¿Qué Nos Queda Por Recorrer Para Proveer Salud Oral De Calidad A Las Personas Adultas En Chile?

Existen factores de riesgo comunes entre las enfermedades de la cavidad oral y las enfermedades crónicas no transmisibles, y se conoce sobre su vinculación con la salud general y la calidad de vida. En Chile, la atención odontológica en el sistema público está destinada principalmente a la población infantojuvenil, y solo algunos de los programas odontológicos incluyen componentes con atención para adultos. La mayor parte de la población adulta atendida accede mediante los Programas de Reforzamiento de la Atención Primaria de Salud (PRAPS), cuya sostenibilidad en el tiempo no es posible de determinar, por lo que es relevante poner el foco en aquella población con mayor daño acumulado y que al día de hoy no tiene acceso garantizado a la atención odontológica.

There are common risk factors between diseases of the oral cavity and chronic non-communicable diseases, and it is known that they are related to general health and quality of life. In Chile, dental care in the public system is mainly aimed at the child and adolescent population, and only some of the dental programs include care for adults. Most of the adult population attended has access through the Primary Health Care Reinforcement Program (PHCRP), whose sustainability over time is not possible to determine. So, it is important to focus on the population with the greatest cumulative damage and without guaranteed access to dental care today.

Oral health policies and decision-making process in Brazil, Colombia and Chile

Abstract Public health policies are crucial for the well-being of the general population; however, the health systems of developed countries still do not include oral health in its system. Thus, it is necessary to understand the process of decision-making in oral health policies to create opportunities for countries to achieve an overall positive health outcome, including oral health. This study aimed to identify the factors influencing the inclusion of oral health on the political agenda in Brazil, Colombia, and Chile. The study sample involved decision-makers at political, technical, and academic levels. The extracted data were analyzed using the software Maxqda® and Kingdon´s theoretical model; defining interactive variables that produce a "window of opportunity" to define the agenda and the insertion of theme in formulating public policies. The decision-making process regarding oral health is influenced by many factors like the need to improve the overall oral health of the population, identified through national epidemiological studies, and the importance of individuals in positions involving political decision-making, who advocate for oral health. Strategies were developed in partnership with the academy that focused on the health rights of the population provided by law; territorial and national programs were also developed. The inclusion and creation of oral health policies depend on actors who advocate for thematic and scientific evidence to support decision-making. A close relationship between academia and stakeholders and knowledge translation is important for the development of public policies that can be effective for health systems.

Instrumentos para medir la capacidad funcional intrínseca y la fragilidad de personas mayores en la Atención Primaria en Chile / Instruments to assess functional capacity and the presence of frailty in older people

BACKGROUND: The evaluation of functional capacity and the presence of frailty is an essential prognostic indicator in older people. Aim: To explore the instruments used to characterize the intrinsic functional capacity (CFI) and frailty in elderly people cared at Primary Health Care Centers (PHC) in Chile. MATERIAL AND METHODS: A narrative review of national and international scientific literature was carried out, including observational studies published in Pubmed (since 2015) and Scielo (since 2010) about tools to assess CFI or frailty. Studies in English or Spanish carried out in Chilean beneficiaries of PHC aged 60 years and over, were included. Results: After the first search, 110 articles were selected in Pubmed and 86 in Scielo. According to the relevance of the title and abstract, 36 articles were preliminarily screened, of which 25 were selected for full reading, 12 of which were finally included in this review. In Chile, the main instrument used to assess CFI is the Functional Examination of the Elderly (EFAM). There are few national studies to assess frailty and the instruments used are mainly based on the Fried criteria and the FTI (Frailty Tilburg Indicator). The reviewed studies suggest improving the coverage and reconsidering the predictive capacity of the measurements used for the assessment of CFI and frailty in older people, suggesting the incorporation of handgrip strength as a predictor of frailty. CONCLUSIONS: The main instruments to assess CFI and frailty in older people cared in PHC in Chile are the EFAM, and the Fried and FTI criteria, respectively.

