Impact of risk assessment on the demand for dental services in Primary Health Care

Background: The access to dental health services is a big problem in many parts of the world. The Primary Health Care proposes the organization of the access with equity and it can be done by stratification of risk and scale of vulnerabilities. The aim was to evaluate the impact of the implementation of risk classification tools to improve the access to dental health demand in Primary Health Care and to evaluate the effectiveness of implantation of the tool: risk classification and Coelho and Savassi’s scale for organization of dental health service demand in one Primary Health Service in São Paulo city. Method: This was a cross-sectional study in which medical records (n = 1215) were evaluated before and after the implementation of the tool. The outcomes were 'immediate care', 'first dental appointment' and 'treatment completed', the independent variables were risk classification, Coelho and Savassi’s scale, caries risk, periodontal disease, soft tissue, age and gender. Descriptive analyzes were performed comparing the variables of the study before and after the implantation of the tools (risk classification and ”Coelho and Savassi” scale). Logistic Regression models and chi-square tests were performed to analyze these associations. Results: The most prevalent age group was 20 to 59 years old, 62.2% before and 59.4% after implantation. The main complaint of dental demand was pain. Regarding the “Coelho and Savassi” scale”, 87.1% presented low social risk (R1), 8.5% medium risk (R2), 4.2% high risk (R3). The immediate care before implantation was 9.4% (n=56) and 39.9% (n=246) after implantation (p <0.001). The first dental appointment was 20.7% before implantation and 34.9% after the implantation (p <0.001). Regarding the treatment completed, there was an increase from 10% to

14.1% after the implantation of the tools (p = 0.001).
Conclusions: The implementation of the tools 'risk classification and "Coelho and Savassi" scale' had impact in organization of odontological demand, with indicated an increase in the number of visits on the same day, first dental appointments and completed treatments. These results reinforce the importance of use of the tools to organize oral health care access.

Background
The access to dental services is still a problem in many places around the world.
The ways in which the health systems are organized and social determinants are factors influencing the access to dental services, with effects on the population's oral health [1,2,3] Access is a big challenge in a universal health system, as oral health is necessary to ensure the comprehensiveness of care. Efforts seeking to broaden this access in an equitable manner are essential.
In Brazil, for many decades, oral health care was typically sought by pregnant women and children, while other population groups accessed dental care services in emergency situations only, or did not access them [4]. Allied to this, the demographic and epidemiological transition, with population aging the increase in the number of non-communicable chronic diseases and persistence of infectious diseases, requires changes in the organization of services to address the population's oral health problems. This model has always been criticized because of its limited coverage and limited access, contributing to an epidemiological oral health profile that is far from the one desired [5], despite universality and the right to health being constitutional [6].
Equitable access should be a constant concern when meeting spontaneous demands. To this end, there are risk assessment instruments in the literature, seeking to organize the supply of oral health services in this context.
The Brazilian Ministry of Health proposes the use of risk and vulnerability assessment by the Family Health Strategy (FHS) as a tool to identify the different risk gradations, the most urgent situations and, based on them, properly prioritize the demands to be met. As an example of what is done in emergency services, situations are classified as acute (immediate, priority or sporadic) and non-acute (scheduled interventions), and represented by colors, the color risk classification scale (CAB) [7].
Coelho and Savassi's scale [8] is an instrument for the stratification of family risk, and its purpose is assessing and monitoring the social and economic reality in the context of each family's life, to establish priorities [9]. The tendency noted with the use of this scale was that the higher the family risk, the higher the individual caries risk in children and periodontal risk in adults, proving to be an important tool for the more equitable organization and prioritization of dental actions.
The scarcity of dental health care experienced by the population improve the demand for urgency care in Oral Health Services (OHS), and despite the implementation of policies and programs aimed at organizing these services, the population still has difficulty accessing them [11], even in regions where OHSs have been implemented in the FHS [12].
Due the challenges involved in the organization of the growing spontaneous demand for oral health, this study aims to evaluate the impact of the implementation of risk assessment scale to expand the access to dental services in PHC.

