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

Introduction

The COVID-19 (Coronavirus Disease 2019) pandemic manifested as pneumonia, origins unknown, in Wuhan, China, in December 2019. ¹1. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020 Feb;395(10223):497-506. https://doi.org/10.1016/S0140-6736(20)30183-5
https://doi.org/10.1016/S0140-6736(20)30... ^,22. Mattos FF, Pordeus IA. COVID-19: a new turning point for dental practice. Braz Oral Res. 2020;34:e085. https://doi.org/10.1590/1807-3107bor-2020.vol34.0085
https://doi.org/10.1590/1807-3107bor-202... Currently, official data point to more than 165 million people infected and more than 3.4 million deaths worldwide. ³3. World Health Organization. WHO Coronavirus Disease (COVID-19) Dashboard. Geneva: World Health Organization; 2020 [cited 2020 Jul 12]. Available from: https://covid19.who.int/
https://covid19.who.int/... The first case in Brazil was detected in February 2020 and, since then, the Pandemic has evolved rapidly and, considering the large territorial expanse, the spread is unevenly distributed across the country. ⁴4. Hallal P, Hartwig F, Horta B, Victora GD, Silveira M, Struchiner C, et al. Remarkable variability in SARS-CoV-2 antibodies across Brazilian regions: nationwide serological household survey in 27 states. medRxiv. [Preprint]. Posted 2020 May 30. https://doi.org/10.1101/2020.05.30.20117531
https://doi.org/10.1101/2020.05.30.20117... To mitigate infection and avoid overloading health systems, collective and individual measures of social distancing, social isolation, quarantine, use of face masks and encouraging hygiene habits were instituted and have recently been acknowledged as efficient. ⁵5. Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine. J Dent Res. 2020 May;99(5):481-7. https://doi.org/10.1177/0022034520914246
https://doi.org/10.1177/0022034520914246... ^–1111. Nadanovsky P, Santos AP. Strategies to deal with the COVID-19 pandemic. Braz Oral Res. 2020 Jun;34:e068. https://doi.org/10.1590/1807-3107bor-2020.vol34.0068
https://doi.org/10.1590/1807-3107bor-202... However, these recommendations are difficult to implement in clinical dental practice, where there is a proximity between dentists and patients, exposure and direct contact with oral and nasal secretions and the use of instruments that amplify the spread of aerosols in the air and on surfaces. ²2. Mattos FF, Pordeus IA. COVID-19: a new turning point for dental practice. Braz Oral Res. 2020;34:e085. https://doi.org/10.1590/1807-3107bor-2020.vol34.0085
https://doi.org/10.1590/1807-3107bor-202... ^,55. Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19): emerging and future challenges for dental and oral medicine. J Dent Res. 2020 May;99(5):481-7. https://doi.org/10.1177/0022034520914246
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https://doi.org/10.1590/1807-3107bor-202... ^,1313. Sarode GS, Sarode SC, Sengupta N, Gadbail AR, Gondivkar S, Sharma NK, et al. Clinical status determines the efficacy of salivary and nasopharyngeal samples for detection of SARS-CoV-2. Clin Oral Investig. 2020 Dec;24(12):4661-2. https://doi.org/10.1007/s00784-020-03630-9
https://doi.org/10.1007/s00784-020-03630...

