Santos et al.

BMC Health Services Research (2024) 24:1176 BMC Health Services Research
https://doi.org/10.1186/s12913-024-11574-z

RESEARCH Open Access

Matrix Support: interface between Specialty

Dental Centers and primary oral health care
in Brazil
Thaislaine Gonçalves Martins Santos1*, Livia Fernandes Probst3,4, Rafaela da Silveira Pinto5, Edilson José Zafalon2 and
Alessandro Diogo De-Carli2,4

Abstract
Background Matrix Support (MS) is a strategy that can be used to improve integration between Primary Health Care
(PHC) and other levels of care.
Objective The aim of this study was to investigate the association between MS carried out in Brazilian Dental
Specialty Centers (CEOs) (secondary level of oral health care) and aspects of the integrated work process with PHC, as
well as contextual variables.
Methods A quantitative cross-sectional study was conducted using data from the Program for Quality Improvement
and Access to CEOs (PMAQ-CEO). Secondary data from the External Evaluation of the second cycle of PMAQ-CEO
were analyzed, including contextual variables obtained from sources such as the Unified Health System (SUS) and
official research institutions. Descriptive analyses were performed, and four multiple models were adjusted to
investigate the association between the variables.
Results The results showed that about half of the CEOs did not carry out therapeutic projects developed with the
oral health teams of PHC. It was found that the lack of therapeutic projects developed with the teams was associated
with the lack of discussion of complex cases by the team, lack of discussion of individual therapeutic project, absence
of joint continuing education activities, lack of construction and discussion of clinical protocols, and lack of belief
in the importance of planning and periodic evaluation. The results suggest that the articulation between PHC and
secondary oral health care still presents weaknesses within the scope of SUS. Comprehensive care needs to be
strengthened, requiring greater intervention from management.
Conclusion It was concluded that the individual factors of CEOs, related to the work process, have a greater
influence on the lack of integration with oral health teams of PHC, compared to the contextual variables of
municipalities.
Keywords Secondary care, Comprehensive health care, National health strategies

3
*Correspondence: Health Technology Assessment Unit, Hospital Alemão Oswaldo Cruz
Thaislaine Gonçalves Martins Santos (HAOC), São Paulo, Brazil
4
thaislainemartins@gmail.com Piracicaba Dental School, State University of Campinas (UNICAMP),
1
Master’s Degree Program in Family Health, Federal University of Mato Piracicaba, Brazil
5
Grosso do Sul (UFMS), Campo Grande, Brazil Department of Social and Preventive Dentistry, Federal University of
2
Faculty of Dentistry, Federal University of Mato Grosso do Sul (UFMS), Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil
Campo Grande, Brazil

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Santos et al. BMC Health Services Research (2024) 24:1176 Page 2 of 10