Methods
This is a cross-sectional study carried out at the Jardim das Palmas Basic Health Unit (BHU), located in the southern region of the city of São Paulo, with 5 FHS teams and 3 OHS teams, consisting of Dental Surgeon, Oral Health Technician and Oral Health Assistant, providing care to 19,136 people distributed in approximately 5,638 families. The population is mostly composed of young adults aged 20-39 (n = 6738) and adults aged 40-49 (n = 2506), totaling 9,242 (48%) individuals, the remainder being divided into the age groups: less than 1 year old (n = 298), from 1 to 4 years old (n = 1117), from 5 to 6 years old (n = 587), from 7 to 9 years old (n = 911), from 10 to 14 years old (n = 1442), from 15 to 19 years old (n = 1647), and 50 years old or older (n = 3,890). Of the total, 59.02% do not have water treatment at home, 16.05% live near open sewers and 88% of the individuals are dependents of the Brazilian Unified Health System (SUS).
Until 2016, the access to oral health services occurred through priority groups, family screening with classification of biological risk and spontaneous demand. The spontaneous dental demand in this BHU was met on a first-come, first-served basis, and no instrument was used to prioritize access. Since April 2016, the BHU began using risk assessment instruments to meet the spontaneous demand: color risk classification scale [7], family risk assessment [8], caries risk and periodontal risk [12], as can see on In color risk classification scale, non-acute situations are identified by the color BLUE and acute situations by the colors: RED (immediate care -high risk of death), YELLOW (priority care -moderate risk), GREEN (sporadic care -low risk or no risk with significant vulnerability). In addition, "Acute" is considered priority, immediate or sporadic care, and "Non-acute" are scheduled interventions [7]. Most of the time, from the perspective of oral health complaints, pain situations are not lifethreatening. Therefore, only the colors blue, yellow and green were used in this research to classify spontaneous dental demand, excluding red.
The color risk classification scale used to prioritize care adopted the colors yellow (pulpitis, edema, dental fracture, uncontrolled bleeding, joint dislocation, painful oral lesions), green (pain on probing, tenderness, trauma without acute symptoms, non-spontaneous bleeding, lesion suspected of malignancy) and blue (history of pulp or periodontal pain, history of lesions on the oral mucosa, history of bleeding without acute symptoms).
The family risk assessment instrument proposed by Coelho and Savassi [8] was also used, divided into 3 categories: R1 -low risk (score lower than 5), R2 -moderate risk (score between 7 and 8), R3 -high risk (score above 9). In the BHU where the study was conducted, Coelho's scale is applied by the Oral Health Team, according to sociodemographic and socioeconomic data collected by the Community Health Agent (ACS), used as an instrument for organizing access.
In addition, the classification of biological risk was used to assess the risk of caries and periodontal disease, along with the soft tissue assessment proposed by the Municipal Health Secretariat of São Paulo [12]. Caries risk was classified as: Low risk (A -no caries lesion, no plaque, no gingivitis and/or no stain), Moderate risk (B -history of dental restoration, no plaque, no gingivitis and/or no active white spot, C -one or more chronic caries lesions, but no plaque, no gingivitis and/or no active white spot), and High risk (D -absence of caries lesion or history of dental restoration, but with presence of plaque, gingivitis and/or active white spot), (Eone or more acute caries lesions), (F -presence of pain and/or abscess) [12]. The soft tissues were classified as: no risk (0 -normal tissues) and presence of risk (1 -soft tissue abnormalities) [12].
color risk classification scaleIn the first appointment, color risk classification scale (BLUE, YELLOW and GREEN) and Coelho and Savassi's scale were used to prioritize spontaneous demands, as well as the number of patients treated. In the second appointment, the classification of biological risk was used in association with Coelho and Savassi's scale to prioritize the access to continued dental treatment, based on the first appointment.
Coelho and Savassi's scale was applied by the OHS after calibration and collection of information from File A.
Secondary data were extracted from the medical records of the patients who accessed the dental service through spontaneous demand in the period prior to (from April 2015 to March 2016) and one year after the implementation of risk assessment (from April 2016 to March 2017), corresponding to a total of (n = 1215) cases.
As inclusion criteria, the records of patients who sought the service through spontaneous demand from April 2015 to March 2017 were evaluated, and the records of cases with no information on more than 70% of the variables were excluded from the study.
The main explanatory variables analyzed were the use of color risk classification scale and Coelho and Savassi's family risk scale [8] as instruments for organizing and prioritizing spontaneous demands. The data on caries risk, periodontal disease, soft tissue, age and sex, adopted as independent variables for adjustment, were obtained from the spontaneous demand monitoring worksheet.
So, this study analyzed the influence of the implementation of color risk classification scale [7], Coelho and Savassi's scale [8] and the biological risk scale [12] on the access to dental services through spontaneous demand, first scheduled appointment and the resolvability of treatment based on the number of completed treatments (CT).
The study's dependent variables were access and resolvability. The following variables were used as proxy for Access: 1) first scheduled dental appointment (yes and no), and 2) sporadic care (yes and no), referring to patients who sought the service through spontaneous demand and were seen on the same day. Resolvability was analyzed based on the number of Completed Treatments (CT) (yes and no).

