Legislation in Hospital Dentistry: Gaps, Perspectives and Desires

Abstract

Objective:  To analyze the existing state legislation, including not only the ordinary laws, but also their infralegal regulation and the state legislation on Hospital Dentistry.

Material and Methods:  A survey was carried out in the databases of the Legislative Assemblies of the Brazilian States and the Federal District, as well as the Regional and Federal Councils of Dentistry in Brazil. Subsequently, a survey was carried out in the databases of the Ministry of Health, State Dental Councils and Federal Dental Council in Brazil.

Results:  Only 8 Brazilian states have legislation in force regarding hospital dentistry, which represents 29.63% of the federative units. Among the Brazilian regions, the Midwest presented the highest prevalence of the laws found (37.50%), followed by the North (25%) and the other regions with the same coverage (12.50%). Also, an orientation and an ordinance from the Ministry of Health, six resolutions from the Federal Council of Dentistry, and a technical note from the National Health Surveillance Agency were found.

Conclusion:  Several States do not have rules on the subject, making it imperative to create a federal rule that not only imposes the presence of the dentist, but also regulates the proportion of the team, workload, and availability.

Keywords: Oral Health; Dental Staff, Hospital; Intensive Care Units; Legislation

Introduction

Law nº 8.080 of 1990, also known as the Organic Health Law, brings, in item II of its article 7, the principle of “comprehensive care”, defining it as the “articulated and continuous set of preventive and curative, individual and collective, required for each case, at all levels of complexity of the system”. Such comprehensiveness, as recommended by law, must cover the entire set of needs of the health system user, in particular, the availability of the professional and the most appropriate health action or service for the case. Strong in this premise, the managers of the health system, in all spheres, must make use of accurate epidemiological data and use them as a tool for perceiving the health needs of the population and, also as an instrument for defining public policies, bringing effective government responses to the health problems faced [¹,²].

In this sense, Hospital Dentistry, as an area of concentration of health knowledge, created with the specific objective of enabling the dentist to compose a multiprofessional team in a hospital environment, including intensive care units (ICU) and home care, has an important role to play, acting at the bedside to provide the bedridden patient with holistic care. Thus, the benefits of inserting the CD in hospital environments are: improvement in patients' quality of life, increased survival, decreased in risks of contracting oral infections, patient hospitalization time and hospital expenses. However, the dentist is faced not only with the lack of training of the hospital staff to deal with oral health, but also with great reservations about their ability to work in a hospital environment [³,⁴,⁵].

Despite these barriers, it appears that, in addition to the dentist, the interprofessional care team has doctors, nurses, nutritionists and psychologists as the main protagonists of patient care, with the objective of longitudinality and integrality of care. It should be reiterated that this care is focused on the person and their needs, always respecting the individual's desires and moral values, so as not to violate the ethical principle of patient autonomy [⁶]. Thus, the multiprofessional health team must be perceived as a facilitating element of this process through the performance of interprofessional and interdisciplinary work provided by the set of knowledge, knowledge and experiences provided [⁶,⁷].

However, even though the importance of Hospital Dentistry is evidenced and recognized by the Federal Council of Dentistry [⁸], there is a vast lack of regulation and legislation. In an attempt to resolve this issue, Federal Deputy Neilton Mulim showed the Project Law nº 2776 in 2008, which would make dental care mandatory for patients with chronic diseases and those cared at home. The project was processed during 11 years in the National Congress until it was fully vetoed by President Jair Bolsonaro [⁹]. Despite the stormy federal scenario, several units of the federation, realizing the topic's relevance, took the lead in the discussion and have been approving laws that establish the mandatory inclusion of dentists in hospitals or ICUs.

In this way, the objective was to analyze the various existing state laws in a comprehensive way, including not only the ordinary laws, but also their infralegal regulation, with the objective of extracting an updated panorama regarding the regulation of Hospital Dentistry in Brazilian States.

