ABSTRACT:

Objective:

To analyze the different profiles of dental service use by the Brazilian elderly and their possible association with sociodemographic factors, comorbidities, functionality and self-perception of oral health.

Methods:

Cross-sectional population-based study, using secondary data from the National Health Survey (PNS) of 2013. The sample size was 2,969 elderly individuals. Latent Class Analysis was used to construct the dependent variable “profile of dental service use” from questions related to this profile. The independent variables formed 3 blocks: sociodemographic; comorbidities; functionalities and self-perception of oral health. The Rao-Scott Test and Standardized Residue Analysis tested the association. To measure the effect of covariates, Odds Ratio was estimated using a multiple hierarchical model of multinomial logistic regression. Significance level was 5%.

Results:

Three latent classes were identified: Direct Disbursement Profile, Health Plan Profile and the Unified Health System (SUS) Profile. White elderly people were associated with the Direct Disbursement and Health Plans profile. The Health Plan profile was more associated with the married marital status or living with a spouse. In the multiple model, low schooling was associated with the profile of SUS users and elderly people diagnosed with cancer with the Health Plan profile. Self-perceiving oral health as bad or very bad increased the chances of belonging to the SUS profile.

Conclusion:

Latent Class Analysis proved to be a powerful strategy for a subtle and detailed understanding of the profile of dental service use and its relationship with associated factors.

Keywords:
Comprehensive health care; Dental health services; Dental care for aged; Aged; Latent class analysis

INTRODUCTION

The increasing elderly population resulting from the higher life expectancy and the reduction in natality rates have represented major changes in the age structure of countries all over the world¹1. Zanesco C, Bordin D, Santos CB, Müller EV, Fadel CB. Fatores que determinam a percepção negativa da saúde de idosos brasileiros. Rev Bras Geriatr Gerontol 2018; 21(3): 293-303. https://doi.org/10.1590/1981-22562018021.170210
https://doi.org/https://doi.org/10.1590/... ^,22. Miranda GMD, Mendes ACG, Silva ALA. O envelhecimento populacional brasileiro: desafios e consequências sociais atuais e futuras. Rev Bras Geriatr Gerontol 2016; 19(3): 507-19. https://doi.org/10.1590/1809-98232016019.150140
https://doi.org/https://doi.org/10.1590/... . The high number of people aged 60 years or more represents a new profile of needs³3. Meira IA, Martins ML, Maciel PP, Cavalcanti YW, Araújo TP, Piagge CSL. Multidisciplinaridade no cuidado e atenção à saúde bucal do idoso. Rev Ciênc Méd 2018; 27(1): 39-45. https://doi.org/10.24220/2318-0897v27n1a3949
https://doi.org/https://doi.org/10.24220... , leading to a growing demand for health care, including dental services and proper oral health care⁴4. Martins AMEBL, Oliveira RFR, Haikal DSA, Santos ASF, Souza JGS, Alecrim BPA, et al. Uso de serviços odontológicos públicos entre idosos brasileiros: uma análise multinível. Ciênc Saúde Coletiva 2020; 25(6): 2113-26. https://doi.org/10.1590/1413-81232020256.19272018
https://doi.org/https://doi.org/10.1590/... . This reality requires a continuous and multidisciplinary care organization that ensures the well-being of this population²2. Miranda GMD, Mendes ACG, Silva ALA. O envelhecimento populacional brasileiro: desafios e consequências sociais atuais e futuras. Rev Bras Geriatr Gerontol 2016; 19(3): 507-19. https://doi.org/10.1590/1809-98232016019.150140
https://doi.org/https://doi.org/10.1590/... .

The problems related to the oral health of the elderly population - such as dental loss, non-functional removable dental prosthesis, lesions in the oral mucosa, periodontitis and radicular cavities - can interfere in the selection of foods by the affected people, in the ability to speak and chew and in social relations⁵5. Castrejón-Pérez RC, Yáñez SAB, Robledo LMG, Funes JAA. Oral health conditions and frailty in Mexican community-dwelling elderly: a cross sectional analysis. BMC Public Health 2012; 12: 773. https://doi.org/10.1186/1471-2458-12-773
https://doi.org/https://doi.org/10.1186/... . In the Brazilian context, it is important to highlight the prevalence of edentulism⁶6. Nascimento JE, Magalhães TA, Souza JGS, Sales MSM, Nascimento CO, Lopes Júnior CWX, et al. Associação entre o uso de prótese dentária total e o tipo de serviço odontológico utilizado entre idosos edêntulos totais. Ciênc Saúde Coletiva 2019; 24(9): 3345-56. https://doi.org/10.1590/1413-81232018249.23002017
https://doi.org/https://doi.org/10.1590/... , which remains as a public health issue despite the evidence that the control or prevention of oral diseases enables the maintenance of the dental arch⁷7. Maia LC, Costa SM, Martelli DRB, Caldeira AP. Edentulismo total em idosos: envelhecimento ou desigualdade social? Rev Bioét 2020; 28(1): 173-81. https://doi.org/10.1590/1983-80422020281380
https://doi.org/https://doi.org/10.1590/... . Among other factors, the regular use of dental services contributed with the maintenance of oral health with fewer complex and preventive treatments, early detection of diseases and improved quality of life among the eldery⁸8. Fonseca EP, Fonseca SGO, Meneghim MC. Fatores associados ao uso dos serviços odontológicos por idosos residentes no estado de São Paulo, Brasil. Rev Bras Geriatr Gerontol 2017; 20(6): 785-96. https://doi.org/10.1590/1981-22562017020.170095
https://doi.org/https://doi.org/10.1590/... .