Manifestaciones orales y recuento de linfocitos T CD4+ en pacientes adultos con infección por VIH atendidos en el Hospital San Juan de Dios. Santiago, Chile

Resumen Introducción: Las lesiones orales clasificadas como fuertemente asociadas a infección por VIH se presentan en casos de inmunosupresión profunda (recuento de linfocitos T CD4+ ≤ a 200 céls/mm3 de sangre). Objetivo: Asociar la presencia de lesiones orales fuertemente asociadas a infección por VIH con el recuento sérico de linfocitos T (LT) CD4+ al momento del diagnóstico. Métodos: Se realizó un estudio transversal en PVVIH atendidas en el Hospital San Juan de Dios entre 2013 y 2019. Las lesiones orales se diagnosticaron por el criterio de EC-Clearinghouse - OHARA, y la inmunosupresión fue determinada según el recuento de LT CD4+. Resultados: De los 240 pacientes reclutados, 35 pacientes presentaron lesiones fuertemente asociadas a infección por VIH y 26 de ellos presentaron inmunosupresión profunda. La probabilidad de ocurrencia de una lesión fuertemente asociada a infección por VIH fue 12,3 veces mayor en pacientes con inmunosupresión profunda. Conclusión: Existe una asociación estadísticamente significativa entre un estado de inmunosupresión profunda y la presencia de manifestaciones orales fuertemente asociadas a infección por VIH/SIDA, lo cual posee relevancia clínica pues se presenta como una herramienta clínica de diagnóstico inicial, progresión de la enfermedad y monitorización de la terapia antiretroviral.

Abstract Background: Oral lesions classified as strongly associated with HIV infection occur in cases of severe immunosuppression (CD4+ T lymphocyte count ≤ 200 cells/mm3 of blood). Aim: To associate the presence of oral lesions strongly associated with HIV infection with CD4+ T lymphocytes count at the time of diagnosis. Methods: A cross-sectional study was carried out in PLHIV treated at the San Juan de Dios Hospital between 2013 and 2019. Oral lesions were diagnosed by the EC-Clearinghouse - OHARA criteria and immunosuppression was determined according to the CD4+ T lymphocyte count. Results: Of the 240 recruited patients, 35 had lesions strongly associated with HIV infection and 26 of them had severe immunosuppression. The probability of occurrence of a lesion strongly associated with HIV infection is 12.3 times higher in patients with severe immunosuppression. Conclusion: There is a statistically significant association between a severe immunosuppression and the presence of oral manifestations strongly associated with HIV/ AIDS infection, which has clinical relevance since it is presented as a clinical tool for initial diagnosis, disease progression and monitoring of antiretroviral therapy.

Dossier: Políticas Públicas de Salud Bucal en Iberoamérica / Dossier: Oral Health Public Policies in Iberian-America / Dossier: Políticas Públicas de Saúde Bucal na Ibero-América

Tenemos el gusto de presentar a nuestros lectores el primer número de 2019 que incluye el dossier temático Políticas Públicas de Salud Bucal en Iberoamérica. Este dossier es resultado de la segunda colaboración de Universitas Odontologica con otras organizaciones. En el número 71 de 2014 publicamos los resúmenes del 5º Congreso Iberoamericano de Periodoncia - 54° Seminario Anual de la Asociación Colombiana de Periodoncia y Oseointegración.

We are pleased to present to our readers the first issue of 2019 that includes the thematic dossier Public Policies of Oral Health in Ibero-America. This dossier is the result of the second collaboration of Universitas Odontologica with other organizations. In issue 71 of 2014, we published the abstracts of the 5th Ibero-American Congress of Periodontics - 54th Annual Seminar of the Colombian Association of Periodontics and Osseointegration.