Dentists are among the professionals most susceptible to contamination by COVID-19. ¹⁴14. Doremalen N, Bushmaker T, Morris DH, Holbrook MG, Gamble A, Williamson BN, et al. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. N Engl J Med. 2020 Apr;382(16):1564-7. https://doi.org/10.1056/NEJMc2004973
https://doi.org/10.1056/NEJMc2004973... Moreover, Brazil has the largest population of dentists in the world and also the largest Public National Health System (SUS), which includes free dental care, with more than 29,000 dentists working in Primary Health Care. ¹⁵15. Pucca Junior GA, Gabriel M, Araujo ME, Almeida FC. Ten years of a National Oral Health Policy in Brazil: innovation, boldness, and numerous challenges. J Dent Res. 2015 Oct;94(10):1333-7. https://doi.org/10.1177/0022034515599979
https://doi.org/10.1177/0022034515599979... ^,1616. San Martin A, Chisini L, Martelli S, Sartori L, Ramos E, Demarco F. Distribution of Dental Schools and dentists in Brazil: an overview of the labor market. Rev ABENO. 2018;18(1):63-73. https://doi.org/10.30979/rev.abeno.v18i1.399
https://doi.org/10.30979/rev.abeno.v18i1... Currently, only 23.7% of Brazilians have private medical or dental insurance, showing that almost ¾ of the population relies on the public sector, especially the more vulnerable population. ¹⁷17. Instituto Brasileiro de Geografia e Estatística. National health survey: 2013: access and use of health services, accidents and violence: Brazil, large regions and states: analysis of results. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2015. Because of the pandemic's evolution and the need to reduce contamination, the Brazilian government recommended that elective dental clinical activities should be minimized by prioritizing urgent and emergency services. ¹⁸18. Chisini LA, Sartori LR, Costa FD, Salvi LC, Demarco FF. COVID-19 pandemic impact on prosthetic treatments in the Brazilian Public Health System. Oral Dis. 2020 Oct 6. https://doi.org/10.1111/odi.13668
https://doi.org/10.1111/odi.13668... ^,1919. Chisini LA, Costa FD, Demarco GT, Silveira ER, Demarco FF. COVID-19 pandemic impact on paediatric dentistry treatments in the Brazilian Public Health System. Int J Paediatr Dent. 2021 Jan;31(1):31-4. https://doi.org/10.1111/ipd.12741
https://doi.org/10.1111/ipd.12741... ^,2020. Cunha AR, Antunes JL, Martins MD, Petti S, Hugo FN. The impact of the COVID-19 pandemic on oral biopsies in the Brazilian National Health System. Oral Dis. 2020 Aug;odi.13620. https://doi.org/10.1111/odi.13620
https://doi.org/10.1111/odi.13620... However, state governments are also able to enact regulations regarding available services, including dental clinics, based on the situation of the pandemic in each of the 27 Federal states.

Thus, the objective of this study was to estimate the impact of the COVID-19 pandemic on dental procedures carried out in the Public Health System. In addition, we tested if regulation by the state could mediate the impact.

Methodology

The present study was reported in accordance with the guideline entitled Strengthening the Reporting of Observational Studies in Epidemiology (STROBE).

Study design and setting

This is a retrospective, ecological time-series study including almost all Brazilian municipalities with data on information systems within the National Public Health System ( Sistema Unico de Saúde - SUS) (n = 5,564, 99.9% of the 5,570 municipalities). Secondary data from the SUS Computer Department (DATASUS; http://www.datasus.gov.br ) were used: Ambulatory Information System (SIA-SUS) and e-gestor (information and management of primary care). Data from the Brazilian Institute of Geography and Statistics (IBGE; http://www.ibge.gov.br ) were also used (population size and regions).

Data on the Human Development Index (HDI), by municipality, were obtained from the databases of the United Nations Development Program (UNDP) ( http://www.atlasbrasil.org.br/2013/ ). State regulations regarding social distancing and the functioning of dental clinics were collected from the official websites of the 27 state governments of Brazil. Data were collected during the month of October 2020 by a single trained researcher.

Dependent variables

The absolute number of procedures per 100,000 inhabitants, performed by Brazilian public services, was the outcome of the present study. The number of dental procedures was collected through the dental procedures registered in the SIA/SUS ( Table 1 ). The procedures were also subdivided into different categories as follows: a) Access to dental service (first dental visit); b) Urgency and Emergency treatments; c) Restorative treatments; d) Tooth extractions; e) Endodontics; f) Individual preventive procedures ( e.g.: fluoride varnish application); g) Collective procedures (e.g.: epidemiological surveys); h) Basic periodontal treatment; i) Prosthesis and j) Surgical periodontal treatment.