Background The National Program to Improve Access and Qual-

Primary Health Care (PHC), represented mainly in Bra- ity of Specialty Dental Centers (PMAQ-CEO, Programa
zil by the Family Health Strategy (ESF, Estratégia Saúde Nacional de Melhoria do Acesso e da Qualidade dos Cen-
da Família in portuguese), is considered the gateway to tro de Especialidades Odontológicas in portuguese), was
health actions and services, aiming to ensure compre- established within the scope of the National Oral Health
hensive care that impacts the health and autonomy of Policy through Ordinance Number 261/GM/MS, of Feb-
individuals. Thus, it encompasses promotion, protection, ruary 21, 2013, and its main objective was to increase
disease prevention, diagnosis, treatment, rehabilitation, access and improve the quality of CEOs throughout Bra-
harm reduction, and health maintenance. It is expected zil [4].
that at this level of care, approximately 80% of the com- The organization of interprofessional healthcare work
munity’s oral health problems will be resolved [1–3]. processes in Brazil, both within teams and in Oral Health
Access to oral health care in Brazil is challenging due Care Networks (RASB, Rede de Atenção à Saúde Bucal
to the history of dental care in the country, which has in portuguese), is referred to as Matrix Support (MS).
been marked by curative and often mutilating actions, This strategy aims to enhance dialogue among differ-
reflecting up to the present day. To overcome persistent ent specialties, professions, and levels of healthcare. MS
inequalities in this area, the National Oral Health Policy provides technical-pedagogical support where it con-
(PNSB, Política Nacional de Saúde Bucal in portuguese), ducts educational support in conjunction with Primary
called Smiling Program (Brasil Sorridente in portuguese), Health Care (PHC), through discussions of clinical cases
was implemented in 2004. This policy considered the and assistance in certain cases considered urgent, which
reorganization of oral health care in Primary Health cannot wait and require specialist care. Thus, it develops
Care (PHC), reinforced service coverage, qualified care a possibility to qualify the Oral Health Teams (OHT) of
through the Oral Health Teams (eSB, equipes de Saúde PHC for comprehensive care and across different levels
Bucal in portuguese) of the Family Health Strategy (FHS) of complexity. In this way, cases that require specialist
and Specialized Care, implementation of Specialty Dental follow-up and cases that can be managed by PHC’s OHT
Centers (CEO, Centros de Especialidades Odontológicas can be specified [1, 8–14].
in portuguese) and Regional Dental Prosthesis Labora- Studies show the difficulties related to access to services
tories, integration of teaching and service through the and the work process of the CEO, situations that may also
GraduaCEO program, addition of fluoride to water treat- be related to contextual factors. As an aggravating factor,
ment stations, and oral health surveillance [4–6]. in CEO settings, the resolution of complex cases prevails,
The CEO are reference establishments for secondary which often requires interprofessional attention that can
care for patients from Primary Health Care (PHC) who be addressed through MS. In its absence, the progress of
require specialized attention. The complexity level of CEO activities is hindered, and the services that should
these cases demands capable professionals of conduct- be offered within PHC are merely referred to, without
ing treatments that require more complex technological necessarily exchanging information between these levels
resources. They offer, at a minimum, the specialties of of oral health care attention, resulting in a high treatment
Special Needs Patient Care, Minor Oral Surgery, End- abandonment rate [15–17].
odontics, Stomatology, and Periodontics. In addition, In this sense, the articulation between Primary Health
they may offer services such as Dental Implants, Ortho- Care (PHC) and Specialized Care (secondary) allows for
dontics, Functional Jaw Orthopedics, Pediatric Den- planning and implementation of services within Health
tistry, and Prosthetic Rehabilitation, at the discretion of Care Networks (RAS, Rede de Atenção á Saúde in portu-
the responsible manager, according to the municipality’s guese). Therefore, this interplay would have the potential
needs. Primary dental care in Brazil is mainly provided to facilitate the resolution of cases stemming from PHC.
by Oral Health Teams (eSB) within the Family Health However, it is noticed that there are not many studies on
Strategy (ESF), focusing on promotion, prevention, MS in CEO settings. Thus, it is necessary to investigate
diagnosis, and basic dental treatments. More complex the topic, so that representative results can be obtained
cases are referred by the eSB to Specialty Dental Centers that have the potential to contribute to significant
(CEO) through a regulatory system that prioritizes based advances in the context of specialized oral health care in
on need and urgency. Integration between these levels interface with PHC [1, 18, 19]. In this sense, the aim of
is essential for effectively addressing oral health issues. this study was to investigate, on a national scale, whether
Interprofessional collaboration, promoted by Matrix there is an association between MS performed in special-
Support (AM), offers technical and educational sup- ized oral health care within the Brazilian Unified Health
port to primary care teams, ensuring comprehensive and System (SUS, Sistema Único de Saúde in portuguese) with
coordinated care for patients [2, 5–7]. aspects of the integrated work process with PHC and
contextual variables.
Santos et al. BMC Health Services Research (2024) 24:1176 Page 3 of 10

