Clin Med. 2022 May;11(9):2613. https://doi.org/10.3390/jcm11092613
https://doi.org/10.3390/jcm11092613... , ⁶6. Alkhuwaiter SS. Criteria of hospital inpatient admission of pediatric dental patient. J Clin Pediatr Dent. 2021 Nov;45(5):344-51. https://doi.org/10.17796/1053-4625-45.5.10
https://doi.org/10.17796/1053-4625-45.5.... such as general anesthesia and medical support for previous comorbidities. This healthcare modality is often chosen when dealing with medically compromised or uncooperative patients at an outpatient level, both for elective and urgent dental treatments. Although feasible, the associated costs and technologies can limit access. ⁷7. Koberova Ivancakova R, Suchanek J, Kovacsova F, Cermakova E, Merglova V. The analysis of dental treatment under general anaesthesia in medically compromised and healthy children. Int J Environ Res Public Health. 2019 Jul;16(14):2528. https://doi.org/10.3390/ijerph16142528
https://doi.org/10.3390/ijerph16142528... , ⁸8. Ibrahim NA, Azizi NZ, Nor NA. Dental procedures and operating time under day-care general anesthesia among medically compromised and uncooperative pediatric patients. Quintessence Int. 2022 Apr;53(5):424-31. https://doi.org/10.3290/j.qi.b2793165
https://doi.org/10.3290/j.qi.b2793165... Furthermore, it has already been demonstrated that the organization of oral health services is an important factor in the use of these resources and technologies for patients with complex disabilities requiring dental treatments. ⁹9. Norderyd J, Faulks D, Molina G, Granlund M, Klingberg G. Which factors most influence referral for restorative dental treatment under sedation and general anaesthesia in children with complex disabilities: caries severity, child functioning, or dental service organisation? Int J Paediatr Dent. 2018 Jan;28(1):71-82. https://doi.org/10.1111/ipd.12305
https://doi.org/10.1111/ipd.12305...

Apart from systemic health problems, caries-related hospital admissions may reflect Public Health problems, such as negligence, socioeconomic disparities in access to oral health services, and the need for advanced treatments for oral diseases that can be managed and prevented by the Primary Health Care setting (outpatient level). However, some patients may require hospital admission due to non-avoidable factors. ¹⁰10. Levine RS. Childhood caries and hospital admissions in England: a reflection on preventive strategies. Br Dent J. 2021 May;230(9):611-6. https://doi.org/10.1038/s41415-021-2945-8
https://doi.org/10.1038/s41415-021-2945-... , ¹¹11. Chen R, Schneuer FJ, Irving MJ, Chow CK, Kumar H, Tsai C, et al. Socio-demographic and familial factors associated with hospital admissions and repeat admission for dental caries in early childhood: a population-based study. Community Dent Oral Epidemiol. 2022 Dec;50(6):539-47. https://doi.org/10.1111/cdoe.12708
https://doi.org/10.1111/cdoe.12708... In addition, there is evidence indicating an increased use of hospital emergency rooms to address dental-related issues, as well as in the number of hospital admissions for non-traumatic dental conditions (e.g. dental caries) in different countries and health systems. ¹²12. Claiborne DM, Kelekar U, Shepherd JG, Naavaal S. Emergency department use for nontraumatic dental conditions among children and adolescents: NEDS 2014-2015. Community Dent Oral Epidemiol. 2021 Dec;49(6):594-601. https://doi.org/10.1111/cdoe.12631
https://doi.org/10.1111/cdoe.12631...

13. Morón EM, Tomar S, Balzer J, Souza R. Hospital inpatient admissions for nontraumatic dental conditions among Florida adults, 2006 through 2016. J Am Dent Assoc. 2019 Jun;150(6):514-21. https://doi.org/10.1016/j.adaj.2019.01.001
https://doi.org/10.1016/j.adaj.2019.01.0...