Exposure

The impact of the pandemic was estimated by comparing the rate of procedures for each month in 2020 with the rates observed in the equivalent months of 2019, considering the period from March to August. For example, the March 2020 procedure rate was compared to the March 2019 rate. For the mediation analysis, the entire pandemic period (from March to August 2020) was compared with the corresponding period in 2019, prior to the pandemic (from March to August 2019).

Mediator

To gain access to the restrictions on dental services, the official regulations implemented by the 27 state governments regarding social distancing and the functioning of dental clinics, were collected from the official press and on the state government websites (every 15 days, from March to August 2020; n = 11). Data on restrictions on dental services were collected from state executive decrees/laws promulgated by the offices of governors, categorized as i) no restriction on dental care (without a report of restriction on dental services) and b) restriction on dental care (mentioning only the possibility of urgent and emergency care). We estimated trajectory groups of dental care restrictions at the municipal level, using group-based trajectory models. A quadratic trajectory was considered, commencing with just one group, i.e., a null model. Five models were originally identified, however, the four-class model was the best fit because it had the lowest BIC (24276.6) and lowest sample-adjusted BIC (24344.1), being classified as a) long-term dental service restriction; b) one month's restriction; c) two months’ restriction and d) no restrictions ( Figure ). Details of trajectory constructions are presented in Table 2 .

Figure
The trajectory of dentistry activity restriction in Brazilian municipalities (n = 5,564).

Confounding variables

The confounding variables evaluated in the study were the population size of municipalities, coverage by the primary health care (Family Health Strategy) and Oral Health teams, the Human Development Index (HDI), Gini Index, months in which the dental procedures were performed, and the regions of Brazil. The population size of municipalities was obtained from the Brazilian Institute of Geography and Statistics and categorized as: a) ≤ 20,000 inhabitants; b) 20,001 to 50,000 inhabitants; c) 50,001 to 150,000 inhabitants; d) > 150,000 inhabitants. ²2. Mattos FF, Pordeus IA. COVID-19: a new turning point for dental practice. Braz Oral Res. 2020;34:e085. https://doi.org/10.1590/1807-3107bor-2020.vol34.0085
https://doi.org/10.1590/1807-3107bor-202... ^,2121. Chisini L, San Martin A, Silva J, Brambatti N, Pietro F, Conde M, et al. Brazilian National Health System dental x-ray coverage in Southern Brazil in 2016: an ecological study. Epidemiol Serv Saude. 2019;28(1):e2018090. https://doi.org/10.5123/S1679-49742019000100005
https://doi.org/10.5123/S1679-4974201900... The coverage by the Family Health Strategy and Oral Health Teams (Proportion %) at the country level were collected from the information and management of primary care databases and both categorized as follows: a) absent (0%); b) incipient (< 30%); c) intermediate (30%–70%); and d) consolidated (≥ 70%). Regarding HDI, municipalities were classified as follows: a) below 0.55 was considered low HDI; b) between 0.55 and 0.699 as average HDI; c) between 0.70 and 0.799 as high HDI; d) 0.80 or above as very high. The Gini index (DATASUS) was used continuously in the model. The Brazilian regions are: South, Southeast, Midwest, North and Northeast.

Data analysis

All analyses were performed using STATA 16.0 software ( https://www.stata.com ). Descriptive statistics were developed using the mean, standard deviation, minimum, maximum and median of independent variables. For the outcome, the mean rates and respective 95% confidence intervals (95%CI) of the procedures were presented. Due to the overdispersion of the data, multilevel mixed-effects negative binomial regression was used to analyze the longitudinal association between the number of procedures and the impact of COVID-19; analysis was performed comparing the respective months of 2020 with the equivalent months in 2019. A stepwise backward procedure was used to select variables in the adjusted model. Only variables presenting a p< 0.250 were retained in the final model.