Method in Epidemiology (STROBE) guidelines [20]. This study

Context and ethical aspects uses data from the external evaluation of the 2nd cycle of
In 2013, the Program for Improving Access and Quality the National Program to Improve Access and Quality of
of Specialty Dental Centers (PMAQ-CEO) was devel- Specialty Dental Centers (PMAQ-CEO, Programa Nacio-
oped, aiming to expand access and improve the quality nal de Melhoria do Acesso e da Qualidade dos Centro de
of the CEOs. In its second cycle, carried out in 2018, the Especialidades Odontológicas in portuguese), carried out
PMAQ-CEO was organized into three phases: adhesion in 2018, in Brazil [4].
and contracting by the managers of the Unified Health
System (SUS), certification and re-contracting, and a Study universe and sample
transversal strategic axis of development that comprises Data from all CEO participants in the second cycle of
a continuous cycle of improving access and quality of the the National Program for Improving Access and Quality
CEOs. The External Assessments were conducted with of Specialized Dental Care Centers (PMAQ-CEO) were
the help of Teaching and Research Institutions from all included. Of the 1,097 CEO accredited in 2018, 1,042
over the country, through interviews with users, CEO participated in the external evaluation, corresponding
professionals, and managers [11]. The answers to these to 94.99% of active CEOs nationwide. Of these, 139 were
interviews constitute the data of the 2nd cycle of the excluded for not responding to relevant study questions.
multicenter study, using microdata related to module II, The study universe consisted of 903 CEOs. The indepen-
which evaluated the work process of the CEOs (exter- dent variables were organized into independent variables
nal evaluation). The microdata used in this study were of the CEO work process and independent variables of
obtained from national information systems with public the municipality, according to the adopted theoretical
and unrestricted access. Therefore, it was not necessary model, as shown in Fig. 1.
to obtain approval from to the Research Ethics Commit- The data was obtained through the public domain
tee [20, 21]. database related to the External Evaluation of the second
cycle of PMAQ-CEO. The selected information pertained
Study design to Modules II.5 – Planning, Evaluation, and Management
This is an analytical quantitative cross-sectional epide- for Organizing CEO Work Processes, II.6 – Matrix Sup-
miological study, conducted nationwide, and the data port (MS), and II.18 – Planning and CEO Team Meeting
collection, organization, and analysis were carried out [4, 17].
from March to July 2022. The article is reported following Socioeconomic data were selected from the Depart-
the STrengthening the Reporting of OBservational studies ment of Informatics of the Unified Health System

Fig. 1 Theoretical model adapted for the study

Santos et al. BMC Health Services Research (2024) 24:1176 Page 4 of 10

(DATASUS/eSUS AB, Departamento de Informática do (IBGE, Instituto Brasileiro de Geografia e Estatística in

Sistema Único de Saúde in portuguese), using the follow- portuguese).
ing information systems: Outpatient Health Information
System (SIA-SUS, Sistema de Informação Ambulatorial Analyzed variables
em Saúde in portuguese), National Registry of Health The variables used in the study and how they were treated
Establishments (CNES, Cadastro Nacional de Estabe- in the statistical analysis are presented in Chart 1.
lecimentos de Saúde in portuguese), and Public Health
Budget Information System (SIOPS, Sistema de Infor- Data organization and statistical analysis
mações Orçamentárias da Saúde Pública in portuguese). After data collection, they were organized into ExcelⓇ
Contextual variables were obtained through consultation spreadsheets and subsequently an analysis was car-
with the Institute of Applied Economic Research (IPEA, ried out. Descriptive analyses of all variables were per-
Instituto de Pesquisa Econômica Aplicada in portuguese) formed, including absolute and relative frequencies. For
and the Brazilian Institute of Geography and Statistics the variables “oral health coverage” and “Gini index”, a

Chart 1 Variables (outcome and independent) used in the study

Variable Presentation Data
source
Outcome
Therapeutic projects built with Categorized: Yes or no PMAQ-
PHC Oral Health Teams CEO
Independent variables of the CEO work process
Discussion of complex cases Categorized: Yes or no PMAQ-
CEO
Discussion of individual therapeu- Categorized: Yes or no PMAQ-
tic projects CEO
Permanent education activities Categorized: Yes or no PMAQ-
CEO
Construction and discussion of Categorized: Yes or no PMAQ-
clinical protocols CEO
Home visits with the teams Categorized: Yes or no PMAQ-
CEO
Do they develop periodic plan- Categorized: Yes or no PMAQ-
ning and evaluations? CEO
Independent variables of the municipality
Oral health coverage Proportion of the population covered by oral health at PHC level*, Calculation from SISAB
the formula: (nº eSFSB * 3450) + (nº eABSB to + nº eSFSB equivalent)*3000 *100
Population estimate
Social Prosperity Social prosperity is the simultaneous occurrence of high human development with IPEA
low social vulnerability, suggesting that, in the portions of the territory where it
occurs, a less vulnerable and socially more prosperous human development trajec-
tory occurs.
Gini Index Measure of income inequality, as it indicates the difference between the income of IBGE
the poorest and the richest. Numerically, it ranges from zero to one. The value zero
represents a situation of total equality, that is, everyone has the same income.
Region Central-West IBGE
North
Northeast
Southeast
South
APS: Primary Health Care
eABSB to: number of Oral Health teams parameterized to adhere to the Access and Quality Improvement Program (PMAQ)
eSB: Oral Health Team
eSFSB equivalent: Oral Health teams in traditional Primary Care equivalent to Oral Health teams linked to Family Health Teams
eSFSB: Family Health Strategy Oral Health Teams
IPEA: Institute for Applied Economic Research
PMAQ-CEO: National Program for Improving Access and Quality of Specialty Dental Centers
IBGE: Instituto Brasileiro de Geografia e Estatística
SISAB: Health Information System for Primary Care
Santos et al. BMC Health Services Research (2024) 24:1176 Page 5 of 10

