Endodontic access and dental extractions in brazilian primary health services: a cross-sectional study

Estudo das aberturas coronárias e exodontias nos serviços primários de saúde brasileiros: estudo transversal

Abstract

Introduction  The COVID-19 pandemic significantly reduced the availability of dental services, exarcebating inequalities in access to oral healthcare in Brazil.

Objective  To analyze two outcomes of dental caries (endodontic access and dental extraction) performed in Brazilian public primary oral health services between 2019 and 2022.

Material and method  An ecological cross-sectional study was carried out, using data collected from the Brazilian Ministry of Health database. A total of 5,345 Brazilian municipalities were analyzed.

Result  The Southeast and Northeast regions had, respectively, the highest mean number of endodontic access procedures and dental extractions. There was a statistically significant drop in both procedures when comparing the years 2019 and 2020, followed by a recovery in these values in the following years. Regarding dental extractions, a significant increase was observed from 2019 to 2022.

Conclusion  These findings indicate an increase in dental extractions compared to endodontic access procedures, alongside persistent regional disparities in access to dental services.

Descriptors:
Primary health care; dental caries; COVID-19; health services needs and demand; oral health

Resumo

Introdução  A pandemia de COVID-19 reduziu significativamente a oferta de serviços odontológicos, agravando as desigualdades no acesso à saúde bucal no Brasil.

Objetivo  Analisar dois desfechos da cárie dentária (acesso à polpa e exodontia) realizados nos serviços públicos de atenção primária à saúde bucal no Brasil entre 2019 e 2022.

Material e método  Foi realizado um estudo observacional transversal, utilizando dados coletados na base de dados do Ministério da Saúde do Brasil. Foram analisados 5.345 municípios brasileiros.

Resultado  As regiões Sudeste e Nordeste apresentaram, respectivamente, a maior média de procedimentos de acesso coronário e de exodontias. Observou-se uma redução estatisticamente significativa em ambos os procedimentos na comparação entre os anos de 2019 e 2020, seguida de uma recuperação desses valores nos anos subsequentes. Em relação às exodontias, verificou-se um aumento significativo entre 2019 e 2022.

Conclusão  Os achados indicam aumento de exodontias em comparação aos procedimentos de acesso coronário, além da persistência de desigualdades regionais no acesso aos serviços odontológicos.

Descritores:
Atenção primária a saúde; cárie dentária; COVID-19; necessidades e demandas em serviços de saúde; saúde bucal

INTRODUCTION

Outbreaks of infections and deaths due to a novel coronavirus in several countries and regions around the world led the World Health Organization to declare a Public Health Emergency of International Concern in 2020¹. In Brazil, the health crisis caused by the novel coronavirus resulted in more than 40 million confirmed cases, ranking sixth worldwide, and more than 700,000 deaths².

In addition to the direct impact of the pandemic on morbidity and mortality resulting from coronavirus infection, the health crisis has negatively affected the supply of dental services around the world³. Dentistry is among the professions at highest risk of COVID-19 transmission and contamination⁴. Consequently, elective dental care was suspended, with procedures restricted to urgent and emergency cases only⁵,⁶. As a result, there was a significant reduction in the supply of oral health services, thereby generating a substantial unmet demand for dental care⁴,⁷. However, procedures aimed at treating pulpitis, pericoronitis, alveolitis, abscesses, mucositis, extensive carious lesions and fractures were maintained in the routine of an oral health professional during the pandemic⁸.

Tooth loss remains a central concern in the country's oral health context, representing a major outcome of the most prevalent oral diseases⁹. As a result of mutilating procedures, tooth loss becomes an aggravating factor in compromising essential human functions, with a consequent negative impact on quality of life⁹,¹⁰. Therefore, oral diseases, inadequate access to healthcare and information, cultural factors, and the predominantly curative-mutilating model are considered the main determinants of tooth loss. This condition results in masticatory impairment, which may compromise nutritional status. Tooth loss also leads to changes in the dental arch and facial profile, including muscle imbalance, lip alterations, and bone resorption, negatively affecting self-esteem and social interaction, with consequent impact on quality of life¹¹.