The characterization of the profile of health service use indicates if citizens who search for care actually obtain access to these services. Therefore, it allows to identify the existing differences both regarding the organization of the services and the social, economic and demographic aspects of the users. It also establishes parameters of reference and goals related to regularly going to the dentist, in order to improve the initiatives and investment of public policies in oral health, considering that the equitable use of health care services is still a challenge⁹9. Marchini L, Ettinger RL. COVID-19 and Geriatric Dentistry: What will be the new-normal? Braz Dent Sci 2020; 23(2 Supl. 2): 1-7. https://doi.org/10.14295/bds.2020.v23i2.2226
https://doi.org/https://doi.org/10.14295... ^,1010. Austregésilo SC, Leal MCC, Marques APO, Vieira JCM, Alencar DL. Acessibilidade a serviços de saúde bucal por pessoas idosas: uma revisão integrativa. Rev Bras Geriatr Gerontol 2015; 18(1): 189-99. https://doi.org/10.1590/1809-9823.2015.13179
https://doi.org/https://doi.org/10.1590/... ^,1111. Sória GS, Nunes BP, Bavaresco CS, Vieira LS, Facchini LA. Acesso e utilização dos serviços de saúde bucal por idosos de Pelotas, Rio Grande do Sul, Brasil. Cad Saúde Pública 2019; 35(4): e00191718. https://doi.org/10.1590/0102-311x00191718
https://doi.org/https://doi.org/10.1590/... ^,1212. Mariño R, Giacaman AG. Patterns of use of oral health care services and barriers to dental care among ambulatory older Chilean. BMC Oral Health 2017; 17: 38. https://doi.org/10.1186/s12903-016-0329-2
https://doi.org/https://doi.org/10.1186/... .

Even though public dental services have been reorganized and improved with the implementation of the National Oral Health policy after 2004¹³13. Schroeder FMM, Mendoza-Sassi RA, Meucci RD. Condição de saúde bucal e utilização de serviços odontológicos entre idosos em área rural no sul do Brasil. Ciênc Saúde Coletiva 2020; 25(6): 2093-102. https://doi.org/10.1590/1413-81232020256.25422018
https://doi.org/https://doi.org/10.1590/... , it is still necessary to redesign the care addressed to the elderly to minimize the impacts of social and oral vulnerabilities that come with age⁸8. Fonseca EP, Fonseca SGO, Meneghim MC. Fatores associados ao uso dos serviços odontológicos por idosos residentes no estado de São Paulo, Brasil. Rev Bras Geriatr Gerontol 2017; 20(6): 785-96. https://doi.org/10.1590/1981-22562017020.170095
https://doi.org/https://doi.org/10.1590/... , in order to prevent the overload of the Brazilian health system¹⁴14. Veras RP, Oliveira M. Envelhecer no Brasil: a construção de um modelo de cuidado. Ciênc Saúde Coletiva 2018; 23(6): 1929-36. https://doi.org/10.1590/1413-81232018236.04722018
https://doi.org/https://doi.org/10.1590/... .

It is known that the higher the schooling of the elderly individual, the higher the use of dental services¹¹11. Sória GS, Nunes BP, Bavaresco CS, Vieira LS, Facchini LA. Acesso e utilização dos serviços de saúde bucal por idosos de Pelotas, Rio Grande do Sul, Brasil. Cad Saúde Pública 2019; 35(4): e00191718. https://doi.org/10.1590/0102-311x00191718
https://doi.org/https://doi.org/10.1590/... . And that factors such as lower schooling or never having attended school, non-white skin color, lower income and going to the dentist with pain or to extract teeth are related to the use of public dental services by the elderly⁸8. Fonseca EP, Fonseca SGO, Meneghim MC. Fatores associados ao uso dos serviços odontológicos por idosos residentes no estado de São Paulo, Brasil. Rev Bras Geriatr Gerontol 2017; 20(6): 785-96. https://doi.org/10.1590/1981-22562017020.170095
https://doi.org/https://doi.org/10.1590/... . However, there are only a few studies about the use of dental services by the elderly in the Unified Health System (SUS), in comparison to private services⁴4. Martins AMEBL, Oliveira RFR, Haikal DSA, Santos ASF, Souza JGS, Alecrim BPA, et al. Uso de serviços odontológicos públicos entre idosos brasileiros: uma análise multinível. Ciênc Saúde Coletiva 2020; 25(6): 2113-26. https://doi.org/10.1590/1413-81232020256.19272018
https://doi.org/https://doi.org/10.1590/... .

Considering the several realities and health needs of the elderly about the factors associated with the use of dental services by this age group, the objective was to analyze the different profile of use of these services by the Brazilian elderly and its possible association with sociodemographic factors, comorbidities, functionality and self-perception in oral health.

METHODS

In this study, we analyzed the data from the National Health Survey (PNS), 2013¹⁵15. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde: 2013: acesso e utilização dos serviços de saúde, acidentes e violências: Brasil, grandes regiões e unidades da federação. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2015.. PNS was a cross-sectional, population-based survey, with a household approach, carried out with the Brazilian Institute of Geography and Statistics (IBGE) and by the Ministry of Health (MS). Based on a complex sample, we investigated the aspects related to several health fields and socioeconomic and demographic aspects in different age groups. Methodological details of the sample are in Freitas (201416. Freitas MPS. Pesquisa Nacional de Saúde: plano amostral. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística ; 2014.) ¹⁶16. Freitas MPS. Pesquisa Nacional de Saúde: plano amostral. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística ; 2014..

PNS investigated 205,546 individuals, being 23,815 elderly (people aged 60 years or older). The weighted percentage of elderly individuals in the sample corresponded to 13.2% of the Brazilian population, including participants whose answers were obtained from a resident of the household where the elderly individual lives, aged more than 18 years. The sample of elderly individuals used in this study corresponds only to residents aged 60 years or more who answered the questions of the oral health module, accounting for 2,969 people.