dichotomization was performed using the median, clas- ceased to be significant (p = 0.8651). The other variables
sifying municipalities into lower and higher coverage, as remained in model 3. In model 4, municipality variables
well as lower and higher Gini index. with p < 0.20 in individual analyses (Region, Oral health
Logistic regression models were built for each indepen- coverage, and Social prosperity) were included. It was
dent variable of the Specialty Dental Centers (CEO) and observed that no contextual variable (from municipali-
municipalities, resulting in the “therapeutic projects built ties) remained significant when analyzed together with
with PHC Oral Health Teams” outcome. Subsequently, CEO variables (p > 0.05). Thus, the final model consisted
four multiple models were adjusted. Firstly, an empty of variables significant in the multilevel multiple model.
model (only with the intercept) was adjusted to calculate In the final model, a higher chance of not carrying out
the intraclass correlation coefficient. Then, a multilevel therapeutic projects built with PHC Oral Health Teams
multiple model was adjusted with variables related to the was observed among the CEOs who did not engage
CEO (model 2), and subsequently, a multilevel multiple in the discussion of complex cases (OR = 2.59; 95% CI:
model only with the CEO variables that remained in the 1.04–6.48), did not conduct discussions of individual
multiple model (model 3). In these two models, the CEO therapeutic projects (OR = 2.85; 95% CI: 1.98–4.10), did
(level 1) nested within the Municipalities (level 2) were not engage in permanent education activities (OR = 2.01;
considered, using the IBGE codes of the municipalities of 95% CI: 1.27–3.17), did not carry out construction and
each CEO. In model 4, variables related to municipalities discussion of clinical protocols (OR = 2.45; 95% CI: 1.80–
(contextual variables) that presented a p-value < 0.20 in 3.34), and did not believe that the actions developed in
individual analyzes were included, and in the final model, the CEO were the result of periodic planning and evalua-
only variables related (p ≤ 0.05) in the multilevel multiple tions (OR = 2.02; 95% CI: 1.48–2.75), p < 0.05.
model remained. From the models, crude and adjusted
odds ratios were estimated, along with their respective Discussion
95% confidence intervals. Model fit was evaluated by the The results of this study demonstrate that nearly half
QIC (quasi-likelihood criterion) and statistical signifi- of the Specialty Dental Centers (CEO) do not carry out
cance. Data analysis was performed using resources from therapeutic projects in collaboration with professionals
R and SAS programs [20, 21]. from PHC Oral Health Teams (eSBs) of Primary Health
Care. The chances of non-implementation were higher
Results among CEOs that do not discuss complex cases, do not
Data from 903 CEO, belonging to 767 municipalities conduct discussions on individual therapeutic projects,
from all five regions of the country, were analyzed. In do not promote permanent education activities, do not
Table 1, when analyzed individually, all variables related develop and discuss clinical protocols, and do not believe
to the CEO showed a significant association with the out- that the actions developed in the CEO are the result of
come “Therapeutic projects built with PHC Oral Health periodic planning and evaluations. These findings con-
Teams” (p < 0.05). Also significant in individual analyses tribute to advancing knowledge in understanding Matrix
were the variables of oral health coverage and social pros- Support (MS) in oral health care in Brazil, in an unprec-
perity of the municipalities (p < 0.05). It was observed that edented way. Therefore, these results reinforce the need
48.1% of the CEO did not carry out therapeutic projects to strengthen Matrix Support and promote integrated
built with PHC Oral Health Teams. Additionally, 7.6% work between CEO and PHC Oral Health Teams. This
did not engage in the discussion of complex cases; 31.9% becomes critical, as the lack of collaborative practices and
did not engage in the discussion of individual therapeutic sharing of knowledge among these teams can negatively
projects; 19.7% did not carry out permanent education affect the quality and continuity of dental care offered to
activities; 47.7% did not engage in the construction and SUS users.
discussion of clinical protocols; 22.7% did not conduct Matrix Support (MS) has proven to be feasible, ini-
home visits with the teams, and for 43.0% of the CEO, the tially with mental health teams, and has expanded over
actions developed were not the result of periodic plan- the years to other teams that are part of the Health Care
ning and evaluations. Networks (RAS), and there is evidence that MS actions
Table 2; Fig. 2 present the results of the multilevel mul- can positively impact the quality of PHC teams [9, 23,
tiple regression analyses. The empty model (model 1) was 24]. However, MS faces significant challenges. It was only
adjusted to calculate the intraclass correlation coefficient. with the creation of the Family Health Support Center
It was observed that the intraclass correlation coefficient (NASF, Núcleos de Apoio a Saúde da Família in portu-
is 0.2578, meaning that around 26% of the total variation guese) in 2008, aimed at enhancing the effectiveness
is due to municipality variables. In model 2, CEO-related and responsiveness of family health teams to popula-
variables were included, and when analyzed together tion issues, that funding from the Ministry of Health was
with the others, the variable “Home visits with the teams” made available to encourage the adoption of the Family
Santos et al. BMC Health Services Research (2024) 24:1176 Page 6 of 10