Mediaciones efectuadas en el ámbito odontológico realizadas por el sistema público de salud. 2010-2015 / Mediations in dentistry made by the public health system. 2010-2015

RESUMEN: Introducción: La Reforma de Salud del 2005 estableció la mediación como un procedimiento obligatorio para la justicia civil, con el objeto de evitar la judicialización de la salud. Esta investigación ahonda en las características de las mediaciones odontológicas del sistema público de salud en Chile. Material y Método: Estudio transversal, de mediaciones generadas por atenciones odontológicas otorgadas en el sistema público de salud entre los años 2005 y 2015 informadas por Unidad de Mediación del Consejo de Defensa del Estado (CDE). Resultados: No se dispone de anterior al año 2010 por falta de registro. Por tanto, solo fue factible analizar desde 2010 al 2015. Se registran 127 mediaciones ingresadas odontológicas, el 61% reclamantes son mujeres. 60,6% proviene de la atención secundaria. 83,4% (106 casos) el reclamo es contra el establecimiento y el tratante. Sólo el 22% logra acuerdo. De estos, el 10% solo requiere explicaciones y solo el 28,5% solicita indemnización. Conclusiones: Una mejor relación profesional-paciente disminuye el riesgo de judicialización, así como una mejor difusión del procedimiento de mediación aumentaría tasa de acuerdos.

ABSTRACT: Introduction: The 2005 Health Reform established mediation as a mandatory procedure for civil justice, in order to avoid prosecution of health. This research delves into the characteristics of the dental mediations of the Chilean public health system. Material and method: Cross-sectional study of mediations generated by dental care granted in the public health system between 2005 and 2015, reported by the Mediation Unit of the State Defense Council (CDE). Results: Not available prior to 2010 due to the lack of registration. Therefore, an analysis was only feasible from 2010 to 2015. There are 127 dentistry mediations registered, 61% of the claimants are women. 60.6% come from secondary care. 83.4% (106 cases) the claim is against the establishment and the practitioner. Only 22% achieve agreement. Of these, 10% only require explanations and only 28.5% ask for compensation. Conclusions: A better professional-patient relationship reduces the risk of prosecution, and a better dissemination of the mediation procedure would increase agreement rate.

Mediación en odontología y Garantías Explícitas en Salud en Chile 2005-2014: las diferencias entre el mundo privado y el público / Mediation in dentistry and Explicit Healthcare Guarantees in Chile 2005-2014: differences between the private and the public areas

RESUMEN: Antecedentes: En Chile desde 2005 se implementó la Ley Auge que establece como derecho de los usuarios, beneficiarios tanto del sistema público o privado de salud, cuatro Garantías Explícitas de Salud denominadas GES, entre las que se incluye la garantía de calidad y dentro de ella se establece la mediación como un procedimiento prejudicial, obligatorio, tendiente a evitar la judicialización de los casos de responsabilidad sanitaria. Este procedimiento contempla dos instancias de mediación según el prestador sea público o privado. Objetivo: describir las mediaciones por atenciones odontológicas en ambos subsistemas. Métodos: estudio trasversal descriptivo sobre las mediaciones efectuadas desde la implementación de este procedimiento (año 2005) hasta el año 2014, por prestaciones odontológicas, otorgadas tanto por prestadores públicos como privados. Resultados: En el periodo de estudio, se efectuaron 519 mediaciones en el ámbito odontológico. La mayoría (60,4%) de las reclamantes en mediaciones públicas son mujeres. Las especialidades o prestaciones odontológicas más comprometidas, información no disponible para las mediaciones públicas, son por atenciones de endodoncia (25%), implantología (16%) y prótesis (15%). El 58% de las mediaciones privadas y sólo el 34% de las públicas finalizan con acuerdo total entre las partes, existiendo dificultades para comparar ambos subsistemas, por la amplia variación en la recolección de datos. Entre las mediaciones públicas, un alto porcentaje de los reclamantes (70%) solo solicita disculpas y/o atención de salud y no busca retribuciones económicas. Conclusión: las reclamantes en las mediaciones en odontología son mayoritariamente mujeres, las especialidades odontológicas más comprometidas son endodoncia, implantes y prótesis, y la mayoría solicita sólo disculpas/explicaciones de los hechos y prestaciones asistenciales. Los registros de las mediaciones públicas y privadas contienen información disímil y parcial, por lo que se no se puede concluir sobre sus diferencias.