The dependent variable was the profile of oral health services’ use by the interviewed elderly individuals. Considering the questionnaire block constituted of seven questions related to the use of oral health services - if the location where dental care was offered was the city of residence; appointment covered by health insurance plan; payment of the appointment; appointment at SUS; main reason of the last visit to the dental surgeon; place of the last appointment; how the appointment was scheduled -, the methodological option was to understand this profile through the Latent Class Analysis (LCA). This is a statistical method that identifies different groups (latent classes) based on the answer patterns observed in categorical variables. It is based on a probability model to identify characteristics that indicate the groups, to estimate the prevalence of each group and to classify each individual in the groups¹⁷17. Hagenaars JA, McCutcheon AL. Applied Latent Class Analysis. Cambridge: Cambridge University Press; 2002.. This type of analysis classifies different individuals as similar, and attributes the same weight for the different questions of the instrument.

The latent variable “profile of oral health services’ use” was created using the Growth Mixture Model (GMM), in the Mplus 6.12^© software, creating and testing models from two to six classes. The six criteria that guided the selection of the best model of analysis were: The AIC test (Akaike Information Criterion); the BIC test (Bayesian Information Criterion); the adjusted BIC test (with the lowest values showing better adjustment to the model); entropy, when the value closest to 1 characterizes a model with a more adequate number of classes; and two likelihood ratio tests (Vuong, Lo, Mendell, Rubin likelihood ratio test - VLMR-LRT and Likelihood ratio test - LMR-LRT), which assess the statistical significance to indicate that the number of classes in the model would not need to be reduced to one less class¹⁸18. Jung T, Wickrama KAS. An introduction to latent class growth mixture analysis and growth mixture modeling. Soc Personal Psychol Compass 2008; 2(1): 302-17. https://doi.org/10.1111/j.1751-9004.2007.00054.x
https://doi.org/https://doi.org/10.1111/... ^,1919. Nylund KL, Asparouhov T, Muthén BO. Deciding on the number of classes in latent class analysis and growth mixture modeling: a Monte Carlo simulation study. Struct Equ Model 2007; 14(4): 535-69. https://doi.org/10.1080/10705510701575396
https://doi.org/https://doi.org/10.1080/... .

The independent variables are in three hierarchized analysis blocks: sociodemographic, comorbidities and oral health functionality and self-perception. Figure 1 shows the hierarchized theoretical model. The sociodemographic block approaches the aspects regarding sex, age, skin color, marital status, living with a spouse or partner, number of people in the household and schooling. The block of comorbidities investigates the presence of diagnosis of systemic arterial hypertension, diabetes, high cholesterol, stroke, depression, pulmonary diseases, cancer or chronic kidney failure. For the functionality block, the answers to the 11 questions were also analyzed by the LCA to generate a single variable that represented this phenomenon as an optimal or moderate functionality, thus verifying the autonomy of the elderly individual to eat, shower, go to the bathroom, dress, walk, lie down, sit down, go shopping, administer finances, take medicines, go to the doctor and go out alone using transportation such as bus, subway, taxi, car etc. For self-perception in oral health, three categories of evaluation were considered for the elderly population: very good/good, regular, or bad/very bad.

The association between the independent variables and the dependent variable (categorized through the LCA) was analyzed using the Rao-Scott test²⁰20. Rao JNK, Scott AJ. On chi-squared tests for multiway contigency tables with cell proportions estimated from survey data. Ann Statist 1984; 12(1): 46-60. https://doi.org/10.1214/aos/1176346391
https://doi.org/https://doi.org/10.1214/... . Significance level was 5%.

The Standardized Residual Analysis was used for the association between the pairs of categories of the dependent variable and the independent variables, enabling the comparison of the patterns in each category. Significance was recognized when excess deviation was higher than 1.96, with significance level of 2.5% (one-tailed test).

The measures of effect of the analyzed factors about the dependent variable were calculated by multiple models of multinomial logistic regression, according to the hierarchized theoretical model presented in Figure 1, based on the hierarchized approach by Victora et al.²¹21. Victora CG, Huttly SR, Fuchs SC, Olinto MTA. The role of conceptual frameworks in epidemiological analysis: a hierarchical approach. Int J Epidemiol 1997; 6(1): 224-7. https://doi.org/10.1093/ije/26.1.224
https://doi.org/https://doi.org/10.1093/... . At first, there was a bivariate analysis in the blocks of independent variables. In each block, the variables with p < 0.25²²22. Hosmer DW, Lemeshow S. Model-Building strategies and methods for logistic regression. In: Hosmer DW, Lemeshow S, editores. Applied logistic regression. 2ª ed. Hoboken: John Wiley & Sons; 2000. p. 91-142. were tested in multiple models. At the end, the variables showing p < 0.05 remained in the final model of each block and were considered as adjustment factors for the subsequent blocks.

The data were analyzed using the software IBM SPSS Statistics, version 20, considering the weight and sampling strata from the PNS database. PNS was approved by the National Research Ethics Commission, of the National Health Council (n. 10853812.7.0000.0008/2013), and the microdata are available at IBGE’s website.

RESULTS

The study sample was composed of 2,969 elderly individuals, mostly female (53.8%), aged 60 to 66 years (50.3%), white (65.8%), married (60.2%), living with a spouse or partner (62.9%), with 1 or 2 people living in the household (53.6%), and with complete elementary school (46.0%). About the presence of comorbidities, most were diagnosed with arterial hypertension (51.9%), but with no history of diseases such as: diabetes (81.6%), high cholesterol (72.6%), stroke (96.5%), arthritis/rheumatism (82.3%), depression (87.8%), pulmonary disease (96.8%), cancer (93.4%) or chronic kidney failure (97.0%). Functionality is optimal for most individuals (89.8%), and self-perception of oral health, very good or good (68.8%). The table with the descriptive analysis of the data is in the Supplementary Material of this article.

The LCA showed that the model with three classes was the most adequate one. Table 1 presents the distribution of the relative frequency of responses to the seven questions about the use of oral health services according to the three classes in the model. With the pattern of answers, it was possible to identify the following profiles: direct disbursement, health insurance profile and SUS profile.