The parametric g-formula approach was used to estimate the total causal effect, the natural direct effect, the natural indirect effect and the controlled direct effect of the associations between the COVID-19 pandemic and dental procedures, considering restriction on services as a mediator. To perform this analysis, we used data from January 2019 to August 2020, with the period from March to August 2020 being considered the pandemic period. We used as the base confounder the months the procedures took place, the Gini Index, HDI and coverage by the Family Health Strategy and Oral Health Teams and, as the post confounder, the regions of Brazil. The Monte Carlo method was employed to estimate the effects. The bootstrap method was used to estimate standard error and the confidence interval of the estimated effects. To perform this assessment, we chose to use 1,000 resamples out of a total of 10,000 observations.

Results

Almost all Brazilian municipalities (n= 5,564) were included in the present study. Table 3 displays the description of confounders and the mediator. The mean rate of total procedures from March to August of 2019 was 88,081.0 95%CI (87,203.8–88,924.2) and 3,605.8 95%CI (3,479.0–3,733.1) from March to August of 2020. Table 4 displays the average monthly procedure rates according to the different groups of procedures.

Table 5 presents the monthly incidence rate ratio of dental procedures investigated and subgroups according to the COVID-19 pandemic. Considering the impact of COVID-19 on the total number of procedures, a reduction of 55% (IRR = 0.45, 95%CI 0.39–0.51) was observed in March; 94% in April (IRR = 0.06, 95%CI 0.06–0.07]; 93% in May (IRR = 0.07, 95%CI 0.06–0.08); 91% in June (IRR = 0.09, 95%CI 0.09–0.10); 88% in July (IRR = 0.12, 95%CI 0.10–0.14); and 91% in August (IRR = 0.09, 95%CI 0.07–0.10). The biggest decrease was observed in collective preventive procedures, with a reduction of ≥ 99% from April to August. Procedures that were less likely to generate aerosols presented the smallest reduction in procedure rates: tooth extraction, prosthesis, and even emergency procedures (42%, 78%, 75%, 68%, 66%, 72%, from March to August, respectively).

The parametric g-formula analysis found a direct effect on the association between the COVID-19 pandemic and dental procedures, considering the total number of procedures (Coef. = −0.23, 95%CI −0.24–-0.22) ( Table 6 ). Moreover, for all procedure groups, the pandemic presented a direct effect on the reduction of the rate of procedures (p < 0.001). The association was not mediated by state restrictions.