ABSTRACT: Background: In Chile since 2005 the AUGE Act establishes the rights of beneficiaries of both the public and private health systems four Explicit Health Guarantees called GES, among them quality assurance. The later included mediation implemented and established as a preliminary procedure, mandatory, intended to avoid prosecution of cases of medical malpractice. This procedure involves two instances of mediation depending on public or private providers. Objective: To describe the mediations arising from dental care in Chile. Methods: A descriptive cross-sectional study on mediatons since the implementation of this procedure (2005) until 2014, by dental benefits granted by both public and private providers. Results: During the study period, 519 mediations were performed in the dental field. The majority (60.4%) of complaints in public context are women. Specialties or more committed dental services, data available only for private mediations, are endodontics (25%), implantology (16%) and prosthetics (15%). 58% of private and only 34% of public mediatons end up with full agreement between the parties, with difficulties to compare the two systems due to the wide variation in data collection. Among public averages, a high percentage of claimants (70%) only request explanations/apologize and/or health benefits and do not economic compensation. Conclusion: claimants are mostly women, the most compromised dental specialties are endodontics, implants and prostheses, and most patients request only apologies/explanations about the facts and provided dental healthcare. The public and private mediations are not entirely comparable since data sources are dissimilar and contain partial information, so it is not possible to conclude about their differences.

Comparative Study of the Oral Health Profile of Institutionalized Elderly Persons in Brazil and Barcelona, Spain / Estudo Comparativo do Perfil de Saúde Bucal em Idosos Institucionalizados no Brasil e em Barcelona, Espanha

Abstract Objective: To compare the oral health profile of institutionalized elderly persons in Brazil and in Barcelona, Spain, by gender and country of residence. Methods: A cross-sectional study was performed of individuals aged 65 years and above (n=1,440), resident in the health region of Barcelona and in Brazil. Two surveys and exams relating to the oral health status of institutionalized elderly persons in Brazil (in 2008) and in Barcelona, Spain (in 2009) were carried out. Periodontal disease, tooth loss and dental caries were analyzed, considering age and cognitive ability. The sample was stratified by gender and country. Bivariate and multivariate Robust Poisson Regression models were used to obtain adjusted Prevalence Ratios (aPR), and a 95% confidence interval (95%CI) was employed. Results: In Barcelona, men and women had a higher prevalence of periodontal illness: Men - calculus (aPR:1.5; CI:1.08-2.19) and pocket (aPR:2.05; CI:1.43-2.93) results. Women - calculus (aPR:2.4; CI:1.77-3.24) and pocket (aPR:3.2; CI:2.29-4.53) results. In Barcelona there was a lower prevalence of edentulism (aPR:0.49; CI:0.37-0.65) and functional edentulism (aPR:0.49; CI:0.40-0.60) among men. The same results were found among women with a lower prevalence of edentulism (aPR:0.49; CI: 0.41-0.58) and functional edentulism (aPR:0.42; CI: 0.30-0.49). Conclusions: A poor state of oral health of men and women was observed in both countries, with the elderly from Barcelona having worse periodontal health and the elderly from Brazil having greater tooth loss. AU