14. Singhal S, Quiñonez C, Manson H. Visits for nontraumatic dental conditions in Ontario’s health care system. JDR Clin Trans Res. 2019 Jan;4(1):86-95. https://doi.org/10.1177/2380084418801273
https://doi.org/10.1177/2380084418801273... - ¹⁵15. Frebel H, Mugayar L, Tomar SL. Hospital Inpatient Admissions of Children and Adolescents for Nontraumatic Dental Conditions in Florida. Pediatr Dent. 2020 May;42(3):212-6. The intersection between DC as a Public Health issue and its treatment in inpatient settings raises the question: how does the Brazilian Unified Health System (SUS) fit into this scenario?

SUS is one of the largest health systems in the world, and the majority of Brazilians rely on it for healthcare. ¹⁶16. Castro MC, Massuda A, Almeida G, Menezes-Filho NA, Andrade MV, de Souza Noronha KV, et al. Brazil’s unified health system: the first 30 years and prospects for the future. Lancet. 2019 Jul;394(10195):345-56. https://doi.org/10.1016/S0140-6736 (19)31243-7
https://doi.org/10.1016/S0140-6736 (19)3... However, concerning Oral Health, dentists primarily work at the outpatient level within SUS, particularly in Primary Health Care (Family Health Strategy; PHC/FHS). ¹⁷17. Cunha CR, Harzheim E, Medeiros OL, D’Avila OP, Martins C, Wollmann L, et al. Primary Health Care Portfolio: assuring of integrality in the family health and oral health teams in Brazil. Cien Saude Colet. 2020 Mar;25(4):1313-26. https://doi.org/10.1590/1413-81232020254.31862019
https://doi.org/10.1590/1413-81232020254... Nonetheless, there is a need to continue improving oral health care in SUS, especially in terms of providing comprehensive care and increasing access of vulnerable populations to oral health services at all levels. ¹⁷17. Cunha CR, Harzheim E, Medeiros OL, D’Avila OP, Martins C, Wollmann L, et al. Primary Health Care Portfolio: assuring of integrality in the family health and oral health teams in Brazil. Cien Saude Colet. 2020 Mar;25(4):1313-26. https://doi.org/10.1590/1413-81232020254.31862019
https://doi.org/10.1590/1413-81232020254... , ¹⁸18. Teixeira CN, Pereira SM, Hilgert JB, Oliveira NM, Ribeiro CC, Neves M, et al. [The use of dental services in the past year in the brazilian population: a systematic review with meta-analysis]. Cien Saude Colet. 2023 Apr;28(4):1087-100. Portuguese. https://doi.org/10.1590/1413-81232023284.11452022
https://doi.org/10.1590/1413-81232023284... Additionally, it is known that SUS users may experience difficulties in accessing emergency dental care within healthcare networks ¹⁹19. Frichembruder K, Mello Dos Santos C, Neves Hugo F. Dental emergency: scoping review. PLoS One. 2020 Feb;15(2):e0222248. https://doi.org/10.1371/journal.pone.0222248
https://doi.org/10.1371/journal.pone.022... and untreated DC remains a relevant problem in the country. ²⁰20. Karam SA, Costa FD, Peres KG, Peres MA, Barros FC, Bertoldi AD, et al. Two decades of socioeconomic inequalities in the prevalence of untreated dental caries in early childhood: results from three birth cohorts in southern Brazil. Community Dent Oral Epidemiol. 2023 Apr;51(2):355-63. https://doi.org/10.1111/cdoe.12747
https://doi.org/10.1111/cdoe.12747...