Material and Methods

Design and Data Collection

A survey was carried out regarding norms, resolutions and ordinary laws regarding hospital dentistry in two stages. The first consisted of a search in the databases of the Legislative Assemblies of the Brazilian States and the Federal District, as well as the Regional and Federal Councils of Dentistry in Brazil, with data available on their respective websites between the 10/12/2021 and 25/12/2021. In the second stage, a survey was carried out in the databases of the Ministry of Health, State Dental Councils and Federal Council of Dentistry in Brazil.

In both stages, the terms “Hospital dentistry; ICU; Oral health; Dental surgeon”. For the selection, there was no period discrimination. As an inclusion criterion, we selected approved Brazilian state laws, as well as regulations and revolutions, and as an exclusion criterion, we used the vetoed or pending bills. The results were compiled and evaluated by initially reading the titles and summaries of laws and regulations and then reading them in full.

Data Analysis

Data were statistically analyzed using Microsoft Excel 365 and Microsoft Power BI Desktop, version 2 (Microsoft Corp., Redmond, WA, USA).

Results

Figure 1 shows the Brazilian federative units divided into those that have, in the support systems for state Legislative Assemblies, a current law that regulates hospital dental care, in dark gray. In the other units, in light gray, no data were found in their search systems available on the internet.

Figure 1
Map of State Legislation in Hospital Dentistry.

It is observed that only 8 Brazilian states have legislation in force regarding hospital dentistry, which represents 29.63% of the federative units. Among the Brazilian regions, the Midwest presented the highest prevalence of the laws found (37.50%), followed by the North (25%) and the other regions with the same coverage (12.50%).

Table 1 presents the identification of the laws found by the methodology of this research. Table 2 describes the results found in the search for standards and resolutions. An orientation and an ordinance from the Ministry of Health were found, in addition to six resolutions from the Federal Council of Dentistry and a technical note from the National Health Surveillance Agency.

Table 1
List of laws in force by federative unit.

State	Law	Year	Subject
Alagoas	8.009	2018	Provides for the obligation to provide dental care to hospitalized patients and those with chronic diseases in public and private health units.
Amapá	2.508	2020	Makes the provision of dental care to hospital patients mandatory.
Distrito Federal	5.744	2016	Provides for the constitutional right to oral health in the Unified Health System where patients are hospitalized.
Mato Grosso	10.659	2017	Mandatory assistance dentistry to patients in hospital.
Mato Grosso do Sul	5.163	2018	Provides for the mandatory presence of dentistry professionals in Intensive Care Units.
Paraná	18.120	2014	Makes the provision of dental care to patients in general hospitals mandatory.
Rio de Janeiro	6.580	2013	Amends law 6.580, of 7/11/2013, to determine dental care in establishments that maintain medical care services under the inpatient modality, in the public and private health network.
Rondônia	4.082	2017	Provides for the mandatory presence of dental professionals in the multidisciplinary team of private hospitals.

Table 2
Norms and resolutions in hospital dentistry.

Resolution	Objective
Guidance without a registration number from the Ministry of Health, 2005	Issuance by the dentist of the Hospitalization Authorization. Establishes the National Oncology Care Policy. It establishes guidelines for the care of the sick and implements a state care network through care units and reference centers. It includes dental care in the accreditation of the High Complexity Assistance Centers in Oncology (CACON) [9]
Ordinance 1032/2010 of the Ministry of Health of June 5, 2010.	Includes dental procedures in the Table of Procedures, Medicines, Orthoses and Prostheses and Special Materials of the Unified Health System (SUS) to assist people with special needs [8,10,11]
Resolution nº 7 of February 24, 2010 - ANVISA	Provides for the minimum requirements for the operation of Intensive Care Units, provides dental care at the bedside and integrates Dentistry into the multidisciplinary team [8]
Resolution nº 118 of May 11, 2012, of the Federal Council of Dentistry	Recognizes the specialty of the dentist's performance in a hospital environment [10]
Technical Note nº 1/2014 of December 26, 2013, from the General Coordination of Oral Health of the Ministry of Health	Establishes the record of dental procedures performed in a Hospital Environment [8,10]
Resolution nº 162/2015 of November 3, 2015 of the Federal Council of Dentistry	Recognizes the practice of Hospital Dentistry by the dentist and establishes a 350hour qualifying course, a limit of students per class and mandatory subjects [8]
Resolution nº 163/2015 of November 9, 2015 of the Federal Council of Dentistry	Conceptualizes Hospital Dentistry and defines the role of the dentist qualified to exercise it [4]
Resolution nº 203/2019 of May 21, 2019 of the Federal Council of Dentistry	Amends Resolution CFO-162/2015, on the criteria for qualification in Hospital Dentistry, reduction of students per class, requirement of course completion work and other measures [23]
Resolution nº 204/2019 of May 21, 2019 of the Federal Council of Dentistry	Changes the paragraphs of Art. 2 of Resolution CFO-163, which deals with the areas of expertise in Hospital Dentistry [24]