The first profile was the most frequent one [59.6% (95% confidence interval -95%CI 56.5 - 62.6)], with prevalence of paid dental appointments, in private offices, with previous scheduling; the main reason for the appointment was to do a teeth cleaning, follow-up or prevention. The health insurance profile represented 18.7% (95%CI 16.4 - 21.3) of the sample and was characterized by approximately half of the users having their appointments covered by the plans; 76.6% did not pay for the appointment and the main reason of the visit was cleaning, follow-up or prevention. Most appointments in this profile also took place in a private office after previous scheduling. The SUS profile corresponded to approximately one fifth of the sample [21.7% (95%CI 19.1 - 24.4)]. Almost all of them were assisted in the same city where they lived in and did not pay for the appointment - made by SUS in 98.6% of the cases, and in Basic Health Units (UBS) in 78.2% of the cases. Even though 53.7% had scheduled the appointment, about one third (32.7%) went straight to the health service without previous scheduling. Approximately one fifth (19.0%) of the elderly individuals in this profile used the services for tooth extraction.

In all profiles, most interviewees attended the appointment in the same city where they lived in, for reasons of cleaning, follow-up or prevention, with previous scheduling. However, LCA allowed to visualize major differences that defined the profile of each latent class, besides other more subtle distinctions, which provided information that allowed a better characterization of the generated latent classes.

In the bivariate analysis with the profiles, we observed associated factors, and it was possible to identify statistically significant excesses of white elderly individuals associated with the direct disbursement and health insurance profiles, whereas the black or brown skin color was associated with the SUS profile. The health insurance profile was more associated with married individuals or those who live with a spouse; single people were more related to the SUS profile. Individuals who live in a household with up to two people were more related to the direct disbursement profile. Regarding schooling, it was observed that those who never attended school or studied only until elementary school were associated with the SUS profile.

In the comorbidity block, elderly individuals with arterial hypertension and diabetes were associated with the SUS profile. Differently from that profile, elderly individuals who presented some pulmonary disease were associated with the direct disbursement profile, and those diagnosed with cancer were mostly associated with the health insurance profile.

In the functionality and oral health self-perception block, elderly individuals who had regular, bad or very bad self-perception were associated with the SUS profile. In the functionality variable, it was observed that elderly individuals presented good independence in the two latent classes generated by the LCA. In the “moderate functionality” classification, there was a higher proportion of elderly individuals who presented difficulties to go out, go to the doctor, administer finances and go shopping alone, besides the association with the SUS profile.

Table 2 presents the results of the hierarchized multiple model of multinomial logistic regression. The reference category of the dependent variable was the direct disbursement profile. Therefore, all of the odds ratio measures compare with this profile. In the sociodemographic block, the variables that remained in the model were marital status, number of people in the household and schooling. Being single and living with more than two people respectively presented chances 75 and 45% higher of classification in the SUS profile. Elderly individuals who never attended school or were only literate respectively presented chances 31 and 48 times higher of belonging to the SUS profile.

Elderly individuals diagnosed with cancer had approximately twice as many chances of being in the health insurance profile, whereas presenting a pulmonary disease remained as a factor inversely associated with the profile. In the last block, controlled by the effect of the previous blocks, considering one’s own oral health as bad or very bad doubled the chances of belonging to the SUS profile.

DISCUSSION

The Brazilian health system is constituted of a public-private mixture that includes three subsystems: public (represented by SUS and its universal character), private (with direct disbursement to pay for the provided service), and supplementary health (provided by health insurance plans)²²22. Hosmer DW, Lemeshow S. Model-Building strategies and methods for logistic regression. In: Hosmer DW, Lemeshow S, editores. Applied logistic regression. 2ª ed. Hoboken: John Wiley & Sons; 2000. p. 91-142.^,2323. Paim J, Travassos C, Almeida C, Bahia L, Macinko J. The Brazilian health system: history, advances, and challenges. Lancet 2011; 377(9779): 1778-97. https://doi.org/10.1016/S0140-6736(11)60054-8
https://doi.org/https://doi.org/10.1016/... . Such subsystems are different, but interconnected. It is possible to use services from all of them simultaneously, depending on access and the purchasing power of the individual²²22. Hosmer DW, Lemeshow S. Model-Building strategies and methods for logistic regression. In: Hosmer DW, Lemeshow S, editores. Applied logistic regression. 2ª ed. Hoboken: John Wiley & Sons; 2000. p. 91-142..