Therefore, another reasonable issue is the extent of caries-related hospital morbidity experienced within SUS: is there a high number of caries-related hospital admissions and in-hospital dental procedures (IDP)? Currently, there is a lack of investigation addressing this question. Although solving the most prevalent oral health problems in the population is a PHC goal, in addition to the efforts guided by the National Oral Health Policy (“Brasil Sorridente”), there is a need to investigate the availability of oral health services and its correlation with DC, which is critical for a country with a continental dimension like Brazil. ⁴4. Moraes RB, Menegazzo GR, Knorst JK, Ardenghi TM. Availability of public dental care service and dental caries increment in children: a cohort study. J Public Health Dent. 2021 Dec;81(1):57-64. https://doi.org/10.1111/jphd.12401
https://doi.org/10.1111/jphd.12401... , ¹⁶16. Castro MC, Massuda A, Almeida G, Menezes-Filho NA, Andrade MV, de Souza Noronha KV, et al. Brazil’s unified health system: the first 30 years and prospects for the future. Lancet. 2019 Jul;394(10195):345-56. https://doi.org/10.1016/S0140-6736 (19)31243-7
https://doi.org/10.1016/S0140-6736 (19)3... , ¹⁷17. Cunha CR, Harzheim E, Medeiros OL, D’Avila OP, Martins C, Wollmann L, et al. Primary Health Care Portfolio: assuring of integrality in the family health and oral health teams in Brazil. Cien Saude Colet. 2020 Mar;25(4):1313-26. https://doi.org/10.1590/1413-81232020254.31862019
https://doi.org/10.1590/1413-81232020254... In the outpatient setting (primary and secondary level), a high number of caries-related dental procedures, such as restorations and fluoride applications, have been performed in recent years within SUS. ²¹21. Chisini LA, Martin AS, Pires AL, Noronha TG, Demarco FF, Conde MC, et al. A 19-years study of the dental procedures performed in the Brazilian Unified Health System. Cad Saude Colet. 2019 Jul;27(3):345-53. Portuguese. https://doi.org/10.1590/1414-462x201900030215
https://doi.org/10.1590/1414-462x2019000... However, there is no analysis of caries-related dental care at the tertiary level in this health system.

Moreover, the COVID-19 pandemic onset negatively impacted the productivity of oral health services within SUS. Although the impact on outpatient dental procedures (including caries-related ones) has been widely measured, ²²22. Chisini LA, Costa FD, Sartori LR, Corrêa MB, D’Avila OP, Demarco FF. COVID-19 Pandemic impact on Brazil’s Public Dental System. Braz Oral Res. 2021 Jul;35:e082. https://doi.org/10.1590/1807-3107bor-2021.vol35.0082
https://doi.org/10.1590/1807-3107bor-202... , ²³23. Cunha AR, Velasco SR, Hugo FN, Antunes JL. The impact of the COVID-19 pandemic on the provision of dental procedures performed by the Brazilian Unified Health System: a syndemic perspective. Rev Bras Epidemiol. 2021 May;24:e210028. https://doi.org/10.1590/1980-549720210028
https://doi.org/10.1590/1980-54972021002... it was not possible to find evidence of caries-related in-hospital assistance (tertiary-level dental care).

Therefore, the objective of this study was to evaluate caries-related hospital morbidity within SUS from 2008 to 2022. In addition to the descriptive morbidity-related outcomes, three alternative hypotheses were explored: (H ₁ ) there was a significant increasing temporal trend in the number of caries-related AIH within SUS from 2008 to 2022, (H ₂ ) there was a significant increasing temporal trend in the number of caries-related IDP within SUS from 2008 to 2022, and (H ₃ ) the COVID-19 pandemic has reduced the number of caries-related AIH and IDP within SUS.

Methodology

Study design

An epidemiological study was carried out, with an ecological, longitudinal, retrospective and quantitative approach. ²⁴24. Merchán-Hamann E, Tauil PL. Proposal for classifying the different types of descriptive epidemiological studies. Epidemiol Serv Saude. 2021 Apr;30(1):e2018126. Portuguese. https://doi.org/10.1590/s1679-49742021000100026
https://doi.org/10.1590/s1679-4974202100... The study evaluated data for Brazil, encompassing all regions and the Federal District. The time frame selected for the analysis was the period from 2008 to 2022 (last 15 years; n = 15), considering annual data. To assess the impact of the COVID-19 pandemic, four periods were defined: pre-pandemic (from April 2019 to March 2020), first year (from April 2020 to March 2021), second year (from April 2021 until March 2022), and third year (April 2022 until March 2023), considering monthly data (n = 12 in each period). To enhance the study report, the Portuguese version of the STROBE initiative checklist (Strengthening the Reporting of Observational Studies in Epidemiology) was used. ²⁵25. Malta M, Cardoso LO, Bastos FI, Magnanini MM, Silva CM. STROBE initiative: guidelines on reporting observational studies. Rev Saude Publica. 2010 Jun;44(3):559-65. https://doi.org/10.1590/S0034-89102010000300021
https://doi.org/10.1590/S0034-8910201000...