Table 1 Individual analyzes of associations between the practice of therapeutic projects built by Specialty Dental Centers (CEO) with
professionals from Primary Health Care Oral Health teams and individual and contextual variables (n = 903)
Variable Category n (%) Therapeutic projects built with PHC OR gross (IC95%) p- value
Oral Health Teams
Yes *No
n (%) n (%)
General sample 903 (100,0%) 469 (51,9%) 434 (48,1%) - -
From Specialty Den-
tal Centers
Discussion of complex Yes 834 (92,4%) 453 (54,3%) 381 (45,7%) Ref
cases No 69 (7,6%) 16 (23,2%) 53 (76,8%) 3,81 (2,17 − 6,70) < 0,0001
Discussion of indi- Yes 615 (68,1%) 389 (63,3%) 226 (36,7%) Ref
vidual therapeutic No 288 (31,9%) 80 (27,8%) 208 (72,2%) 4,41 (3,23 − 6,01) < 0,0001
projects
Permanent education Yes 725 (80,3%) 421 (58,1%) 304 (41,9%) Ref
activities No 178 (19,7%) 48 (27,0%) 130 (73,0%) 3,70 (2,61 − 5,24) < 0,0001
Construction and Yes 472 (52,3%) 315 (66,7%) 157 (33,3%) Ref
discussion of clinical No 431 (47,7%) 154 (35,7%) 277 (64,3%) 3,56 (2,68 − 4,73) < 0,0001
protocols
Home visits with the Yes 600 (66,4%) 347 (57,8%) 253 (42,2%) Ref
teams No 205 (22,7%) 86 (42,0%) 119 (58,0%) 1,85 (1,33 − 2,57) 0,0002
No information 98 (10,9%) 36 (36,7%) 62 (63,3%) -
Do they develop Yes 417 (46,2%) 274 (65,7%) 143 (34,3%) Ref
periodic planning and No 388 (43,0%) 159 (41,0%) 229 (59,0%) 2,72 (2,04 − 3,63) < 0,0001
evaluations? No information 98 (10,9%) 36 (36,7%) 62 (63,3%) -
Contextual
Region North 51 (5,6%) 20 (39,2%) 31 (60,8%) 1,66 (0,78 − 3,54) 0,1878
North East 366 (40,5%) 201 (54,9%) 165 (45,1%) 0,92 (0,57 − 1,47) 0,7299
Midwest 64 (7,1%) 37 (57,8%) 27 (42,2%) 0,86 (0,42 − 1,76) 0,6873
South 318 (35,2%) 155 (48,7%) 163 (51,3%) 1,21 (0,75 − 1,95) 0,4353
Southeast 104 (11,5%) 56 (53,8%) 48 (46,2%) Ref
Oral health coverage ≤ 67,55% (Median) 452 (50,1%) 207 (45,8%) 245 (54,2%) 1,68 (1,27 − 2,22) 0,0003
> 67,55% 451 (49,9%) 262 (58,1%) 189 (41,9%) Ref
Social Prosperity Very tall 418 (46,3%) 216 (51,7%) 202 (48,3%) Ref
High 106 (11,7%) 37 (34,9%) 69 (65,1%) 1,96 (1,24 − 3,11) 0,0038
Average 130 (14,4%) 75 (57,7%) 55 (42,3%) 0,77 (0,51 − 1,16) 0,2166
Low 126 (14,0%) 70 (55,6%) 56 (44,4%) 0,85 (0,56 − 1,29) 0,4547
Very low 123 (13,6%) 71 (57,7%) 52 (42,3%) 0,78 (0,51 − 1,18) 0,2418
Gini Index ≤ 0,52 (Median) 492 (54,5%) 262 (53,3%) 230 (46,7%) 0,91 (0,69 − 1,21) 0,5137
> 0,52 411 (45,5%) 207 (50,4%) 204 (49,6%) Ref
*Outcome event. Ref: Reference category for independent variables. OR: Odds ratio. CI: Confidence interval