It is known that the prevalence of elderly individuals paying for an appointment with the dentist or using a health insurance plan to use the dental service corroborates the findings in the literature⁴4. Martins AMEBL, Oliveira RFR, Haikal DSA, Santos ASF, Souza JGS, Alecrim BPA, et al. Uso de serviços odontológicos públicos entre idosos brasileiros: uma análise multinível. Ciênc Saúde Coletiva 2020; 25(6): 2113-26. https://doi.org/10.1590/1413-81232020256.19272018
https://doi.org/https://doi.org/10.1590/... ^,88. Fonseca EP, Fonseca SGO, Meneghim MC. Fatores associados ao uso dos serviços odontológicos por idosos residentes no estado de São Paulo, Brasil. Rev Bras Geriatr Gerontol 2017; 20(6): 785-96. https://doi.org/10.1590/1981-22562017020.170095
https://doi.org/https://doi.org/10.1590/... ^,1111. Sória GS, Nunes BP, Bavaresco CS, Vieira LS, Facchini LA. Acesso e utilização dos serviços de saúde bucal por idosos de Pelotas, Rio Grande do Sul, Brasil. Cad Saúde Pública 2019; 35(4): e00191718. https://doi.org/10.1590/0102-311x00191718
https://doi.org/https://doi.org/10.1590/... ^,1313. Schroeder FMM, Mendoza-Sassi RA, Meucci RD. Condição de saúde bucal e utilização de serviços odontológicos entre idosos em área rural no sul do Brasil. Ciênc Saúde Coletiva 2020; 25(6): 2093-102. https://doi.org/10.1590/1413-81232020256.25422018
https://doi.org/https://doi.org/10.1590/... ^,2424. Oliveira RFR, Souza JGS, Haikal DS, Ferreira EF, Martins AMEBL. Equidade no uso de serviços odontológicos provenientes do SUS entre idosos: estudo de base populacional. Ciênc Saúde Coletiva 2016; 21(11): 3509-23. https://doi.org/10.1590/1413-812320152111.22532015
https://doi.org/https://doi.org/10.1590/... ^,2525. Bastos TF, Medina LPB, Sousa NFS, Lima MG, Malta DC, Barros MBA. Income inequalities in oral health and access to dental services in the Brazilian population: National Health Survey, 2013. Rev Bras Epidemiol 2019; 22(Supl. 2): E190015.SUPL.2. https://doi.org/10.1590/1980-549720190015.supl.2
https://doi.org/https://doi.org/10.1590/... ^,2626. Silva AE, Langlois CO, Feldens CA. Use of dental services and associated factors among elderly in southern Brazil. Rev Bras Epidemiol 2013; 16(4): 1005-16. https://doi.org/10.1590/S1415-790X2013000400020
https://doi.org/https://doi.org/10.1590/... - funding pattern similar to that of doctors’ appointments²⁷27. Destro JR, Boing AF, d’Orsi E. Fatores associados à realização de consultas médicas por idosos no Sul do Brasil estudo de base populacional. Rev Bras Epidemiol 2014; 17(3): 692-704. https://doi.org/10.1590/1809-4503201400030010
https://doi.org/https://doi.org/10.1590/... ^,2828. Bastos GAN, Santos IS, Costa JSD, Capilheira MF. Uso de serviços ambulatoriais nos últimos 15 anos comparação de dois estudos de base populacional. Rev Bras Epidemiol 2011; 14(4): 620-32. https://doi.org/10.1590/S1415-790X2011000400009
https://doi.org/https://doi.org/10.1590/... . The compared data analysis of the National Household Sample Survey (PNAD), conducted in 1993, 2003 and 2008, and PNS 2013, also shows increasing use of medical and dental appointments throughout these years²⁹29. Pilotto LM, Celeste RK. Tendências no uso de serviços de saúde médicos e odontológicos e a relação com nível educacional e posse de plano privado de saúde no Brasil, 1998-2013. Cad Saúde Pública 2018; 34(4): e00052017. https://doi.org/10.1590/0102-311x00052017
https://doi.org/https://doi.org/10.1590/... .

On the other hand, the higher prevalence of use of dental appointments motivated by cleaning, follow-up, maintenance or prevention diverges from results in other studies, which point to the low use of this service for routine/maintenance procedures¹¹11. Sória GS, Nunes BP, Bavaresco CS, Vieira LS, Facchini LA. Acesso e utilização dos serviços de saúde bucal por idosos de Pelotas, Rio Grande do Sul, Brasil. Cad Saúde Pública 2019; 35(4): e00191718. https://doi.org/10.1590/0102-311x00191718
https://doi.org/https://doi.org/10.1590/... ^,1212. Mariño R, Giacaman AG. Patterns of use of oral health care services and barriers to dental care among ambulatory older Chilean. BMC Oral Health 2017; 17: 38. https://doi.org/10.1186/s12903-016-0329-2
https://doi.org/https://doi.org/10.1186/... ^,2424. Oliveira RFR, Souza JGS, Haikal DS, Ferreira EF, Martins AMEBL. Equidade no uso de serviços odontológicos provenientes do SUS entre idosos: estudo de base populacional. Ciênc Saúde Coletiva 2016; 21(11): 3509-23. https://doi.org/10.1590/1413-812320152111.22532015
https://doi.org/https://doi.org/10.1590/... ^,3030. Silva AER, Echeverria MS, Custódio NB, Cascaes AM, Camargo MBJ, Langlois CO. Uso regular de serviços odontológicos e perda dentária entre idosos. Ciênc Saúde Coletiva 2018; 23(12): 4269-76. https://doi.org/10.1590/1413-812320182312.30562016
https://doi.org/https://doi.org/10.1590/... . This can be considered as a positive result; however, it does not show the successful control of oral diseases in this age group, because other reasons that are often mentioned by elderly individuals to use dental services are dental prosthesis, tooth extraction, restoration procedures¹²12. Mariño R, Giacaman AG. Patterns of use of oral health care services and barriers to dental care among ambulatory older Chilean. BMC Oral Health 2017; 17: 38. https://doi.org/10.1186/s12903-016-0329-2
https://doi.org/https://doi.org/10.1186/... , cavity, bleeding, relationships affected by oral problems²⁴24. Oliveira RFR, Souza JGS, Haikal DS, Ferreira EF, Martins AMEBL. Equidade no uso de serviços odontológicos provenientes do SUS entre idosos: estudo de base populacional. Ciênc Saúde Coletiva 2016; 21(11): 3509-23. https://doi.org/10.1590/1413-812320152111.22532015
https://doi.org/https://doi.org/10.1590/... , conventional treatments, urgency¹³13. Schroeder FMM, Mendoza-Sassi RA, Meucci RD. Condição de saúde bucal e utilização de serviços odontológicos entre idosos em área rural no sul do Brasil. Ciênc Saúde Coletiva 2020; 25(6): 2093-102. https://doi.org/10.1590/1413-81232020256.25422018
https://doi.org/https://doi.org/10.1590/... and toothache^,2424. Oliveira RFR, Souza JGS, Haikal DS, Ferreira EF, Martins AMEBL. Equidade no uso de serviços odontológicos provenientes do SUS entre idosos: estudo de base populacional. Ciênc Saúde Coletiva 2016; 21(11): 3509-23. https://doi.org/10.1590/1413-812320152111.22532015
https://doi.org/https://doi.org/10.1590/... .