Ethical aspects

Data were collected from national open access databases, as public domain. Considering the ecological approach, there was no direct interaction with human subjects. Furthermore, there was no data for the identification of SUS users. Therefore, in accordance with national resolution 510 of April 7, 2016, published by the National Health Council - Ministry of Health, ²⁶26. Ministério da Saúde (BR). Resolução nº 510, de 7 de abril de 2016. Dispõe sobre as normas aplicáveis a pesquisas em ciências humanas e sociais. Diário Oficial União, 25 Maio 2016. ethical approval by a Research Ethics Committee was not required.

Data source

Data used in the study were collected from SUS and made available by the Department of Informatics (DATASUS). In terms of assessing caries-related hospital morbidity within SUS and its funded services, data available from the National Hospital Information System (SIH/SUS) were used. ²⁷27. Ministério da Saúde (BR). Sistema Único de Saúde (DATASUS). Brasília, DF: Ministério da Saúde; 2023 [cited 2023 Apr 29]. Available from: https://datasus.saude.gov.br/
https://datasus.saude.gov.br/... It is a system for managing and consolidating SUS-related data. SIH/SUS data are based on Hospital Admission Authorizations (AIH), which considers the diagnosis that led to hospital admission, as well as financial and sociodemographic data. Additionally, data from approved caries-related IDP were used, also from SIH/SUS. Indeed, the SIH/SUS is considered a valuable tool for epidemiological monitoring of health conditions and diseases in Brazil. ²⁸28. Bittencourt SA, Camacho LA, Leal MC. [Hospital Information Systems and their application in public health]. Cad Saude Publica. 2006 Jan;22(1):19-30. Portuguese. https://doi.org/10.1590/S0102-311X2006000100003
https://doi.org/10.1590/S0102-311X200600...

Variables

The primary outcome variable was the number of caries-related AIH in SUS from 2008 to 2022, considering its raw and normalized values per 1,000,000 residents in each year (correcting for the population factor due to possible demographic changes over time). The circumstance (elective or urgent), regime (public or private), number of deaths, and hospital mortality rate (HMR) were also retrieved. HMR was obtained from the ratio between the number of deaths and AIH in each year. The projection of residents in Brazil between 2008 and 2022 from the Brazilian Institute of Geography and Statistics (IBGE) was used as a proxy measure. ²⁹29. Instituto Brasileiro de Geografia e Estatística. Brasília, DF; 2023 [cited 2023 Apr 29]. Available from: http://www.ibge.gov.br/
http://www.ibge.gov.br/... Secondary variables included sociodemographic (sex, color/race, age, city, state, and region in which AIH were approved) and financial (absolute costs) data.

In addition, the number of caries-related IDP carried out in the SUS was collected as a secondary variable. It is important to clarify that these procedures may result from caries-related AIH or be secondary to other oral diseases, and it is not possible to differentiate them. Restorative procedures were divided into: restorations in primary teeth (SIH/SUS codes: #0307010023 “restorations in primary teeth”; #0307010112 “restoration in anterior primary teeth with composite resin” ; #0307010082 “ restoration in posterior primary teeth with composite resin ”; #0307010104 “ restoration in posterior primary teeth with glass ionomer cement ”; #0307010090 “ restoration in posterior primary teeth with amalgam ”), restorations in permanent teeth (SIA/SUS codes: #0307010031 “ restoration in anterior permanent teeth with composite resin ”; #0307010040 “ restoration in posterior permanent teeth ”; #0307010120 “ restoration in posterior permanent teeth with composite resin ”; #0307010139 “restoration in posterior permanent teeth with amalgam” ), and other caries-related interventions (SIH/SUS codes: #0307010074 “ atraumatic restorative treatment” ; #0101020090 “ temporary sealing of dental cavity” ; #0101020058 “cariostatic application - per tooth ”; #0101020066 “ sealant application - per tooth” ; #0101020074 “topical fluoride application - individual per session” ). The number of procedures was also normalized by the population factor, as mentioned above.