Discussion

To the best of our knowledge, there are no other comparative studies in the literature regarding the legislation and its application in real environments in order to allow the respective assessment of clinical effectiveness. Therefore, this is a pioneering study. Interestingly, most state legislation is from the Midwest, so we hypothesize that it is a local phenomenon arising from the independent action of professional groups and associations in each location for the approval of the aforementioned laws. It was not possible to establish a causal relationship that explains the higher incidence of legislation in the Midwest region in proportion to the rest of the country. There is no identifiable correlation between sociodemographic indices or the number of qualification courses available, for example, and the approval of these laws in the analyzed region.

The difficulties of other regions are the lack of political support, the lack of knowledge of parliamentarians and society as a whole about the subject, the false perception of the budgetary impact of the measure, analyzed only from the perspective of the increase in expenses with personnel, equipment and materials for the health units and, the lobbying of private companies and other actors in the field of Health to prevent the approval of such laws.

In Brazil, the institutionalization and officialization of Hospital Dentistry has been slow and quite troubled. It is estimated that the first services undertaken were performed only in the 1970s and 1980s. In 2008, there was the creation of Project Law nº 2.776-B, which would make the presence of the dentist in a hospital environment mandatory [¹⁰]. It is important to mention that the length of the Project Law process reflects the disregard for the problem of the need for dental professionals in hospitals.

State laws have different contents and, in relation to the federal scenario, there is a political difficulty and an increase in costs. In addition to the fiscal crisis and restriction on health spending, expressed by the Public Spending Ceiling, which is a strong complicating factor for the approval of the measure at the federal level. Also, during the last federal government (2019-2022), there was resistance to the approval of the measure, motivated by the perception that it would result in increased public spending.

Despite this, the Project was approved by the Chamber of Deputies and the Federal Senate, being, however, vetoed by the President of the Republic in 2019, which prevented it from becoming mandatory throughout the national territory by public hospitals and private, dental care in a medium to large hospital environment for ICU patients, hospitalization (including home care) and patients with chronic diseases. The President claimed “the matter is unconstitutional because the measure would violate the Fiscal Responsibility Law, since it would increase mandatory public expenditure, without the equivalent cancellation of another and without estimating its budgetary and financial impact” [¹¹]. However, the national and international literature shows that the insertion of the dentist in the hospital reduces the costs of hospitalization and infection prevention, being considered a primordial investment for Public Health, in which it drastically reduces hospital expenses.

However, in the absence of a federal law, the matter remains governed by state legislation already approved and also by existing infra-legal instruments, according to the hierarchy of norms of the Brazilian legal system, according to which, in the absence of legal regulation by a given entity, Federation, ordinances, resolutions and other normative instruments of a lower degree can fill the normative vacuum, provided, of course, they maintain a relationship of material compatibility with the Constitution of the Republic [¹²].