Elderly individuals with better financial conditions are favored considering the use of services for prevention procedures and several treatments²⁵25. Bastos TF, Medina LPB, Sousa NFS, Lima MG, Malta DC, Barros MBA. Income inequalities in oral health and access to dental services in the Brazilian population: National Health Survey, 2013. Rev Bras Epidemiol 2019; 22(Supl. 2): E190015.SUPL.2. https://doi.org/10.1590/1980-549720190015.supl.2
https://doi.org/https://doi.org/10.1590/... . An important fact is that most elderly individuals who use private dental services in Brazil already wears prosthesis or present lower self-reported need to wear or change the dental prosthesis when compared to elderly individuals who attend the public service³¹31. Azevedo JS, Azevedo MS, Oliveira LJC, Correa MB, Demarco FF. Uso e necessidade de prótese dentária em idosos brasileiros segundo a Pesquisa Nacional de Saúde Bucal (SBBrasil 2010): prevalências e fatores associados. Cad Saúde Pública 2017; 33(8): e00054016. https://doi.org/10.1590/0102-311x00054016
https://doi.org/https://doi.org/10.1590/... . Even with the funding from regional dental prosthesis laboratories in SUS, the number of offered dental prosthesis is much lower than the real necessity of the population³⁰30. Silva AER, Echeverria MS, Custódio NB, Cascaes AM, Camargo MBJ, Langlois CO. Uso regular de serviços odontológicos e perda dentária entre idosos. Ciênc Saúde Coletiva 2018; 23(12): 4269-76. https://doi.org/10.1590/1413-812320182312.30562016
https://doi.org/https://doi.org/10.1590/... . The prosthetic treatment is still mainly offered by private dental services³⁰30. Silva AER, Echeverria MS, Custódio NB, Cascaes AM, Camargo MBJ, Langlois CO. Uso regular de serviços odontológicos e perda dentária entre idosos. Ciênc Saúde Coletiva 2018; 23(12): 4269-76. https://doi.org/10.1590/1413-812320182312.30562016
https://doi.org/https://doi.org/10.1590/... .

Studies with data from the national oral health analyses - SB Brasil 2003 and SB Brasil 2010 - already revealed inequalities of race/color in the use of dental services by elderly individuals, with prevalence of use among the white people³²32. Souza EHA, Oliveira PAP, Peagle AC, Goes PSA. Raça e o uso dos serviços de saúde bucal por idosos. Ciênc Saúde Coletiva 2012; 17(8): 2063-70. https://doi.org/10.1590/S1413-81232012000800017
https://doi.org/https://doi.org/10.1590/... ^,3333. Ferreira CDO, Antunes JLF, Andrade FBD. Fatores associados à utilização dos serviços odontológicos por idosos brasileiros. Rev Saúde Pública 2013; 47(Supl. 3): 90-7. https://doi.org/10.1590/S0034-8910.2013047004721
https://doi.org/https://doi.org/10.1590/... . A black elderly person, for instance, had 62% less chances of having used dental services at least once in life than a white elderly individual³²32. Souza EHA, Oliveira PAP, Peagle AC, Goes PSA. Raça e o uso dos serviços de saúde bucal por idosos. Ciênc Saúde Coletiva 2012; 17(8): 2063-70. https://doi.org/10.1590/S1413-81232012000800017
https://doi.org/https://doi.org/10.1590/... . Besides, white elderly individuals have been the majority among the ones who used these services more recently³²32. Souza EHA, Oliveira PAP, Peagle AC, Goes PSA. Raça e o uso dos serviços de saúde bucal por idosos. Ciênc Saúde Coletiva 2012; 17(8): 2063-70. https://doi.org/10.1590/S1413-81232012000800017
https://doi.org/https://doi.org/10.1590/... ^,3333. Ferreira CDO, Antunes JLF, Andrade FBD. Fatores associados à utilização dos serviços odontológicos por idosos brasileiros. Rev Saúde Pública 2013; 47(Supl. 3): 90-7. https://doi.org/10.1590/S0034-8910.2013047004721
https://doi.org/https://doi.org/10.1590/... . The results of this study show the permanence of these inequalities to the detriment of black elderly individuals.

It was possible to observe the higher use of dental services by married elderly individuals, corroborating the findings in the literature that recorded higher prevalence of this outcome by elderly people who live with a spouse or partner¹¹11. Sória GS, Nunes BP, Bavaresco CS, Vieira LS, Facchini LA. Acesso e utilização dos serviços de saúde bucal por idosos de Pelotas, Rio Grande do Sul, Brasil. Cad Saúde Pública 2019; 35(4): e00191718. https://doi.org/10.1590/0102-311x00191718
https://doi.org/https://doi.org/10.1590/... , suggesting that they also take better care of their teeth, possibly due to the importance of oral health in marital relations⁷7. Maia LC, Costa SM, Martelli DRB, Caldeira AP. Edentulismo total em idosos: envelhecimento ou desigualdade social? Rev Bioét 2020; 28(1): 173-81. https://doi.org/10.1590/1983-80422020281380
https://doi.org/https://doi.org/10.1590/... . However, some local studies did not show such an association²⁴24. Oliveira RFR, Souza JGS, Haikal DS, Ferreira EF, Martins AMEBL. Equidade no uso de serviços odontológicos provenientes do SUS entre idosos: estudo de base populacional. Ciênc Saúde Coletiva 2016; 21(11): 3509-23. https://doi.org/10.1590/1413-812320152111.22532015
https://doi.org/https://doi.org/10.1590/... ^,3030. Silva AER, Echeverria MS, Custódio NB, Cascaes AM, Camargo MBJ, Langlois CO. Uso regular de serviços odontológicos e perda dentária entre idosos. Ciênc Saúde Coletiva 2018; 23(12): 4269-76. https://doi.org/10.1590/1413-812320182312.30562016
https://doi.org/https://doi.org/10.1590/... .