Data collection

Data collection was based on the considerations of Bittencourt et al . (2006) ²⁸28. Bittencourt SA, Camacho LA, Leal MC. [Hospital Information Systems and their application in public health]. Cad Saude Publica. 2006 Jan;22(1):19-30. Portuguese. https://doi.org/10.1590/S0102-311X2006000100003
https://doi.org/10.1590/S0102-311X200600... regarding the applicability of SIH/SUS in epidemiological studies in public health, as well as on the procedure carried out by a similar study. ³⁰30. Vargas DGM, Cunha AR, Probst LF, Zafalon EJ, Pereira PZ, Tagliaferro EPS, et al. Characteristics and in-hospital morbidity trends associated with oral and oropharyngeal cancers in Brazil. BMC Oral Health. 2022 Jul;22(1):276. https://doi.org/10.1186/s12903-022-02312-0
https://doi.org/10.1186/s12903-022-02312... The data was collected by a single researcher in April 2023. Caries-related AIH were screened using the filters available in SIH/SUS to stratify according to the list of morbidities of the International Statistical Classification of Diseases and Related Health Problems - 10th revision, (ICD-10), reviewed by the World Health Organization. DC is included in Chapter XI, which deals with diseases of the digestive system (K00-K93 codes), identified by K02. ³¹31. International Statistical Classification of Diseases and Related Health Problems. 10th revision (ICD-10). Genebra: World Health Organization; 2023 [cited 2023 Apr 29]. Available from: https://icd.who.int/
https://icd.who.int/...

Data analysis

Statistical analysis was carried out using the JAMOVI (version 2.3.15, Sydney, Australia) and PAST (version 4.03, Oslo, Norway) softwares. The significance level (p) was set at 5% (α = 0.05). The data were presented using descriptive measures of frequency (absolute and relative), central tendency (mean), and dispersion (standard deviation, minimum, and maximum). To assess the temporal tendency of caries-related AIH, the hypothesis of first-order serial autocorrelation was examined by Durbin-Watson statistic (DW), which was rejected in the normalized values (1,000,000 residents; DW: 1.914, p = 0.432). The same outcome was observed for the number of caries-related IDP in normalized values (DW: 1.512, p = 0.171). Furthermore, the hypothesis of normality of the residuals was examined and confirmed by the Shapiro-Wilk statistic (W) in both datasets (W: 0.942 and 0.920, p = 0.409 and 0.252, respectively). ³²32. Pagano M, Gauvreau K, Heather M. Principles of bioestatistics. 3a. ed. Boca Raton: CRC Press; 2022. 620 pp. https://doi.org/10.1201/9780429340512
https://doi.org/10.1201/9780429340512...

33. Latorre MR, Cardoso MR. Time series analysis in epidemiology: an introduction to methodological aspects. Rev Bras Epidemiol. 2001 Nov;4(3):145-52. https://doi.org/10.1590/S1415-790X2001000300002
https://doi.org/10.1590/S1415-790X200100... - ³⁴34. Antunes JL, Cardoso MR. Using time series analysis in epidemiological studies. Epidemiol Serv Saude. 2015 Jul-Sep;24(3):565-76. https://doi.org/10.5123/S1679-49742015000300024
https://doi.org/10.5123/S1679-4974201500...

Hence, the slope value (β ₁ ; angular coefficient) was estimated by linear regression using the Ordinary Least Squares (OLS) method after the logarithmic transformation (log10) of the dependent variable. The Annual Percent Change (APC) was estimated by the expression = ${[-1+{10}^{(}{\beta }^{1)}]}^{\ast }100\%$ . The 95% confidence interval (CI _95% ) for the APC was estimated using the minimum and maximum β ₁ -values after OLS approach, using the expression = $[{\beta }_1\pm \text{(}t\text{-critical value}{\beta }_1\text{-standard error})]$ . The trend over time was determined as stationary (p ≥ 0.05), increasing (p < 0.05 and positive angular coefficient), or decreasing (p < 0.05 and negative angular coefficient). ³³33. Latorre MR, Cardoso MR. Time series analysis in epidemiology: an introduction to methodological aspects. Rev Bras Epidemiol. 2001 Nov;4(3):145-52. https://doi.org/10.1590/S1415-790X2001000300002
https://doi.org/10.1590/S1415-790X200100... , ³⁴34. Antunes JL, Cardoso MR. Using time series analysis in epidemiological studies. Epidemiol Serv Saude. 2015 Jul-Sep;24(3):565-76. https://doi.org/10.5123/S1679-49742015000300024
https://doi.org/10.5123/S1679-4974201500... Moreover, Generalized Linear Models (GLM) were used to compare the incidence ratios of caries-related AIH and IDP. Considering Quasi-Poisson distributions (QPO), a robust variance correction was carried out, and incidence rate ratios (IRR) were compared by maximum likelihood estimation in the logarithmic link-function (Log-likelihood ratio). ²²22. Chisini LA, Costa FD, Sartori LR, Corrêa MB, D’Avila OP, Demarco FF. COVID-19 Pandemic impact on Brazil’s Public Dental System. Braz Oral Res. 2021 Jul;35:e082. https://doi.org/10.1590/1807-3107bor-2021.vol35.0082
https://doi.org/10.1590/1807-3107bor-202... , ³²32. Pagano M, Gauvreau K, Heather M. Principles of bioestatistics. 3a. ed. Boca Raton: CRC Press; 2022. 620 pp. https://doi.org/10.1201/9780429340512
https://doi.org/10.1201/9780429340512...