Endodontics was incorporated into the oral health services of the Brazilian Unified Health System (SUS) in 2004, through the establishment of Dental Specialty Centers at the secondary level of care¹². However, the Brazilian Health System contains flaws in relation to its principle of universality. There are challenges in specialized care, primarily related to long waiting lists, where the demand for services far exceeds the available supply¹³. Between 2011 and 2017, a smaller portion of the population gained access to the public endodontic service, which is one of the most sought-after dental specialties. In contrast to the decrease in financial transfers to oral health, there was a significant growth in private dental plans in the same period, underscoring a national scenario marked by social inequalities in access to dental care¹⁴.

Previous studies have demonstrated the reduction in dental care during the COVID-19 pandemic and have described regional inequalities in access to oral health in Brazil⁴,⁷. However, there is no evidence regarding how dental services are organizing to meet pent-up demand, nor on the impact of a failure to provide timely care for cases of severe oral disease. Understanding these patterns may provide indirect evidence of access to conservative treatment and the potential long-term impact of the pandemic on oral healthcare. Therefore, this study aimed to analyze endodontic access and dental extraction procedures performed in Brazilian public primary healthcare services between 2019 and 2022.

MATERIAL AND METHOD

Study Design and Protocol

We conducted a cross-sectional ecological study based on secondary data from Brazilian municipalities obtained from the Ministry of Health, regarding the 2019–2022 period. The recommendations of the Reporting of Studies Conducted using Observational Routinely collected Data (RECORD) were followed to report the data in this article.

Experimental Unit and Data Collection

Data were retrieved from the Primary Health Care Information System (SISAB) database. Data extraction was performed on August 2023. We use standardized filters for municipality, year, and the procedures of interest: Endodontic Access (03.07.02.001-0) and Dental extraction (04.14.02.013-8), as performed in Brazilian municipalities. The data collected referred to the whole of Brazil and the 12 months of each year (2019, 2020, 2021, and 2022).

Initially, researches access SISAB platform¹⁵. The second step was indicating configuration of data output: we selected “Municípios” (municipalities) to “Report Line” and “Procedimentos SB” (oral health procedures) to the “Report Column”. The third step was selecting of filters: it was determined that the type of team would be “Eq. Saúde Bucal-SB” (oral health team) and that the professional category would be “Cirurgião-dentista” (dental surgeon). No filters were selected for “Age group”, “Sex”, “Place of service”, and “Type of service”. Finally, in the “Kind of Production” field was selected “Atendimento Odontológico” (Oral Health Care). The forth step was selecting the procedures: “aces. polpa/medica por dente” (endodontic access) and “exodontia de dente permanente” (dental extraction) without adding filters for “Tipo de consulta” (Type of appointment), “Vigilância em saúde bucal” (oral health surveillance) and “conduta” (management).

Finally, the tables were downloaded. The data collected from DATASUS, regarding the number of procedures performed, were then tabulated in a Microsoft Excel™ 2010 spreadsheet (Microsoft ™ Ltd., Washington, USA) organized by year, region, state and municipality.

Brazilian municipalities are obligated to inform their production to SISAB in order to receive governmental funds. Thus, the pandemic period may have had little or no impact on data entry. All municipalities with dental procedures available in the SISAB database were included in the study. No missing data was founded. Since we use secondary data entered by the municipalities, there is a possibility of inconsistencies. However, it is not possible to find these input inconsistencies. Potential recording inaccuracies inherent to health information systems are addressed as a study limitation.

Data Processing and Analysis

No data transformation was applied; no population adjustment was applied; variables were used as originally collected: categorical variables (municipality, state, region and year) or numerical variables (endodontic access procedures and dental extraction). The data tabulated in a Microsoft Excel™ spreadsheet were imported into Jamovi® (version 2.6.44) software to perform statistical analyses. Initially, measures of central tendency were calculated. Initially, we carry out a normality test to understand the distribution of data (Levene Test), indicating a non-parametric distribution of data. For comparison between years, the Wilcoxon test was applied for each procedure analyzed, allowing for paired comparison (each municipality compared with itself over the years). A significance level of 5% was considered.