Results
The analyzed data were collected from 1215 records that met the inclusion criteria. Table 1 shows the number and profile of patients who accessed UBS Jd. das Palmas' dental service through spontaneous demand, before and after the implementation of risk assessment.
Soft tissue risk and periodontal tissue risk were not described by the OHS prior to the implementation of risk assessment, being found in only a few medical records.
The data were registered after the implementation of the new spontaneous demand record. Thus, it was observed that, of the total patients, 85.2% (n=525) were at moderate risk of periodontal disease, and 99% (n=610) were at low risk of soft tissue injuries.  (Table 2).
No statistically significant differences were found when analyzing variables: caries risk, soft tissue risk and periodontal risk, DH, and the outcomes of sporadic care, first dental appointments, and completed treatments ( Table 2). Table 3 shows the distribution of family risk (Coelho and Savassi's scale) and variables: caries risk, periodontal risk, color risk classification scale (CAB), sporadic care, first appointment and CT. A statistically significant association between family risk and periodontal risk was estimated (p=0.046). Table 4 shows the distribution of color risk classification scale and variables: caries risk, periodontal risk, Coelho and Savassi's scale, sporadic care, first appointment and number of completed treatments. Regarding caries risk and color risk classification scale, the results pointed to an association between yellow/green risks (priority or sporadic care) and high caries risk (p<0.001). When we evaluated the association between number of completed treatments and color risk classification scale, the results were statistically significant (p=0.028).