In this sense, in Amapá, Ordinary Law nº 2508, of 09/04/2020, made the provision of dental care in public or private hospitals to patients in a hospital regime mandatory, being applied with the consent of the patient or family member and admitting the collection of values for the service. The Mato Grosso State, in Ordinary Law nº 10659/2017, follows the same premises as above, adding that, in patient units, care can be provided by other professionals under the supervision of a dentist, except in the ICU, where the work is exclusive of this professional [¹³,¹⁴].

Law nº 5744/2016 of the Federal District establishes in its first article the constitutional right to oral health in the Unified Health System of the Federal District where patients are hospitalized. It makes mandatory the presence of a dental professional as an integral part of the clinical staff of physicians when necessary and mandatory in intensive care units. The standard does not address particular environments, the number of professionals or the level of assistance [¹⁵].

Mato Grosso do Sul, under the light of Law nº 5.163 of 03/20/2018, alludes that the presence of the dental professional is mandatory in the multiprofessional ICU teams in public and private hospitals in the state. It should be noted that this law does not deal with other hospitalized patients, being exclusive to ICU inmates [¹⁶].

In contrast, the state of Paraná distinguishes itself by inserting the dentist in the multiprofessional teams, an obligation enacted in Law No. On the other hand, the state of Rondônia, under Ordinary Law No. 4082 of 06/19/2017, made the presence of dental professionals mandatory only in private hospitals [¹⁸]. In the oldest state legislation, Rio de Janeiro, through Law nº 6580 of 11/07/2013, has the widest range of norms found, as transcribed in its first article and also includes a fine for non-compliance with its articles [¹⁹].

Art. 1º Hospitals, nursing homes, maternity hospitals and similar establishments, which maintain medical care services under the inpatient modality, must rely on Dental Surgeons in the planning, coordination and execution of measures for the prevention and control of hospital infection, considering aspects specific to oral health [¹⁹].

In order to regulate the performance of dentists in hospital environments, including intensive care units, the Ministry of Health and the National Health Surveillance Agency (ANVISA) edited several regulations to promote oral health. ANVISA Resolution nº 7 of 2010 became a relevant document, as it tried to include bedside dental care in the minimum operating requirements of the ICU, as well as including the dentist in the multiprofessional team. This resolution stipulates a period of up to three years for the necessary adjustments regarding the requirements related to human resources [²⁰]. This document was the first step towards the implementation of a series of measures so that the more than 2,300 Intensive Care Units in Brazil are safer and that the care for critical patients is of high quality, with qualified professionals. Article 3 of RDC nº 7/2010 also determines its application in all general Intensive Care Units in the country, whether public, private or philanthropic, civil or military. Article 18 describes bedside services that must be provided, either by their own means or by outsourced means, including dental care.

In addition, in 2015, Resolution CFO-162/2015 recognized the practice of Hospital Dentistry by dentists. It provides for professionals in the field to take a Hospital Dentistry Course with a minimum of 350 hours, of which 30% would be devoted to practical activities and the remaining 70% would be taught in theoretical classes. The basic subjects to be taught in the course are the hospital routine (management, bioethics, biosafety, medical records, prescription, rounds, clinical practice, patient safety, urgency and emergency), clinical workup (interpretation of exams, main problems, patients systemically compromised, drug interactions) and Basic Life Support (BLS). With this certification, the professional can then apply for registration with the Federal Council of Dentistry, with the proper registration where he already has the main registration. In this way, the professional will already be able to exercise their functions and competencies in the hospital environment. In Brazil, there are already more than 2,000 dentists qualified in the profession, a number that should be celebrated and expanded.

It should be noted that Article 26 of the Dental Ethics Code (chapter X) deals with Hospital Dentistry, which establishes that it is the responsibility of the dental surgeon to hospitalize and assist patients in public and private hospitals, with and without philanthropic character, respecting the technical standards -administrative institutions. Article nº 27 provides that dental activities performed in hospitals will comply with the relevant rules, and article nº 28 establishes that it is an ethical violation to carry out any intervention outside the legal scope of Dentistry [²¹].