Resumo Objetivo: Comparar o perfil de saúde bucal de idosos institucionalizados no Brasil e em Barcelona, Espanha, segundo gênero e país de residência. Métodos: Foi realizado estudo do tipo cross-seccional, em indivíduos de 65 anos e mais (n=1.440), residentes na Região Sanitária de Barcelona, Espanha e no Brasil. Foram realizados dois levantamentos epidemiológicos para averiguar as condições de saúde bucal em idosos do Brasil (em 2008) e de Barcelona-ES (em 2009). Foram estudadas as seguintes condições com seus respectivos indicadores: doença periodontal (CPI), perda dentária (edentulismo e edentulismo funcional) e cárie dentária (CPO-D). A amostra foi estratificada pelo gênero e país dos idosos. Foram realizadas Regressão de Poisson Bivariada e Multivariada para a obtenção das Razões de Prevalência Ajustadas (RPa) com seus respectivos Intervalos de Confiança com 95% de significância (IC95%). Resultados: Em Barcelona-ES, homens e mulheres tiveram uma alta prevalência de doença periodontal em relação aos idosos brasileiros: homens: cálculo (RPa:1,5; IC:1,08-2,19) e bolsa periodontal (RPa:2,05; IC:1,43-2,93). Mulheres: cálculo (RPa:2,4; IC:1,77-3,24) e bolsa periodontal (RPa:3,2; IC: 2,29-4,53). Em Barcelona-ES foi encontrada uma baixa prevalência de edentulismo (RPa:0,49; IC:0,37-0,65) e edentulismo funcional (RPa:0,49; IC: 0,40-0,60) entre os homens. Resultados semelhantes foram observados entre as mulheres, com uma baixa prevalência de edentulismo (RPa:0,49; CI:0,41-0,58) e edentulismo funcional (RPa:0,42; CI:0,30-0,49). Conclusões: Foi observada uma precária condição de saúde bucal entre homens e mulheres idosos em ambos os países, sendo que os idosos de Barcelona-ES tiveram uma pior condição periodontal e os idosos brasileiros tiveram uma maior perda dentária. AU

Pay-for-performance and efficiency in primary oral health care practices in Chile / Pago por desempeño y eficacia de las prácticas de atención sanitaria primaria oral en Chile

Background Payment mechanisms for health care providers have been used as a strategy to improve management, health indicators, cost containment, equity and efficiency. Among the mechanisms implemented in the past decade is pay-for-performance (P4P). In Chile, it was incorporated since 2003 in primary care in addition to the salary by seniority and training. Objectives To assess the impact of P4P on the efficiency of primary oral health care providers in Chile. Methods We performed a retrospective cohort study to compare the performance of oral healthcare practices belonging to primary health providers measured by the rate of dental discharge in 6 year-old children between years in which P4P was used and years in which P4P was not used, in the 52 municipalities of the Metropolitan Region of Chile. We also explored whether rurality, and the human development index (HDI) had an association with the efficiency of health care teams. We calculated the rate of discharge per 1000 patients, and its adjusted and unadjusted association with the predictors of interest, using a Random-effects Poisson regression. Results We found statistically significant differences in the rate of dental discharges when comparing P4P versus no P4P (822.59/1000 and 662.59/1000, respectively, p < 0.0001) and high versus low HDI (692.23/1000 and 832.85/1000, respectively, p = 0.01). Rurality was not statistically associated with P4P (727.24/1000 in rural and 770.19/1000 in urban municipalities, p = 0.553). Unadjusted and adjusted rate ratios were very similar. Conclusions P4P financial incentives can improve the performance of primary care dental practices, and seem to be useful interventions to improve the performance of oral health care providers.