Health Strategy in PHC. However, this implementation between reference teams, MS teams, and managers
was limited to municipalities where managers showed occurs, and healthcare is executed integrally [12, 22, 25].
sensitivity to this methodology. As a result, there is a The discussion of complex cases is an important MS
shortage of studies evaluating the effectiveness of the strategy, and this study to showed that most of CEO
Family Health Strategy.Additionally, it was inserted as teams teams engage in this practice. It is relevant to high-
public policy without professional qualification, resulting light that, although less than 8% of teams do not engage
in a lack of knowledge on the subject and difficulties in its in the discussion of complex cases, teams that did not
application by most services [2, 19, 22, 25]. engage had 2.59 times more chances of not carrying out
Other aspects that need to be overcome are the hier- therapeutic projects built with PHC Oral Health Teams
archization among professionals, the fragmented health- than teams that did. These results reinforce the discus-
care system, and the dominant biomedical model. sion of complex cases as a facilitator of resolution and
Therefore, it is necessary for all involved parties to be quality of oral health care in PHC, favoring the optimiza-
trained and open to comprehensive changes, so that tion of time for patient care [26, 27].
a partnership of regular and productive encounters
Santos et al. BMC Health Services Research (2024) 24:1176 Page 7 of 10

Table 2 Multiple multilevel analyzes of associations with the practice of therapeutic projects built by Specialty Dental Centers (CEO)
with professionals from the Primary Health Care Oral Health teams and individual and contextual variables (n = 903)
Variable Category Model 1 Model 2 Model 3 (significant Model 4 (including con- Final model
(empty (CEO variables) CEO variables) textual variables)
model)
OR p- value OR p- value OR adjusted p- value OR p- value
adjusted adjusted (IC95%) adjusted
(IC95%) (IC95%) (IC95%)
From Specialty
Dental Centers
Discussion of Yes - Ref Ref Ref Ref
complex cases No 2,58 0,0421 2,59 0,0414 2,66 0,0400 2,59 0,0414
(1,03–6,45) (1,04–6,48) (1,04–6,76) (1,04–6,48)
Discussion of Yes - Ref Ref Ref Ref
individual thera- No 2,85 < 0,0001 2,85 < 0,0001 2,84 < 0,0001 2,85 < 0,0001
peutic projects (1,98 − 4,09) (1,98 − 4,10) (1,96 − 4,10) (1,98 − 4,10)
Permanent edu- Yes - Ref Ref Ref Ref
cation activities No 2,01 0,0028 2,01 0,0027 1,98 0,0042 2,01 0,0027
(1,27 − 3,16) (1,27 − 3,17) (1,24 − 3,17) (1,27 − 3,17)
Construction Yes - Ref Ref Ref Ref
and discus- No 2,45 < 0,0001 2,45 < 0,0001 2,37 < 0,0001 2,45 < 0,0001
sion of clinical (1,80 − 3,33) (1,80 − 3,34) (1,73 − 3,24) (1,80 − 3,34)
protocols
Home visits with Yes - Ref - - - - - -
the teams No 1,03 0,8651
(0,71 − 1,51)
No -
information
Do they de- Yes - Ref Ref Ref Ref
velop periodic No 2,00 < 0,0001 2,02 < 0,0001 2,00 < 0,0001 2,02 < 0,0001
planning and (1,44 − 2,76) (1,48 − 2,75) (1,45 − 2,77) (1,48 − 2,75)
evaluations? No - - - -
information
Contextuais
Region North - 1,26 0,6589 - -
(0,45 − 3,56)
North East 1,34 0,4628
(0,61 − 2,94)
Midwest 0,80 0,6179
(0,34 − 1,89)
South 1,12 0,6894
(0,65 − 1,92)
Southeast Ref
Oral health ≤ 67,55% - - - 1,28 0,1967 - -
coverage (Median) (0,88 − 1,87)
> 67,55% Ref
Social Prosperity Very tall - - - Ref - -
High 1,29 0,3414
(0,76 − 2,19)
Average 0,91 0,7888
(0,45 − 1,84)
Low 0,84 0,6560
(0,39 − 1,80)
Very low 1,16 0,7160
(0,52 − 2,58)
QIC 1252,72 957,83 955,88 967,06 955,88
*Outcome event. Ref: Reference category for independent variables. OR: Odds ratio. CI: Confidence interval. Variance between municipalities = 0.2596; Residual
variance = 0.7473; ICC: Intraclass correlation coefficient (Part of the total variation that is due to the contextual level - Municipalities) = 0.2578
Santos et al. BMC Health Services Research (2024) 24:1176 Page 8 of 10