Results

From 2008 to 2022, 3,474 caries-related AIH and 63,657 caries-related IDP were approved within SUS. Table 1 presents the descriptive measures and analysis of the temporal trend, and Figure presents this panorama over the last 15 years. It is noteworthy that there was no data available for caries-related IDP in 2008 and 2009. In 2019, both variables reached their highest numbers but experienced an expressive decrease in 2020. However, when considering caries-related AIH, the linear trend lines indicate a significant slope angle from the beginning to the end of the time series. This pattern was not observed in caries-related IDP. Moreover, disregarding the COVID-19 pandemic years (2020, 2021, and 2022), the temporal trend of caries-related AIH continued to increase significantly (p = 0.043), and caries-related IDP increased significantly (p = 0.032, APC = 8.14% [CI95% = 0.69, 16.1%], R ² = 0.429).

Examining sex differences, the projected resident population suggested a relative proportionality (M:F) in all years (data not shown). However, 2,079 (59.8%) caries-related AIH were in males and only 1,395 (40.2%) in females, but there was no statistically significant difference in incidence ratio (female versus male, p = 0.102, IRR = 0.650, CI _95% = 0.390, 1.065).

Moreover, from 2008 to 2022, R$ 1,160,843.09 was allocated for caries-related AIH. Of these, 10 deaths were reported, accounting for a HMR of 0.29%. When stratified between elective and urgent, all deaths reported were urgent cases (HMR: 1.15%; six male and four female users). Table 2 presents the absolute and relative frequency of the other caries-related AIH features. It is noteworthy that color/race and regime, as non-mandatory data, showed a high frequency of missing data (not reported or ignored). In addition, by comparing the region of Brazil where hospital admissions occurred with the region where SUS users resided, similar frequencies were observed, indicating that the majority of users were hospitalized in the region where they lived.

Among Brazilian states, the majority of caries-related AIH were approved in São Paulo (2,236; 64.4%). Additionally, 1,623 (46.7%) were approved in Brazilian state capitals (often in São Paulo city, 1,273, 78.4%), while a small number was approved in municipalities with extreme poverty (26; 0.74%). At last, it is important to highlight that the number of caries-related AIH was lower than other hospitalizations related to oral health issues in Brazil over the last 15 years, such as “other disorders of the teeth and supporting structures” (87,905 AIH; K00-K01, K03-K08 codes) and “other diseases of the oral cavity, salivary glands, and maxillary bones” (156,550 AIH; K09-K14). Table 3 presents the frequency of caries-related IDP by group, with the predominance of restorations in permanent teeth.

Furthermore, Table 4 presents the incidence rate of caries-related AIH and IDP in pre-pandemic years and during the pandemic. The incidence of caries-related AIH was 73.7% lower in the first pandemic year and 47.8% lower in the second pandemic year, with no statistically significant difference in the third pandemic year. Moreover, the incidence of caries-related IDP was 79.5% lower in the first pandemic year, 63,2% lower in the second pandemic year, and 34% lower in the third pandemic year.