Discussion
The study used risk assessment as an instrument to organize the access to dental care, demonstrating that using risk assessment tools increased the access of patients who sought the service for urgent reasons, as well as the access to the first dental appointment and the number of completed treatments.
As spontaneous demand is one of the ways through which patients seek access to the BHU, a window of opportunity opens for the team to interact with the population and, consequently, obtain information on the needs of access to these services. In this way, the knowledge about the profile of patients who seek emergency care in the unit generates subsidies for improving the OHS team's work process, ensuring that the population's needs are satisfactorily met.
The imbalance between supply and demand are also factors influencing the organization of the access to dental services, allied to the insufficient quantity of OHSs to cover a territory with social differences and increasing number of individuals who depend on SUS.
A study carried out in São Paulo evaluated the access to dental services following the implementation of the Brasil Sorridente program in 2004 and found that socioeconomic inequalities in this access still persist, despite the improvements in the oral health coverage system [14].
Using risk assessment instruments, as proposed in this study, enhances the access to the first appointment through spontaneous demand. A study conducted in Recife attributed the lack of registration of procedures by health professionals to the low access to the first dental appointment, as well as to care practices being focused on the main complaint without formulation and execution of a preventive therapeutic plan to meet the detected needs, requiring greater attention in the organization of this access [15].
The main reason that led patients to seek urgent dental care was pain, followed by complaints of broken tooth and gingival inflammation, as also observed in other studies [16,17,18].
Although pain relief and restoration of masticatory function are the main reasons reported [19,20], it is known that patients tend to use urgent care as an alternative "gateway" to obtain dental care [12], hence why it is important to use instruments to identify and assist in the organization of access, integrating health care and prevention/promotion, allowing the development of patient-centered care practices [21].
When analyzing the age of the patients who sought the service, adults aged 20-59 predominated, similarly to a study conducted in the countryside of São Paulo, where 63.85% of those whose access to oral health care happened through spontaneous demand were aged 20-49 [12]. This suggest the difficulty of access to adult dental services, leading to tooth loss [14]. In a research performed to assess the oral health of adult workers, tooth loss ranged from 18-81% in the nine age groups studied, with the higher percentages corresponding to older individuals [22], indicating a cohort effect with a history of absence of Public Policies focused on the oral health of adults and older adults.
One reason why the adults had completed fewer treatments could be the limitation in the opening hours of oral health services, a fact that is corroborated by the National Oral Health Policy [23], which states that adults, especially workers, have difficulty accessing health units.
The lower demand for these services by the older population was justified in another study as being due to the lack of teeth [14] and was also observed in the National Health Survey (2013) [24], where 28.9% of those aged 60 or older had not seen a dentist. The study by Kaliembo et al [25], conducted in developing countries, assessed the prevalence of oral health needs of adults aged 50 and older that had not been met, obtaining high values for China, Ghana and India. A study conducted in São Paulo revealed the difficulty of access to public dental care, with reduction in the provision of services for adults and older adults [26]. These data demonstrate that a population with priority health care needs could be experiencing difficulty accessing health services.
However, the results of the present study showed that the access of patients aged 60 or older to the first dental appointment had improved, a relevant fact considering that for years this population was denied access to oral health services, culminating in the worsening of oral diseases and edentulism. This result points to the use of risk assessment as an important instrument for ensuring equity in the organization of access, seeing as health teams are constantly faced with the difficulty of planning and prioritizing care, failing to meet the needs of the population due to the high demand for dental services [27].
The adoption of risk stratification protocols has become increasingly common, especially in emergency services. The use of these protocols and their respective scales has an important impact on the quality of the access of these services [7].
The results showed an increase in the number of first appointments following the adoption of risk assessment, favoring the continuity and management of care [7].
When assessing the implementation of color risk classification scale [7], we identified an association between caries risk and number of completed treatments.
These results indicate that patients at higher risk of caries were identified as high priority, resulting in better resolvability due to the increase in the number of completed treatments.
It is important that, in addition to clinical and biological risks, family risk is also assessed. In this study, we found that most families who had access to dental services (87.1%) were at low family risk, and 4.2% were considered as high risk, requiring more attention from the oral health team. Some studies using family risk assessment have identified a relationship between high family risk and higher chance of caries [28]. However, in the present work, we only found association between periodontal disease and family risk, corroborating the study by Peres et al [10].
Given the growing demand for health services, many studies have been trying to answer how best to organize the access to PHC. One of the models proposed in the literature is advanced access, which aims to "do today's work today" [29]. However, this model has not yet been extensively explored in Dentistry, and we have as challenge proposing models of organization of access that allow spontaneous demands to be satisfactorily met, ensuring the continuity of care and promoting preventive actions.
A limitation of this study concerns the collection of secondary data from medical records, as the access to information is restricted to the data available. However, attentiveness on the part of the team responsible for the records was noted, which greatly contributes to the acquisition of knowledge, and there was a robust supply of information to be used in the analysis. Although associations with risk assessment were verified, the influence of time was not considered.

Conclusions
The study provides relevant data regarding the organization of dental services, demonstrating the importance of having one or more risk assessment instruments, which may contribute to a better understanding of the needs of the population Consent for publication All authors declare consent for publication.

Availability of data and material:
The dataset is available to researchers who wants to explore the data. Researchers that wants to explore the datasets please send email to: danielle.ramos@einstein.br   Dental health service flow chart