Introduction

Despite existing for more than a century, dentistry continues to struggle in proving its effectiveness when facing the health needs of the population [1]. Since its origin, dentistry has prioritized practical and surgical techniques, based on prosthetics reabilitations and dental materials, isolating itself from other healthcare specialties. An antiquated point of view in the face of global socioeconomic problems and higher chronic disease burden within the population [2,3].

In Brazil, due to political and historical motivations, a lobby called “Collective Health”, which favors an angle more closely related to social and structural factors of diseases, was created to counteract traditional public health practices, namely the biologic approach. Such influence led to the formulation and testing of different models of dentistry in Brazil [4,5].

A significant part of Brazilian public oral health services are located in Primary Care, more specifically within "family health teams", who implement individual, family-based and collective health actions that involve promotion, prevention, protection, diagnosis, treatment, rehabilitation, harm reduction and palliative care. These services are offered free of charge to all people living within Brazilian territory, according to their needs. These multidisciplinary teams consist of a medical doctor, nurse, nursing assistant, and community health agents. The oral health teams may also be included [6].

The family health teams are responsible for 2000 to 3500 people within a defined region. Defined populations and continuous provision of care means that bonds and co-responsibility between the teams and the population are favorable. This allows for reliable monitoring of the effects of health interventions, hence reducing the risk of iatrogenic events, which are often associated to the lack of knowledge on an individual’s life history, as well as poor care coordination [6].

The introduction of the National Oral Health Policy of Brazil (from Portuguese, PNSB), in 2004, was one of few global experiences in which public dental care was incorporated into Primary Health Care (PHC), attaining national coverage [7,8]. Countries such as Canada, which have well-established public health systems, are still unable to offer free access to public oral healthcare [9].

The oral health actions provided in the PNSB can be divided into: addition of fluoride to water sources; health education in the form of debates, workshops, videos, theaters, groups, posters and leaflets; supervised dental brushing; topical application of fluoride; diagnosis and treatment of soft and hard tissue lesions of the oral cavity, within the scope of primary care, aided by clinical care provided by the oral health team in the Family Health Care Units, notably the focus of the present study; rehabilitation actions, shared between primary and secondary care, with the support of the Dental Speciality Centers (from Portuguese CEO) that offer services for oral cancer, care for patients with special needs, endodontics, periodontics, and more complex surgery [8].

The new guidelines go beyond traditional dental approaches, as they promote advances in the work process. The concept of health promotion is the theoretical guideline of this model, moving the focus from provision of manual procedures to an approach that promotes support, information, responsibility and autonomy, which should also apply to the dental work provided in community-based multidisciplinary health units, known as Family Health Care Units [6,8].

In order to develop patient autonomy, the healthcare team should endeavor to encourage self-care practices, reducing medicalization and excessive dependence on healthcare professionals or services. For this purpose, teams need to understand the patients under their responsibility, their living conditions, the representations and values that they attribute to health, their habits and the actions required to solve problems related to illness and disease prevention [6].

Innovations aimed at dental practices that plan to overcome traditional management strategies, have been presented. These include the pursuit of biopsychosocial completeness, creating therapeutic bonds and gathering valuable information on the users’ family and work background, alongside multi-professional teamwork [10–13].

One may argue, therefore, that the new Brazilian oral health policy anticipates the implementation of a modern practice that is similar to the proposals of the "La Cascada Declaration" and are debated in current academic circles: control of common oral diseases by a community health care worker, integration of oral health into other policies and other areas of health, revision of the training curriculum, implementation of a practice where maintenance of preserved dentition overlaps financial interests in procedures, hence reducing unnecessary procedures [1–3].

Over a decade after the founding of PNSB, one should analyze in detail the reality of daily practice. One should contemplate if the dental surgeons working within PNSB embody these intentions of the health promotion approach or remain fixed to a surgical approach for one of the most common dental diseases—caries. Considering dental caries as a common theme, this study sought to approach it as the driving force for the interviews. The study aimed to clarify the response to the following question: do dental surgeons working within this new model have a broader outlook on patient care?

To appropriately analyze this at the intended level is a complex task, since clinical activity occurs in a unique way and is interspersed by interests, values as well as private and subjective tensions, hence demanding studies performed in a qualitative perspective in their natural settings [14]. The aim of this study was to understand the meanings and values that dental surgeons attribute to their practice in the Primary Healthcare setting, in order to identify congruences and contradictions to the proposals of the PNSB.

Methods

Data analysis

Data was explored by inductive content analysis and included complete transcription of the interviews, re-readings using suspended attention, as well as elaboration and classification of comments (Fig 1) [14,20]. This was achieved using a basic text editing software for reading and preparation of comments. Analysis was performed by the main researcher, alongside a group of five invited researchers (co-authors) (Fig 1). Each co-author was trained and calibrated by: 1—presentation of the project by the main researcher, who reported a review of the literature and the objectives of the study; and 2 –review of the technique and steps required for the method presented, with the support of experienced researchers in this area.

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Fig 1. Flow chart of the content analysis.