Discussion

In summary, the data available show that the number of caries-related AIH in the last 15 years was small in relation to other oral diseases of SUS users. The majority of SUS users who were hospitalized received elective care for DC, which are non-urgent hospital admissions. There was a predominance of adults, males, whites, and residents of the Southeast region of Brazil. Considering the region of hospitalization, there was also a predominance of health services in the Southeast region and in state capitals, especially in the city of São Paulo. Lastly, the majority of caries-related IDP were restorations in permanent teeth, which is in line with the predominant features in relation to SUS users.

Therefore, the first alternative hypothesis (H ₁ ) was accepted, indicating a significant increasing temporal trend in the number of caries-related AIH in the SUS from 2008 to 2022. However, the second (H ₂ ) was partially accepted, as there was no significant increasing temporal trend in the number of caries-related IDP in the SUS from 2010 to 2022, which was only observed when the COVID-19 pandemic years were removed from the calculation (from 2010 to 2019). At last, the third hypothesis (H ₃ ) was accepted, since the number of caries-related AIH and IDP within SUS was lower during the COVID-19 pandemic years, especially in the first and second years.

In the initial analysis, the primary outcome can be interpreted in two ways: the increase in the number of caries-related AIH may reflect the increasing access to this service of SUS users (positive) or barriers to accessing outpatient oral health services prior to tertiary care (negative). The number of elective hospital admissions was an important variable, as these admissions were the majority in the last 15 years (more than 3/4 of caries-related AIH in the SUS), strengthening the positive perception of the outcome.

However, caries-related AIH occurred in a restricted panorama, concentrated in a single region of Brazil (Southeast), and more than 1/3 in a single city (São Paulo). This may represent inequalities in tertiary oral health care access in Brazil, which would be a negative outcome. As discussed by Mello et al. (2014) ³⁵35. Mello AL, Andrade SR, Moysés SJ, Erdmann AL. [Oral health care in the health network and the regionalization process]. Cien Saude Colet. 2014 Jan;19(1):205-14. Portuguese. https://doi.org/10.1590/1413-81232014191.1748
https://doi.org/10.1590/1413-81232014191... , oral health care by SUS focuses on primary and secondary care (Dental Specialty Centers). Tertiary dental care is often limited to some specialties, such as traumatology and stomatology.

Furthermore, the caries-related hospital admissions evaluated here were restricted to the K02 code (ICD) in the AIH, and other oral diseases that arise from an untreated caries lesion (e.g. pulpal/periapical diseases and odontogenic infections) ³⁶36. Habib F, Chaly PE, Junaid M, Musthafa HM. Caries experience, clinical consequences of untreated dental caries and associated factors among school going children - A cross-sectional study. Indian J Dent Res. 2020;31(2):180-5. https://doi.org/10.4103/ijdr.IJDR_120_19
https://doi.org/10.4103/ijdr.IJDR_120_19... were not accounted for in hospital morbidity described here. In fact, DATASUS only distinguishes DC from other diseases that affect teeth and tooth-supporting tissues. ²⁷27. Ministério da Saúde (BR). Sistema Único de Saúde (DATASUS). Brasília, DF: Ministério da Saúde; 2023 [cited 2023 Apr 29]. Available from: https://datasus.saude.gov.br/
https://datasus.saude.gov.br/... This might explain the high number of caries-related IDP compared to the number of caries-related AIH: other oral diseases required restorative procedures as part of the treatment. In addition, although DC was the reason for hospital admissions, adverse events and systemic complications during the procedures, as well as iatrogenesis that may result in death, ³⁷37. Stewart K, Choudry MI, Buckingham R. Learning from hospital mortality. Clin Med (Lond). 2016 Dec;16(6):530-4. https://doi.org/10.7861/clinmedicine.16-6-530
https://doi.org/10.7861/clinmedicine.16-... were not presented by DATASUS, leading to a bias when attributing deaths and hospital mortality rates to caries-related AIH, as it is not possible to identify the death event.