In Brazil, despite the tendency of increasing use of dental services throughout the years by the elderly individuals in all schooling levels, the schooling differences of this use are still expressed by the highest prevalence among those with higher schooling²⁹29. Pilotto LM, Celeste RK. Tendências no uso de serviços de saúde médicos e odontológicos e a relação com nível educacional e posse de plano privado de saúde no Brasil, 1998-2013. Cad Saúde Pública 2018; 34(4): e00052017. https://doi.org/10.1590/0102-311x00052017
https://doi.org/https://doi.org/10.1590/... , with association between the shortest time spent since the last dental appointment and the elderly’s higher schooling¹¹11. Sória GS, Nunes BP, Bavaresco CS, Vieira LS, Facchini LA. Acesso e utilização dos serviços de saúde bucal por idosos de Pelotas, Rio Grande do Sul, Brasil. Cad Saúde Pública 2019; 35(4): e00191718. https://doi.org/10.1590/0102-311x00191718
https://doi.org/https://doi.org/10.1590/... ^,1212. Mariño R, Giacaman AG. Patterns of use of oral health care services and barriers to dental care among ambulatory older Chilean. BMC Oral Health 2017; 17: 38. https://doi.org/10.1186/s12903-016-0329-2
https://doi.org/https://doi.org/10.1186/... ^,2626. Silva AE, Langlois CO, Feldens CA. Use of dental services and associated factors among elderly in southern Brazil. Rev Bras Epidemiol 2013; 16(4): 1005-16. https://doi.org/10.1590/S1415-790X2013000400020
https://doi.org/https://doi.org/10.1590/... ^,3030. Silva AER, Echeverria MS, Custódio NB, Cascaes AM, Camargo MBJ, Langlois CO. Uso regular de serviços odontológicos e perda dentária entre idosos. Ciênc Saúde Coletiva 2018; 23(12): 4269-76. https://doi.org/10.1590/1413-812320182312.30562016
https://doi.org/https://doi.org/10.1590/... ^,3333. Ferreira CDO, Antunes JLF, Andrade FBD. Fatores associados à utilização dos serviços odontológicos por idosos brasileiros. Rev Saúde Pública 2013; 47(Supl. 3): 90-7. https://doi.org/10.1590/S0034-8910.2013047004721
https://doi.org/https://doi.org/10.1590/... ^,3434. Cascaes AM, Camargo MBJ, Castilhos ED, Silva ERA, Barros AJD. Gastos privados com saúde bucal no Brasil análise dos dados da Pesquisa de Orçamentos Familiares, 2008-2009. Cad Saúde Pública 2017; 33(1): e00148915. https://doi.org/10.1590/0102-311x00148915
https://doi.org/https://doi.org/10.1590/... . It is important to highlight the convergence found with other studies⁴4. Martins AMEBL, Oliveira RFR, Haikal DSA, Santos ASF, Souza JGS, Alecrim BPA, et al. Uso de serviços odontológicos públicos entre idosos brasileiros: uma análise multinível. Ciênc Saúde Coletiva 2020; 25(6): 2113-26. https://doi.org/10.1590/1413-81232020256.19272018
https://doi.org/https://doi.org/10.1590/... ^,2424. Oliveira RFR, Souza JGS, Haikal DS, Ferreira EF, Martins AMEBL. Equidade no uso de serviços odontológicos provenientes do SUS entre idosos: estudo de base populacional. Ciênc Saúde Coletiva 2016; 21(11): 3509-23. https://doi.org/10.1590/1413-812320152111.22532015
https://doi.org/https://doi.org/10.1590/... as to the higher use of dental services from SUS by elderly individuals with lower schooling. Even though economic variables have not been inserted in this study, schooling can be considered as a proxy for income²⁹29. Pilotto LM, Celeste RK. Tendências no uso de serviços de saúde médicos e odontológicos e a relação com nível educacional e posse de plano privado de saúde no Brasil, 1998-2013. Cad Saúde Pública 2018; 34(4): e00052017. https://doi.org/10.1590/0102-311x00052017
https://doi.org/https://doi.org/10.1590/... , and the more frequent use of dental services in SUS has also been associated with lower family income⁴4. Martins AMEBL, Oliveira RFR, Haikal DSA, Santos ASF, Souza JGS, Alecrim BPA, et al. Uso de serviços odontológicos públicos entre idosos brasileiros: uma análise multinível. Ciênc Saúde Coletiva 2020; 25(6): 2113-26. https://doi.org/10.1590/1413-81232020256.19272018
https://doi.org/https://doi.org/10.1590/... ^,2424. Oliveira RFR, Souza JGS, Haikal DS, Ferreira EF, Martins AMEBL. Equidade no uso de serviços odontológicos provenientes do SUS entre idosos: estudo de base populacional. Ciênc Saúde Coletiva 2016; 21(11): 3509-23. https://doi.org/10.1590/1413-812320152111.22532015
https://doi.org/https://doi.org/10.1590/... , which can show the equity in the use of these services⁴4. Martins AMEBL, Oliveira RFR, Haikal DSA, Santos ASF, Souza JGS, Alecrim BPA, et al. Uso de serviços odontológicos públicos entre idosos brasileiros: uma análise multinível. Ciênc Saúde Coletiva 2020; 25(6): 2113-26. https://doi.org/10.1590/1413-81232020256.19272018
https://doi.org/https://doi.org/10.1590/... .

The SUS profile identified in this study was mostly composed of elderly individuals with low schooling, black and brown skin color, who reported few options of prosthetic treatment and dental implant. However, it is not correct to understand SUS as a poor system addressed to the more vulnerable population, since it is based on the principles of universality, integrality and equity, and includes social participation³⁵35. Ramos EMB, Diniz IM. Pobreza, proteção social e cidadania: uma análise do direito à saúde no Brasil a partir da Constituição Federal de 1988. Barbarói 2019; (55): 57-80. https://doi.org/10.17058/barbaroi.v0i0.8182
https://doi.org/https://doi.org/10.17058... .

The association identified among the hypertensive and diabetic elderly individuals with the SUS profile probably occurred because they shared the same social determinants that interfere in the pattern of health services’ use. Francisco et al.³⁶36. Francisco PMSB, Segri NJ, Borim FSA, Malta DC. Prevalência simultânea de hipertensão e diabetes em idosos brasileiros: desigualdades individuais e contextuais. Ciênc Saúde Coletiva 2018; 23(11): 3829-40. https://doi.org/10.1590/1413-812320182311.29662016
https://doi.org/https://doi.org/10.1590/... revealed that in the capitals of the South/Southeast/Center-West regions of Brazil there were higher prevalence rates of arterial hypertension and diabetes among the black and brown elderly population, those with ≤ 8 schooling years, both non-smokers and smokers, and those with excess weight.