Antecedentes Se han venido utilizando mecanismos de pago a los profesionales de la atención sanitaria para mejorar la gestión, los indicadores sanitarios, la contención de costes, la equidad y la eficacia. Entre los mecanismos introducidos en el último decenio se encuentra el pago por desempeño- pay for performance (P4P). En Chile, se lleva incorporando a la atención primaria desde 2003, además del salario por antigüedad y la formación. Objetivos Evaluar el impacto del P4P sobre la eficacia de los profesionales de la atención sanitaria oral primaria en Chile. Métodos Realizamos el estudio comparativo de un grupo, para comparar el desempeño de las prácticas de los cuidados sanitarios orales de los profesionales de la salud primaria, medido mediante el índice de las altas dentales en niños de seis años, entre los años en que se utilizó el P4P y los años en que no, en cincuenta y dos municipios de la región metropolitana de Chile. También exploramos si la ruralidad y el índice de desarrollo humano (IDH) estaban asociados a la eficacia de los equipos de atención sanitaria. Calculamos el índice de altas por 1000 pacientes, y su asociación ajustada y no ajustada a los predictores del interés, utilizando el modelo de regresión de los efectos aleatorios de Poisson. Resultados Encontramos diferencias estadísticamente significativas en el índice de altas dentales al comparar P4P frente a no P4P (822,59/1000 y 662,59/1000, respectivamente, p < 0,0001), y el elevado frente al bajo IDH (692,23/1000 y 832,85/1000, respectivamente, p = 0,01). La ruralidad no estuvo estadísticamente asociada al P4P (727,24/1000 en municipios rurales y 770,19/1000 en municipios urbanos, p = 0,553). Los ratios no ajustados y ajustados fueron muy similares. Conclusiones Las incentivas financieras P4P pueden mejorar el desempeño de las prácticas de atención primaria dental, y parecen resultar unas intervenciones útiles para mejorar el desempeño de los profesionales de la atención sanitaria oral.

Comunidad informada: estrategia para mejorar uso del GES Salud Oral en población de 6 años / Community oral health literacy: improving use of oral-health care guarantee in children aged 6

La evaluación del GES salud oral integral para niños/as de 6 años (GES-6años) mostró una baja utilización de esta garantía, con un menor uso en los beneficiarios de escuelas municipales. El empoderamiento y la alfabetización en salud de los padres permiten mejorar su rol como agentes promotores de la salud de sus hijos. Objetivo: implementar y evaluar una estrategia de empoderamiento y alfabetización en salud bucal de la comunidad sobre sus derechos garantizados en salud para aumentar el uso de la garantía GES-6años. Métodos: diseño mixto. Mediante metodología cualitativa se diseñará un instrumento comunicacional, adecuado cultural y socialmente, para ser enviado a la comunidad beneficiaria de esta garantía. Mediante un ensayo comunitario no aleatorio este instrumento, orientado a empoderar y alfabetizar sobre la salud bucal y el GES-6años, será enviado como carta personalizada (intervención) firmada por el alcalde/sa con un mensaje dirigido a los niños/as beneficiarios del GES-6años y otro dirigido a sus padres/apoderados. Se seleccionarían escuelas por conglomerados (comunas) de las dos regiones del país seleccionadas por conveniencia según residencia de los investigadores participantes del estudio. De las comunas cuyas autoridades acepten participar, se seleccionarían aleatoriamente las comunas a intervenir y las comunas controles. El análisis de los datos evaluará si existen diferencias estadísticamente significativas en la prevalencia de uso de estas garantías entre los niños/as de los establecimientos de educación municipal de las comunas intervenidas respecto a los de las comunas controles.

The assessment of comprehensive oral health care for children aged 6 (GES-6years) showed low utilization of this guarantee, with lower use for children from municipal public schools. The empowerment and health literacy of parents improve their role as oral-health promoters for their children. Objective: To implement and to assess a strategy of empowerment and health literacy of the community about their guaranteed health rights to increase the use of GES-6years. Methods: A mixed design. Using qualitative methodology we will design a communication tool, culturally and socially appropriate to be sent to the beneficiary community of this guarantee. Using a nonrandomized community trial, this instrument designed to empower and improve oral health literacy on GES-6 guarantee, will be sent as personalized letter (intervention) signed by the mayor of the municipality with a message aimed to children beneficiaries for GES -6years and another addressed to their parents/guardians. Schools would be selected from clusters (communes) of the two regions selected for convenience. Communes will be randomly selected among those whose authorities agree to participate, and will be selected as for intervention or control. Data analysis will assess the differences in the prevalence of use of this guarantee among children from municipal schools belonging to the intervention or control arm.