Adapted from Faria-Schutzer et al [20].

https://doi.org/10.1371/journal.pone.0216640.g001

The process of division by themes was started using steps 2 and 3, in which all authors evaluated the transcriptions using suspended attention, re-readings and commentaries were made. Each comment was linked to excerpts (quotes) from the interviews. The main researcher then organized the comments and excerpts provided by the authors, subsequently grouping them into themes. Associated themes then gave rise to themes, accompanied by quotes from the interviews.

After organization of the themes, the main researcher presented and discussed the results with all authors (step 5, Fig 1), aiming to meticulous refine the material according to the suggestions, as well as to select appropriate quotes that best represented the principle idea of each theme (step 6, Fig 1). The themes were then validated by the LPCQ group (step 7, Fig 1), by means of a presentation by the main researcher regarding the representative themes and quotes. The group subsequently provided suggestions based on the following criteria: 1—heterogeneity between themes; 2—internal homogeneity of themes; and 3—suitability of the name of each theme. Finally, the required adjustments were applied.

Results

Overview of findings

Dental surgeons were invited to talk about their thoughts, feelings and experiences regarding the treatment of dental caries, achieved by interviews lasting 30–50 minutes, according to the individuals willingness to express their opinions. Four main themes emerged from the data analyzed: (1) Therapy centered on the tooth, not the person; (2) Dental caries: an imprecise pretext for dental therapy; (3) Dental appointments as a synonym for manual intervention; and (4) Outmoded concepts of disease. Numbers preceded by the letter “E” at the end of discursive excerpts indicate the participants code. Sociodemographic characteristics of the sample are described in Table 1.

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Table 1. Sociodemographic characteristics of the dental surgeons from Family Health Care Units, Piracicaba, SP, 2016.

https://doi.org/10.1371/journal.pone.0216640.t001

Discussion

A recent literature review on oral healthcare in PHC revealed difficulties regarding overcoming conventional dental practices, with persistence of management focused primarily on technique [23]. This was also identified in the present study, indicating that, despite the intention of a broad reformulation by the new model, dental practice is strongly rooted in tradition, even when applied to a PHC. Dental surgeons still value their work through a perspective centered on a conventional point of view, which favors mechanistic interventions. This was described by Warmling et al [24], who reported the original professional identity, revealing the influences of dental teaching policies on the shaping of the dental surgeons identity, emphasizing that the original dental curriculum makes no mention of a clinic, which have been restricted to medical courses.

One may consider that this is the likely reason that certain ideas endure despite the creation and application of modern denistry. Therefore, this study corroborates the idea that a restricted dental focus continues to guide principle ideas of prevention, education and rehabilitation. The meaning attributed to treatment and healthcare, thus, rarely exceeded the limits of the tooth, biofilm, sugar, hygiene and restoration.

This phenomenon may be regarded as a barrier to practice improvement, since restricting the treatment plan in this manner disregards the importance of a person centered approach, which is more appropriate than simply performing technical procedures and obsessing over oral hygiene.

The PNSB guidelines involve aspects of the person-centered approach, by encouraging the interrelationships over time, defending the common risk factor approach, valuing health concerns and experiences [8,23]. Clinical practice, however, continues to be centered around manual procedures, while the importance of the holistic approach to both patient and community are ignored. Baldani et al. [25] argued that, in this context, a practice based on humanization is employed. However, their study was based on the evaluation of simpler aspects of the dental surgeons opinions.

The almost exclusive emphasis of proximal etiological factors for dental caries is a complicating factor in the patient-dental surgeon relationship, which may reduce treatment compliance and perpetuate natural disease progression. This patient-healthcare professional bond is a critical therapeutic resource, which assumes an exchange of knowledge between the professionals and peoples concerns, objective and subjective themes [26].

In terms of beliefs regarding bacterial plaque, dental surgeons were observed to disregard wider factors of the disease process, restricting themselves to biological and individual ideations of the disease, rather than concern for social aspects [27].

Uncertainty regarding dental caries concepts resulted in imprecision to define the focus of the dental surgeons work. Botazzo [27] suggested that caries are perceived as a fetish for dental surgeons, since they are a a diffuse, polymorphic and indefinite element, which allow for the generic “drill and fill” approach adopted by the profession. Comments arising from restorative and cosmetic dentistry, the industry and common sense, synergistically justify any form of dental interventions.

The multiple meanings given to caries also explains the inconsistency of perception of their prevalence, with contradiction between witnessing several or few cases of caries, in accordance with the statement that “dentists, when talking about caries, don’t know anymore what they’re talking about” [27] and thus dental procedures are performed in an automatic and unreflective manner, preserving mechanical tradition in detriment to the new guidelines.

Regarding the overlap observed between caries and need for fillings, one may refer to the Baders and Shugars [28] model. The authors aimed to explain clinical decision by dental surgeons regarding the treatment for caries, suggesting that they operate via pattern recognition from “mental scripts” in which detection of alteration is automatically related to the interventionist decision [28].