Discussion

The overall findings from this study are that the COVID-19 pandemic had a heavy and negative impact on the supply of dental treatments in the Public Health System in Brazil. The decrease in the number of procedures varied from 55% in the first month of the COVID-19 pandemic to over 88% in the following months of the evaluation. The reduction was observed for all procedures, including emergencies. A reduction is to be expected considering that, since the middle of March, several regions were recommending quarantine, social distancing measures, closure of schools and the reduction of non-essential activities to flatten the curve and prevent the health system from collapsing. ²²22. Yang HM, Lombardi Junior LP, Castro FFM, Yang AC. Evaluating reduction in CoViD-19 cases by isolation and protective measures in São Paulo State, Brazil, and scenarios of release. medRxiv [Preprint]. Posted 2020 June 4. https://doi.org/10.1101/2020.05.19.20099309
https://doi.org/10.1101/2020.05.19.20099... ^,2323. Martins MD, Carrard VC, Santos CM, Hugo FN. COVID-19-Are telehealth and tele-education the answers to keep the ball rolling in Dentistry? Oral Dis. 2020 Jul;odi.13527. https://doi.org/10.1111/odi.13527
https://doi.org/10.1111/odi.13527... Also, considering the high risk of contamination in dental clinics, ²2. Mattos FF, Pordeus IA. COVID-19: a new turning point for dental practice. Braz Oral Res. 2020;34:e085. https://doi.org/10.1590/1807-3107bor-2020.vol34.0085
https://doi.org/10.1590/1807-3107bor-202... ^,2424. Li Y, Ren B, Peng X, Hu T, Li J, Gong T, et al. Saliva is a non-negligible factor in the spread of COVID-19. Mol Oral Microbiol. 2020 Aug;35(4):141-5. https://doi.org/10.1111/omi.12289
https://doi.org/10.1111/omi.12289... ^,2525. Diegritz C, Manhart J, Bücher K, Grabein B, Schuierer G, Kühnisch J, et al. A detailed report on the measures taken in the Department of Conservative Dentistry and Periodontology in Munich at the beginning of the COVID-19 outbreak. Clin Oral Investig. 2020 Aug;24(8):2931-41. https://doi.org/10.1007/s00784-020-03440-z
https://doi.org/10.1007/s00784-020-03440... ^,2626. Cirillo N. COVID-19 outbreak: succinct advice for dentists and oral healthcare professionals. Clin Oral Investig. 2020 Jul;24(7):2529-35. https://doi.org/10.1007/s00784-020-03323-3
https://doi.org/10.1007/s00784-020-03323... health institutions and professional councils issued guidance to reduce activities in dental services to only emergency and urgent care. Even though the reduction at the beginning of the pandemic was considerable, when the exponential growth took off, the systems almost suffered a shutdown. ²⁰20. Cunha AR, Antunes JL, Martins MD, Petti S, Hugo FN. The impact of the COVID-19 pandemic on oral biopsies in the Brazilian National Health System. Oral Dis. 2020 Aug;odi.13620. https://doi.org/10.1111/odi.13620
https://doi.org/10.1111/odi.13620... ^,2727. Santos MB, Pires AL, Saporiti JM, Kinalski MA, Marchini L. Impact of COVID-19 pandemic on oral health procedures provided by the Brazilian public health system: COVID-19 and oral health in Brazil. Health Policy Technol. 2021 Mar;10(1):135-42. https://doi.org/10.1016/j.hlpt.2021.02.001
https://doi.org/10.1016/j.hlpt.2021.02.0... ^,2828. Chisini LA, Costa FS, Salvi LC, Demarco FF. Endodontic treatments in the Brazilian Public Health System: influence of COVID-19 pandemic. Health Policy Technol. 2021 June;10(2):100514. https://doi.org/10.1016/j.hlpt.2021.100514
https://doi.org/10.1016/j.hlpt.2021.1005... ^,2929. Chisini LA, Castilhos ED, Costa FS, D’Ávilla OP. Impact of the COVID-19 pandemic on prenatal, diabetes and medical appointments in the Brazilian National Health System. Rev Bras Epidemiol. 2021;24:e210013. https://doi.org/10.1590/1980-549720210013
https://doi.org/10.1590/1980-54972021001... A national online survey with more than 3,000 dentists from all regions found that more than 95% of those interviewed had reduced the number of patients they were seeing or were only attending emergencies or were not attending at all. ³⁰30. Moraes RR, Correa MB, Queiroz AB, Daneris A, Lopes JP, Pereira-Cenci T, et al. COVID-19 challenges to dentistry in the new pandemic. PLoS One. 2020 Nov;15(11):e0242251. https://doi.org/10.1371/journal.pone.0242251
https://doi.org/10.1371/journal.pone.024... Also, there was a difference between dentists working in public and private networks. While almost 80% of the dentists in public clinics were maintaining only emergency appointments, 52% of private dentists reported seeing fewer patients than usual due to the pandemic. This reduction may result in a sharp increase in the demand for dental care post-COVID-19. ³¹31. Kalash DA. How COVID-19 deepens child oral health inequities. J Am Dent Assoc. 2020 Sep;151(9):643-5. https://doi.org/10.1016/j.adaj.2020.05.015
https://doi.org/10.1016/j.adaj.2020.05.0... ^,3232. Mallineni SK, Innes NP, Raggio DP, Araujo MP, Robertson MD, Jayaraman J. Coronavirus disease (COVID-19): characteristics in children and considerations for dentists providing their care. Int J Paediatr Dent. 2020 May;30(3):245-50. https://doi.org/10.1111/ipd.12653
https://doi.org/10.1111/ipd.12653... An improvement in Brazilian oral health indicators has been observed, especially among children and adolescents. ³³33. Roncalli AG, Sheiham A, Tsakos G, Araújo-Souza GC, Watt RG. Social factors associated with the decline in caries in Brazilian children between 1996 and 2010. Caries Res. 2016;50(6):551-9. https://doi.org/10.1159/000442899
https://doi.org/10.1159/000442899... The lack of promotion of preventive activities could have a significantly negative impact, compromising the good results observed over the past decade. ³⁴34. Barasuol JC, Garcia LP, Freitas RC, Dalpian DM, Menezes JV, Santos BZ. Dental care utilization among children in Brazil: an exploratory study based on data from national household surveys. Cien Saúde Colet. 2019 Feb;24(2):649-57. https://doi.org/10.1590/1413-81232018242.03232017
https://doi.org/10.1590/1413-81232018242... Thus, the drastic reduction in dental services offered due to the Pandemic, in the public health system, may further polarize the huge inequalities already present in oral health. ³⁴34. Barasuol JC, Garcia LP, Freitas RC, Dalpian DM, Menezes JV, Santos BZ. Dental care utilization among children in Brazil: an exploratory study based on data from national household surveys. Cien Saúde Colet. 2019 Feb;24(2):649-57. https://doi.org/10.1590/1413-81232018242.03232017
https://doi.org/10.1590/1413-81232018242... ^,3535. Chisini LA, Sarmento HR, Collares K, Horta BL, Demarco FF, Correa MB. Determinants of dental prosthetic treatment need: a birth cohort study. Community Dent Oral Epidemiol. 2020 Dec;cdoe.12608. https://doi.org/10.1111/cdoe.12608
https://doi.org/10.1111/cdoe.12608...