Ethical Aspects

This study was conducted in accordance with the provisions of Resolution 510 of National Health Council (Brazilian Ministry of Health). As secondary data from the public domain database were used, ethical approval by an independent committee was not required.

RESULT

Data from 5,345 Brazilian municipalities were identified, comprising 444 (8.31%) from the North Region, 1,799 (33.66%) from the Northeast Region, 1,539 (28.79%) from the Southeast Region, 1,097 (20.52%) from the South Region, and 466 (8.72%) from the Central-West Region. From this total, municipalities presenting outlier values in any of the analyzed years were excluded, resulting in 5,318 municipalities. Ten (2.25%) municipalities were excluded from the North Region, 6 (0.38%) from the Northeast Region, 6 (0.39%) from the Southeast Region, 3 (0.27%) from the South Region, and 3 (0.64%) from the Central-West Region.

Figure 1 presents the box-plots resulting from the descriptive analysis of the number of dental extractions and endodontic access performed from 2019 to 2022 among Brazilian Regions. The region with the highest average number of endodontic access was the Southeast in all the years analyzed (2019: 110.3; 2020: 71.2; 2021: 99.3; 2022: 120.4). Regarding dental extractions, the Northeast Region had the highest average in all years (2019: 306.9; 2020: 255.6; 2021: 317.1; 2022: 334.6).

Figure 1
Descriptive analysis of the number of dental extractions and endodontic access performed from 2019 to 2022 among Brazilian regions.

Table 1 presents the mean differences between the years analyzed for Endodontic access and Dental extraction procedures. The two procedures showed a statistically significant reduction between 2019 and 2020 (endodontic access: -27.00, CI: -29.00; -25.00; Dental extractions -84.50, CI: -90.00; -79.00), as expected due to the restrictions imposed by the COVID-19 pandemic. In the following years, both procedures increased significantly, showing a recovery in dental activity. However, when comparing 2019 and 2022, endodontic access does not present statistical difference (-0.50, CI: -2.00; 0.50, p=0,388), meanwhile dental extraction presents a statistical increase (12.00, CI: 8.04; 16.00, p<0.001), indicating a greater trend to mutilating procedures.

Table 1
Analysis of mean differences between the years included in the study for Endodontic access and Dental extraction procedures

Evaluated years		Endodontic access		Dental extractions
		Mean Difference (95% CI)	p-value	Mean Difference (95% CI)	p-value
2019	2020	-27.00 (-29.00; -25.00)	<0.001	-84.50 (-90.00; -79.00)	<0.001
2019	2021	-8.50 (-10.00; -7.00)	<0.001	-13.50 (-17.74; -9.50)	<0.001
2019	2022	-0.50 (-2.00; 0.50)	0.388	12.00 (8.04; 16.00)	<0.001
2020	2021	15.50 (14.00; 17.50)	<0.001	69.00 (65.00; 73.08)	<0.001
2020	2022	24.50 (22.50; 26.50)	<0.001	98.00 (93.00; 103.61)	<0.001
2021	2022	9.00 (8.00; 10.25)	<0.001	30.50 (27.45; 33.50)	<0.001

• Wilcoxon test. CI: Confident Intervals. Source: The authors.

DISCUSSION

The analysis of dental extraction and endodontic access procedures carried out between 2019 and 2022, in the present study, showed a higher prevalence of extractions in the Northeast Region and of endodontic access in the Southeast Region, which may be related to inequalities in access to dental care. Few nationwide studies have simultaneously assessed these two procedures as indirect indicators of the balance between conservative and mutilating dental care in Brazilian primary health services. Furthermore, the comparison between the recovery patterns of endodontic access and dental extractions provides additional evidence that, although dental services resumed after the pandemic, the increase in dental extractions was proportionally greater than the recovery of conservative procedures. This finding expands current knowledge by suggesting that the pandemic may have aggravated the historical pattern of tooth loss within the public health system.