The dental surgeons preference for mechanical treatment is well documented in the literature, with a common recurrence in articles for cariology that focus on the biological-centered perspective for dental caries [2,29–32].

Baelum [2] stated that high-speed dental instruments represent the devotion of most dental surgeons to traditional treatments, as well as to unnecessarily encourage the power of these interventions in oral health promotion, classifying dental surgeons as “dental mechanics”. Renshaw [33] attributed an obsession for all that is technical to dental surgeons. Baelum et al. [11] considered the “drill and fill” paradigm as consolidated in several ways, with concern over the difficulties of breaking such a vicious cycle.

Dental surgeons have been observed to consider dental appointments as synonymous with manual procedures, which is relevant when considering the context in this study. The professional being paid on a production basis is pointed out in literature as being one of the main inducers of technicality [2,34,35]. Tooth, isolated from body and society, is a simpler intervention object; therefore the procedure-centered practice fits well [24,27,36,37].

Finally, outdated scientific ideas regarding disease helps to explain more invasive approaches from a technical point of view. Although, discussion on the technical aspects of disease management is not the focus of our study, it is important to highlight that current evidence demands a minimally invasive approach when surgical interventions are required, allowing preservation of physiological structures and avoiding possible repetitive restoration cycles [22,38–40]. The concept of dental caries being contagious has been scientifically disproven, although it is still prevalent in dental surgeon’ statements [21,22].

The literature reveals examples of experiences of health promotion in different countries that illustrates the limitations of dentistry. Saekel [41] used a thought-provoking analysis of German public oral health policies to aid decisions on the implementation of an appropriate system in China. The author condemned the catastrophic oral health consequences of an invasive and restorative approach that prevailed over a long period of time throught Germany, instead showing the benefits, although partial and insufficient, obtained after its reform in the 1980s. The idea that a modus operandi anchored in outdated assumptions about oral diseases, namely the "Drill and Fill" type, when implemented through wide public policies, collaborates the perpetuation of oral disease burden [41].

Fejerskov et al. [3] described a series of studies from countries including as Denmark, Finland and Norway, that have implemented different successful paradigm-shifting experiences in oral health services by incorporating up-to-date diagnostic and therapeutic approaches, and demonstrated the potential of achieving epidemiological benefits from policy shifts.

The PNSB has many differences compared to the aforementioned proposals, including several advances such as its inclusion in a more comprehensive health policy of Primary Health Care, multiprofessional teamwork, its allocation within Family Care Units, continuous monitoring over time, among others. However, advances to the reality of the practice model, moving from a surgical to a health promotion approach, are required.

Potential means to change dental providers’ ideas from surgical to health promotion have been discussed in the literature. The dental curriculum is a growing concern, demonstrated by dental schools around the world seeking to provide students with community-based experiences, increasing the number of interdisciplinary courses, and blending basic with clinical sciences [42,43]. Extramural training in Brazil provides dental students with enriching experiences by placing them in different socioeconomic environments, that are often very different from their own background, allowing improved training and more adequate practice [43]. However, barriers involving difficult placements are often identified, some linked to the values and interests that permeate the practice and training of dentists, as well as academic political ideas, hence limiting the development of new attitudes in dental surgeons [43].

Considering the inability of dentistry to provide effective oral healthcare, Fejeskov et al [3] described the need for a new cadre of dental professionals capable of meeting the current health needs based on scientifically up-to-date knowledge. The authors of the current study believe that while such profound changes are not implemented, some of the recommendations could be adapted and applied in the current dentistry cuuriculum, as well as in continuing education cycles for dentists already trained and employed within oral health policies.

Study limitations

The qualitative study performed does not allow one to generalize over the results obtained, which refers to a restricted population, studied within a specific context. However, one hopes that the findings are relevant to contribute to a broader discussion, since there is a current global effort to transform dental practice towards the health promotion aproach, and interested parties must consider the similarities and contextual differences compared to those presented in this study.

Another limitations of the present study are linked to the interviewer. Primarily, despite nine years of healthcare experience, the aforementioned had no previous experience with formal interviews, although similarities regarding comprehensive listening should be considered. Secondly, interviews were conducted by a dental surgeon interviewing professionals from the same field, which could reduce the objectivity of the study and the degree of freedom on the part of the participants. On the other hand, facilitation of communication should be considered, as the participants could use the specific language and jargon, thus providing their ideas and arguments spontaneously and naturally.

Conclusions

The findings from this study revealed counterproductive values and meanings associated with traditional treatment modalities, even in an oral healthcare model that advocates for innovations. To promote oral healthcare in diverse populations, there is a need to assign more than simply traditional dental surgeons to different healthcare models. Internationally, there is also an urgent need to implement a reform in dentistry, or to introduce new modalities.

Our study may be relevant to other countries aiming to implement oral healthcare in public health services. Public policies need to identify the limitations of dentistry and to act to optimize health in the population.

Supporting information

Acknowledgments

The authors would like to thank Espaço da Escrita—Coordenadoria Geral da Universidade—UNICAMP—for the language services provided.