Accordingly, the Federal Council of Dentistry recognized in its Code of Ethics in 2012, the legal practice of the dental surgeon in the hospital environment, as well as conceptualizing the object of professional practice and creating the qualification in Hospital Dentistry in 2015. Subsequently, it improved the course qualification, with the inclusion of BLS, better distribution of practical (30%) and theoretical (70%) hours, as well as a maximum number of 30 students per class and mandatory subjects. In 2019, through Resolution CFO-204, the dental surgeon's areas of activity were expanded, including teaching and research, performance in multiprofessional, interdisciplinary and transdisciplinary teams, and professional integration for promotion, maintenance, prevention and health protection in a hospital environment [⁹,²²,²³,²⁴].

Although the main objective of this work is the normative analysis, it is important to emphasize the approach on the training of the dentist in the area of Hospital Dentistry and the role of university hospitals in interface with the SUS since, in these spaces, Hospital Dentistry is exercised in a concrete way, effectively contributing to Public Health. Interestingly, on 21/06/2021, the National Curriculum Guidelines (DCN) for the undergraduate course in Dentistry in Brazil were released by the Ministry of Education/National Council of Education/Chamber of Higher Education, and in article nº 25 reports “the need for inclusion theoretical content and clinical practice related to dental care to individuals kept in Health Institutions, including hospital environments” [²⁵].

The COVID-19 health crisis is the most recent example of the need for the dental team in the hospital setting, as the dental surgeon is responsible not only for ensuring the oral hygiene of hospitalized patients, but also for avoiding infectious outbreaks that could worsen Covid [²⁶] frames. It is important to note that the coronavirus enters through the air and passes through the oral cavity, where it has a high viral load. Thus, a patient who does not have good oral hygiene can have complications due to the presence of bacteria and microorganisms in the mouth that can go to the lungs [²⁷,²⁸,²⁹].

The execution of public policies can be understood as the act of allocation of structure and resources aimed at achieving socially desired goods and interests, according to previously established goals and priorities, in accordance with government management plans and the fulfillment of constitutional precepts [³⁰]. Therefore, the lack of legislation that orders the dentist's presence in a hospital environment generates a public health problem. It is important to emphasize that the law, as a legal norm, regularly approved by the representatives of the people, plays the fundamental role of governing society and the State according to democracy. The literature is still incipient and no data were found on proposals for structuring teams, workflows and workloads. It is not possible to identify, for example, the number of ICU beds per dentist.

The limitations of this study are related to the bias of not having a single repository for information research, and then it is not possible to verify the actual application of the laws. In addition, there was a limitation of state data, so the research was also carried out at the municipal level. The findings reported allow an overview of the standardization of Hospital Dentistry in Brazil, its main government guidelines and gaps in care. They promote the debate on the subject and enable an integrative analysis between the various legislative texts, aiming at the construction of a universal, solid, sustainable and executable proposal for regulating the dentist's performance in the hospital environment.

Finally, our research shows the absence of the legislative power of the Union, which leads to the elaboration of heterogeneous and incomplete State laws. The aim is not only the creation of a federal rule, but also a standardization of working hours, salary floor, and all other ordinances for a perfect ethical adjustment of conduct.

Conclusion

Despite the scientific and statistical panorama being favorable to the performance of dentists in a hospital environment, the present study showed that many States do not even have norms on the subject and that those existing are mismatched, fragmented and insufficient. In this way, it becomes imperative to bring this issue to the public debate, with the leadership of the category in permanent dialogue with civil society, legislators and regulatory authorities for the creation of a federal rule that not only imposes the presence of the dentist, as well as discipline the proportion in the team, workload and availability.

• Financial Support
  None.

Data Availability

The data used to support the findings of this study can be made available upon request to the corresponding author.

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Edited by

• Academic Editor: Wilton Wilney Nascimento Padilha

Publication Dates

• Publication in this collection
  18 Dec 2023
• Date of issue
  2024

History

• Received
  26 Oct 2022
• Reviewed
  02 Jan 2023
• Accepted
  07 Apr 2023