Fig. 2 Odds ratio of the final model of associations with the practice of therapeutic projects constructed by the Specialty Dental Centers (CEO) with
professionals from Primary Oral Health Care teams - Outcome event = no (n = 903)

These results suggest that over 30% of CEO teams that more chances of not conducting therapeutic projects
do not engage in discussing individual therapeutic proj- built with eSB compared to teams that performed HPE.
ect with PHC Oral Health Teams (eSB) had 2.85 times Health Permanent Education (HPE) is a practice in
more chances of not carrying out therapeutic projects Brazil, guided by the National HPE Policy as the main
built with eSB compared to teams that discuss the PTS. institutional strategy for the qualification of SUS profes-
This was the independent variable with the greatest effect sionals [28, 29]. Its practice brings a differential to health
on the outcome, meaning not discussing the PTS was teams through professional qualification, becoming a
the factor most associated with not conducting MS. The crucial point for the quality of the work process, as it has
Matrix Support (MS) strategy occurs through interdisci- the potential to contribute to the construction of values,
plinary exercise, aiming at comprehensive care, expand- quantify and enrich health work management. In this
ing access to health needs, and enhancing integrated and perspective, the knowledge and analysis of social reality
coordinated action. It involves a sum of perspectives that processes are improved, increasing resolution, human-
favors a process of shared construction in a proposal for ization, and care coordination [30–32].
pedagogical-therapeutic intervention. This implies out- It is observed that almost half of the CEO teams do not
comes alongside Primary Health Care (PHC), as PHC engage in the construction and discussion of clinical pro-
Oral Health Teams (eSB) experiencing MS perform bet- tocols, and these teams had 2.45 times more chances of
ter, reducing the gap between specialists and PHC pro- not carrying out therapeutic projects built with the eSB
fessionals, and are more likely to overcome limitations of the APS than the teams that do engage in this con-
of hierarchical systems that restrict responsibility trans- struction. Therefore, it becomes necessary to reinforce in
fer. Thus, it promotes the dialogical and integrated func- these teams the purpose of protocols, to reduce failures in
tioning of health teams that discuss and collectively act the execution of procedures, rationalizing them, includ-
on clinical, health, or management cases, reinforcing the ing in relation to time. Thus, a better clinical practice
importance of MS to enhance its resolution capacity. The and greater safety in care are facilitated [18, 19, 33] How-
Singular Therapeutic Project (PTS, Projeto Terapêutico ever, the implementation of clinical protocols alone will
Singular in Portuguese), is a set of coordinated thera- not, in fact, promote significant advances, as profession-
peutic proposals for an individual, a family, or a group, als need to integrate them into their work continuously.
developed through collective discussion by an interdisci- Therefore, it becomes relevant to improve and enhance
plinary team with Matrix Support, when necessary [11, the coordination between the management of both levels
26, 27]. of care, seeking improvements to generate impacts truly
On a positive note, it is observed that 19.7% of CEO focused on the comprehensiveness of care [19, 33, 35].
teams do not carry out HPE activities jointly with PHC The adoption of clinical protocols is a way to overcome
Oral Health Teams (eSB) of APS, and these results results the fragmentation of the healthcare system, facilitat-
reinforce its importance, as these teams had 2.01 times ing action management and respecting the principles of
Santos et al. BMC Health Services Research (2024) 24:1176 Page 9 of 10