Our results also pointed to significant reductions in specialized dental procedures, such as prosthetics, endodontics and periodontal surgical treatment. However, prosthetics procedures exhibited a smaller decrease, probably due to the less frequent use of instruments that generate aerosols. ³⁶36. Patil S, Moafa IH, Bhandi S, Jafer MA, Khan SS, Khan S, et al. Dental care and personal protective measures for dentists and non-dental health care workers. Dis Mon. 2020 Sep;66(9):101056. https://doi.org/10.1016/j.disamonth.2020.101056
https://doi.org/10.1016/j.disamonth.2020... In addition, prosthesis procedures may be being performed due to the long manufacturing lead time and the need to finalize procedures started prior to the pandemic. The reduction in endodontic procedures may be explained by the high production of aerosols and the prioritization of tooth extractions in view of its more conservative treatment. ³⁷37. Gugnani N, Gugnani S. Safety protocols for dental practices in the COVID-19 era. Evid Based Dent. 2020 Jun;21(2):56-7. https://doi.org/10.1038/s41432-020-0094-6
https://doi.org/10.1038/s41432-020-0094-... Additionally, endodontic procedures and periodontal surgical procedures depend on referrals of primary care made in elective dental visits. ³⁸38. Chapple IL, Bouchard P, Cagetti MG, Campus G, Carra MC, Cocco F, et al. Interaction of lifestyle, behaviour or systemic diseases with dental caries and periodontal diseases: consensus report of group 2 of the joint EFP/ORCA workshop on the boundaries between caries and periodontal diseases. J Clin Periodontol. 2017 Mar;44 Suppl 18:S39-51. https://doi.org/10.1111/jcpe.12685
https://doi.org/10.1111/jcpe.12685...

The pandemic required measures to be taken by governments to curb the spread of the virus, ¹¹11. Nadanovsky P, Santos AP. Strategies to deal with the COVID-19 pandemic. Braz Oral Res. 2020 Jun;34:e068. https://doi.org/10.1590/1807-3107bor-2020.vol34.0068
https://doi.org/10.1590/1807-3107bor-202... one of which was the restriction of elective dental procedures. The mediation analysis carried out in this study showed that, regardless of the restrictive regulations adopted for elective procedures, there was a reduction in the number of procedures performed, i.e. , the restriction did not mediate the association between the pandemic and the number of procedures performed. This may be explained by the reorganization of services in the Health Units to cope with the circumstances imposed by the pandemic, not just those related to dental services.