Considering the predominance of elective caries-related AIH in the SUS, it is known that a significant number of IDP are performed on patients with special needs that require general anesthesia (which is often offered in public health services). ³⁸38. Marinho MA, Ramos FC, Cardoso AL, Silva-Júnior GO, Faria MD, Bastos LF, et al. Dental treatment under general anesthesia in patients with special needs provided by private and public healthcare services-a retrospective, comparative study. Healthcare (Basel). 2022 Jun;10(6):1147. https://doi.org/10.3390/healthcare10061147
https://doi.org/10.3390/healthcare100611... However, there is no information about the clinical features of SUS users, limiting the understanding of this outcome, although the high prevalence of DC in patients with special needs is a reality, ³⁹39. Pecci-Lloret MR, Pecci-Lloret MP, Rodríguez-Lozano FJ. Special care patients and caries prevalence in permanent dentition: a systematic review. Int J Environ Res Public Health. 2022 Nov;19(22):15194. https://doi.org/10.3390/ijerph192215194
https://doi.org/10.3390/ijerph192215194... which would justify the high number of elective in-hospital care observed in the SUS over the last 15 years.

Furthermore, the COVID-19 pandemic onset was an immediate challenge to oral health services around the world, including within the SUS. Chisini et al. (2021) ²²22. Chisini LA, Costa FD, Sartori LR, Corrêa MB, D’Avila OP, Demarco FF. COVID-19 Pandemic impact on Brazil’s Public Dental System. Braz Oral Res. 2021 Jul;35:e082. https://doi.org/10.1590/1807-3107bor-2021.vol35.0082
https://doi.org/10.1590/1807-3107bor-202... demonstrated a reduction of outpatient restorative dental procedures (primary and secondary care) in 2020 compared to 2019 (March - August). In addition, they demonstrated an average of approximately 31,300 monthly restorative dental procedures per 100,000 inhabitants between March and August 2019, which reduced to approximately 947 in 2020. These numbers corroborate the perspective that DC care is predominantly done in an outpatient setting within SUS. However, with the COVID-19 outbreak, all levels of care were impacted, including the tertiary care, also considering caries-related dental assistance. Moreover, the impact on restorative dental procedures within SUS is linked to the decline of oral health actions and assistance, which mainly affect Brazilians who depend on the public health sector, ²²22. Chisini LA, Costa FD, Sartori LR, Corrêa MB, D’Avila OP, Demarco FF. COVID-19 Pandemic impact on Brazil’s Public Dental System. Braz Oral Res. 2021 Jul;35:e082. https://doi.org/10.1590/1807-3107bor-2021.vol35.0082
https://doi.org/10.1590/1807-3107bor-202... , ²³23. Cunha AR, Velasco SR, Hugo FN, Antunes JL. The impact of the COVID-19 pandemic on the provision of dental procedures performed by the Brazilian Unified Health System: a syndemic perspective. Rev Bras Epidemiol. 2021 May;24:e210028. https://doi.org/10.1590/1980-549720210028
https://doi.org/10.1590/1980-54972021002... although the extension at the tertiary level has not been delimited for all types of dental procedures.

As limitations, it is important to acknowledge the ecological study approach (without adjustments). In addition, there is no information about which professional requested in-hospital dental care for DC, as well as which professional carried out caries-related IDP (non-compulsory data). The absence of data for caries-related IDP procedures in 2008 and 2009 can be justified by their inclusion in 2010 ⁴⁰40. Brazil. Portaria n. 1.032, de 5 de maio de 2010. Inclui procedimento odontológico na Tabela de Procedimentos, Medicamentos, Órteses e Próteses e Materiais Especiais do Sistema Único de Saúde - SUS, para atendimento às pessoas com necessidades especiais. Diário Oficial União, 6 maio 2010. . Future investigations should continue to monitor these variables over time and evaluate other features in clinical charts that are not available from SIH/SUS.

Conclusion

Over the past 15 years, SUS has experienced a pattern in caries-related hospital morbidity, including an increase in the number of hospital admissions and in-hospital dental procedures (particularly before the COVID-19 pandemic), as well as discrepancies between different sociodemographic components. Moreover, there was a reduction in the caries-related tertiary dental care after the COVID-19 pandemic onset.

Acknowledgments

The authors would like to thank the Coordination for the Improvement of Higher Education Personnel (CAPES) for the master’s and doctoral scholarship of Larissa Dias Vilela and Ricardo Barbosa Lima.

References

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