Abbreviations
universality and equity proposed by SUS [19, 33]. There- ASSB Secondary Oral Health Care (Atenção Secundária em Saúde
fore, it becomes essential to develop work processes that Bucal)
enable the formation and management of an oral health CEO Specialty Dental Centers (Centro de Especialidades
Odontológicas)
care network because when there is no clear vision of eSB Oral Health Team (Equipe de Saúde Bucal)
where one wants to go, each individual will conduct the ESF Family Health Strategy (Estratégia Saúde da Família)
work process individually, and there will hardly be any IBGE Brazilian Institute of Geography and Statistics (Instituto
Brasileiro de Geografia e Estatística)
quality gains, persisting a fragmented model in which IPEA Institute of Applied Economic Research (Instituto de Pesquisa
services do not articulate, and as a result, do not meet the Econômica Aplicada)
real needs of the population in a continuous and longitu- MS Matrix Support
PHC Primary Health Care
dinal manner [19, 34]. PMAQ-CEO National Program to Improve Access to and Quality of
When CEOs engage in more planning actions, the Specialty Dental Centers (Programa Nacional de Melhoria
outcomes of Matrix Support (AM) are better [1]. How- do Acesso e da Qualidade dos Centro de Especialidades
Odontológicas)
ever, these results showed that, for 43.0% of CEO teams, PNSB National Oral Health Policy (Política Nacional de Saúde Bucal)
actions were not the result of periodic planning and RASB Oral Health Care Network (Rede de Atenção à Saúde Bucal)
evaluations. These CEOs had 2.02 times more chances SUS Unified Health System (< Emphasis Type="Italic”> Sistema
Único de Saúde</Emphasis>)
of not carrying out therapeutic projects built with APS
eSBs than those whose actions were the result of periodic Acknowledgements
planning and evaluations. These findings are in line with Not applicable.

the study by Vieira et al. (2021), which analyzed planning Author contributions
in public secondary oral health care services in the state TGMS: Contributed to the study concept, design, acquisition and
of Amazonas and reinforce that the absence of planning interpretation of data for the research and drafting of the manuscript. LFP:
Contributed to the study concept, design, acquisition and interpretation of
has the potential to negatively impact the quality of oral data for the research and drafting of the manuscript. RSP: Contributed to the
health care for the population. In this context, planning is study conception, design and drafting of the manuscript. EJZ: Contributed
considered an important tool for the effective functioning to the study conception, design and drafting of the manuscript. ADC:
Contributed to the study conception, design and drafting of the manuscript.
of the SUS, being highly relevant for health management
[10, 36–39], especially as it promotes care coordination Funding
and comprehensiveness. No funding was received for this study.

This study has limitations inherent to the cross-sec- Data availability

tional design and the use of secondary data. Therefore, Public data from National Program to Improve Access and Quality of Dental
its results should be interpreted cautiously, although Specialty Centers (PMAQ-CEO) is available at https://aps.saude.gov.br/ape/
pmaq/ciclo2ceo/. Public data from Health Information System for Primary
all measures to verify the reliability and accuracy of the Care (SISAB, Sistema de Informação em Saúde para a Atenção Básica) is
databases were performed prior to the analysis execution. available at https://egestorab.saude.gov.br/paginas/acessoPublico/relatorios/
Therefore, from a research perspective, the need for relHistoricoCobertura.xhtml. Public data from Instituto de Pesquisa Econômica
Aplicada (IPEA) is available at http://www.ipeadata.gov.br/Default.aspx.
studies with methodological approaches that allow for a Public data from Instituto de Instituto Brasileiro de Geografia e Estatística
deeper exploration of issues related to the study object is (IBGE) is available at http://tabnet.datasus.gov.br/cgi/ibge/censo/cnv/ginibr.
emphasized. This object is mainly influenced by proce- def. All secondary data were organized in spreadsheets that comprised
the researcher’s own database, using the Microsoft Excel program. The
dural aspects close to the daily routine of health services, researcher’s own database used and analyzed during the current study is
the structure of the health care network, and professional available from the corresponding author upon reasonable request.
qualification. To achieve this, mixed methodological
strategies are required, allowing for data collection and Declarations
encompassing analyses that address the complexity of the
Ethics approval and consent to participate
topic at hand. The microdata used in this research were obtained from national information
systems of public and unrestricted access. Therefore, submission to the
Conclusion Research Ethics Committee was not necessary.

The conclusion states that the absence of certain actions Consent for publication
during the dental health work process negatively influ- Not applicable.
enced the interaction between the CEO and Primary
Competing interests
Health Care (PHC). Factors related to the CEOs’ work The authors declare no competing interests.
process, such as scarce discussion of cases and therapeu-
tic projects, low performance of PHC activities, low rates Received: 6 May 2024 / Accepted: 11 September 2024
of development and discussion of clinical protocols, and
lack of belief in the importance of periodic planning and
evaluation, may decrease the interaction between the two
levels of care.
Santos et al. BMC Health Services Research (2024) 24:1176 Page 10 of 10

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