To reduce the negative impact of the Pandemic on the population´s oral health, some efforts should be made by policymakers, including the use of teledentistry for primary oral health care, ³⁹39. Carrer FC, Matuck BF, Lucena EH, Martins FC, Pucca Junior GA, Galante ML, et al. Teledentistry and the Unified Health System: an important tool for the resumption of primary health care in the context of the cOVID-19 Pandemic. Pesqui Bras Odontopediatria Clin Integr. 2020;20 suppl 1:e0140. https://doi.org/10.1590/pboci.2020.155
https://doi.org/10.1590/pboci.2020.155... which could be adapted for preventive approaches. Brazilian dentists have already attempted to implement teledentistry in their practices since the start of the Pandemic. ³⁰30. Moraes RR, Correa MB, Queiroz AB, Daneris A, Lopes JP, Pereira-Cenci T, et al. COVID-19 challenges to dentistry in the new pandemic. PLoS One. 2020 Nov;15(11):e0242251. https://doi.org/10.1371/journal.pone.0242251
https://doi.org/10.1371/journal.pone.024... Also, a more minimally invasive approach should be considered, especially reducing the use of aerosols in the dental. ⁴⁰40. BaniHani A. Gardener C, Procida Raggio D, Santamaria RM, Albadri S. Could COVID-19 change the way we manage caries in primary teeth? Current implications on Paediatric Dentistry. Int J Paediatr Dent. 2020 Sep;30(5):523-5. https://doi.org/10.1111/ipd.12690
https://doi.org/10.1111/ipd.12690... In addition, emergency care should be maintained. Before the pandemic, despite the expansion in Primary Health Care services, the SUS system was already challenged by several problems, including the fragmentation of actions, underfunding and low quality of management. ⁴¹41. Almeida PF. Primary health care in Brazil and the 40 years of Alma-Ata: acknowledging the challenges in order to move forward. Cad Saude Publica. 2018 Aug;34(8):e00136118. https://doi.org/10.1590/0102-311X00136118
https://doi.org/10.1590/0102-311X0013611... With the Pandemic, the difficulties were exacerbated, requiring a reorganization of health practices to contain the spread of the virus, incorporating new biosafety routines and protocols into the service, which would require additional human and physical resources and equipment. ⁴²42. Ren YF, Rasubala L, Malmstrom H, Eliav E. Dental care and oral health under the clouds of COVID-19. JDR Clin Trans Res. 2020 Jul;5(3):202-10. https://doi.org/10.1177/2380084420924385
https://doi.org/10.1177/2380084420924385...

Considering the strengths of this study, we investigated the association between the COVID-19 pandemic and procedures performed in Brazilian oral health public services, at a municipal level, using time-series analysis and controlling the analyses through the factors that could bias the results or even be mediators. Also, we have followed up on the number of procedures carried out during 6 months of Pandemic development and compared them with the same months from the previous year. Moreover, this study presents weaknesses that we should point out, such as those related to the use of secondary data, which may be under- or over-reported. Furthermore, the reporting of these data may have been affected by the context of the COVID-19 Pandemic. Moreover, the evaluation of state restrictions for dental care might include regulations from state health departments, information not investigated by this study.

Conclusion

This study observed a drastic reduction in dental procedures performed in the Public Dental Health System after the appearance of COVID-19 in Brazil, which resulted in a near shutdown of the system. A significant reduction was observed for all kinds of treatment, preventive, curative or emergency and, reductions in all groups of procedures were associated with the period of the COVID-19 Pandemic in Brazil. Additionally, the restrictions imposed through state executive decrees did not mediate the association between the COVID-19 pandemic and dental procedures, considering the total number of procedures and all groups of dental procedures.

Acknowledgment

This study was partly funded by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – Brasil (CAPES) – Finance Code 001. Also, corresponding author received a grant from State agency (FAPERGS-PRONEX # 16.0471-4)

References

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