Elderly individuals who presented with pulmonary disease were associated with the direct disbursement profile, whereas those diagnosed with cancer were mostly associated with the health insurance profile. The difficulties to access public health services in both situations³⁷37. Pinto CR, Lemos ACM, Assunção-Costa L, Alcântara AT, Yamamura LLL, Souza GS, et al. Gerenciamento da DPOC no Sistema Único de Saúde do estado da Bahia: uma análise do padrão de utilização de medicamentos na vida real. J Bras Pneumol 2019; 45(1): e20170194. https://doi.org/10.1590/1806-3713/e20170194
https://doi.org/https://doi.org/10.1590/... ^,3838. Brustolin F, Ferretti F. Itinerário terapêutico de idosos sobreviventes ao câncer. Acta Paul Enferm 2017; 30(1): 47-59. https://doi.org/10.1590/1982-0194201700008
https://doi.org/https://doi.org/10.1590/... may justify these findings.

Knowing the perception about oral health provides subjective and quantitative data³⁹29. Pilotto LM, Celeste RK. Tendências no uso de serviços de saúde médicos e odontológicos e a relação com nível educacional e posse de plano privado de saúde no Brasil, 1998-2013. Cad Saúde Pública 2018; 34(4): e00052017. https://doi.org/10.1590/0102-311x00052017
https://doi.org/https://doi.org/10.1590/... that are important to be considered in studies about the use of dental services⁴⁰40. Nunes CSR, Silva MP, Barcessat ARP. Acesso aos serviços de saúde bucal de adultos e idosos. Estação Científica 2017; 7(3): 9-18. https://doi.org/10.18468/estcien.2017v7n3.p09-18
https://doi.org/https://doi.org/10.18468... . There was a prevalence of regular and bad or very bad self-perception among the elderly in the SUS profile. This result is in accordance with the literature, which points to the association of negative oral health self-perception and elderly individuals, both black and brown⁴¹41. Nico LS, Andrade SSCA, Malta DC, Pucca Júnior GA, Peres MA. Saúde Bucal autorreferida da população adulta brasileira resultados da Pesquisa Nacional de Saúde. Ciênc Saúde Coletiva 2016; 21(2): 389-98. https://doi.org/10.1590/1413-81232015212.25942015
https://doi.org/https://doi.org/10.1590/... , with lower schooling⁴¹41. Nico LS, Andrade SSCA, Malta DC, Pucca Júnior GA, Peres MA. Saúde Bucal autorreferida da população adulta brasileira resultados da Pesquisa Nacional de Saúde. Ciênc Saúde Coletiva 2016; 21(2): 389-98. https://doi.org/10.1590/1413-81232015212.25942015
https://doi.org/https://doi.org/10.1590/... ^,4242. Sousa JLS, Henriques A, Silva ZP, Severo M, Silva S. Posição socioeconômica e autoavaliação da saúde bucal no Brasil: resultados da Pesquisa Nacional de Saúde. Cad Saúde Pública 2019; 35(6): e00099518. https://doi.org/10.1590/0102-311x00099518
https://doi.org/https://doi.org/10.1590/... , unfavorable socioeconomic status⁴²42. Sousa JLS, Henriques A, Silva ZP, Severo M, Silva S. Posição socioeconômica e autoavaliação da saúde bucal no Brasil: resultados da Pesquisa Nacional de Saúde. Cad Saúde Pública 2019; 35(6): e00099518. https://doi.org/10.1590/0102-311x00099518
https://doi.org/https://doi.org/10.1590/... and higher use of dental services from SUS²⁴24. Oliveira RFR, Souza JGS, Haikal DS, Ferreira EF, Martins AMEBL. Equidade no uso de serviços odontológicos provenientes do SUS entre idosos: estudo de base populacional. Ciênc Saúde Coletiva 2016; 21(11): 3509-23. https://doi.org/10.1590/1413-812320152111.22532015
https://doi.org/https://doi.org/10.1590/... .

Among the limitations of this study, it is important to consider this is a cross-sectional analysis, so it is not possible to measure temporal variations or to make causal inferences. Despite adding the chances of reverse causality and memory bias, the several possibilities of research about the health of the population are reinforced, since these can be created based on the use of data from surveys.

The use of LCA showed to be superior to the use of traditional cluster methods, which only characterize the profile of service use based on the analysis of each question separately. In the case of direct disbursement, there was prevalence of this type of payment method, without, however, excluding from this group a percentage of elderly individuals whose main reason to see the dentist was tooth extraction. However, this was the profile who mostly used services for reasons of maintenance of dental prosthesis. This fact shows that the social response of the State regarding the dental mutilation that It causes is still submissive to the purchasing power of this type of treatment.

The SUS profile was the one that mostly assisted elderly individuals in the same city where they lived, showing the UBS as the main place of use. This result shows primary care as a gateway that organizes access to the care networks, with capacity to work with previous scheduling and direct care, with no need for scheduling. In this sense, it increases the possibilities of access, considering that only a few reported pain as a reason for use. However, this profile had the highest proportion of elderly individuals whose reason for the last appointment was pain, allied to a very low proportion of dental implants as a reason for this appointment, which reinforces the still persisting gap in dental rehabilitation among SUS users.

The analysis of different profiles of dental services’ use allowed to identify that single Brazilian elderly individuals, living in households with more than two people, who never attended school or are only literate, and wo consider their own oral health as bad or very bad, presented higher chances of belonging to the SUS profile. This characterization emphasizes the importance of SUS for this population group, especially considering the perspective of equity, in the sense that it is able to reach the population that needs it the most. Thus, it restates its needs for expansion, strengthening, and qualification of the provided services.

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