In the last century, oral health care for Brazilians remained outside the country's public health policies, which generated a scenario of precarious oral health conditions and inequalities in the population's access to dental care¹⁶. This scenario began to change with the inclusion of oral health teams in the Family Health Strategy. However, even after thirty years of oral health teams operating in the Unified Health System, access to dental care remains inequitable and restricted¹⁷. Furthermore, the suspension of elective care at the beginning of the COVID-19 crisis is likely to have had a negative impact on the epidemiological advances in oral health achieved in Brazil and increased social inequalities in access to Dentistry¹⁸,¹⁹, findings reinforced by the regional differences and the higher prevalence of dental extractions observed in this study.

In Brazil, the COVID-19 health crisis was responsible for a reduction of more than 50% in primary dental care⁴ and almost 90% in child care²⁰. However, the country showed a significant increase in primary dental procedures after the first year of the pandemic. When comparing the years 2019 and 2022, there was a growth of approximately 9%, which corresponds to more than 3 million additional services²¹. Similar movement was observed in subsidized and private dental care in Iran, which initially experienced a reduction of approximately 46%, but with a gradual increase post-COVID²². In the United States, studies also demonstrated a decrease in the use of dental services during the pandemic. Notably, a faster recovery in emergency service provision was observed, reaching values that exceeded pre-pandemic levels²³.

Aiming to manage and reduce the unmet demand left by the pandemic scenario, some strategies have been adopted. Teledentistry has been employed to address the high demand backlog in primary health care services. This service does not require face-to-face contact between the professional and the patient, showing high patient adherence²⁰,²⁴. In the same way, to combat the precariousness of children's eating habits and oral hygiene, Italy has sought to expand the use of remote communication media to provide oral hygiene guidance for parents and children²⁵. Additionally, in Iran, ways of expanding access to dental care have been discussed in light of the financial losses resulting from the pandemic period, such as state subsidies for dental treatments for the economically disadvantaged portion of the population²². Strategies such as Teledentistry has been included in the Brazilian scenario since COVID-19 pandemic. However, this initiative does not seem to be sufficient to reduce dental extractions in primary health services, observed in this study. Therefore, it is essential to realign proposals and strategic alliances to find practical solutions to the challenges that preceded and were left by the pandemic²⁶.

Data from the period preceding the COVID-19 health crisis already demonstrated difficulties in accessing specialized services in Brazil, given the high demand for these procedures¹⁴. Only a small portion of the Brazilian population had access to endodontic treatment through the Unified Health System (SUS), which was aggravated during the pandemic by the sharp reduction in the number of endodontic treatments and a drop in the productivity of endodontists¹⁴. The resumption of regular dental activities in 2022 promoted a significant increase in the production of this specialty in the Brazilian public health system²⁷. However, this increase was not matched to a increase of endodontic access performed by primary health teams in present study.

Brazil already had a high rate of tooth loss in adults and the elderly²⁸. Data from the National Health Survey showed that 14 million Brazilians over the age of 18 live without any teeth in their mouths²⁹. Tooth loss is a reflection of inequality in access to healthcare and occurs more intensely in the socioeconomically disadvantaged population, representing dentistry focused on carrying out non-conservative curative procedures³⁰,³¹. However, the presence of Dental Specialty Centers has been directly associated with lower proportions of extractions compared to other procedures offered to the population by the public network³². The findings may indicate a greater use of mutilating procedures, which could potentially increase the burden of tooth loss.

Socioeconomic status is directly related to oral health conditions. Tooth loss, as an outcome of more serious and extensive cases of caries, is more frequently associated with lower-income groups, as they are less exposed to fluoridated water and more susceptible to high carbohydrate consumption and unsatisfactory oral hygiene³³. Several social factors can be linked to inequalities in access to health services, such as education level, per capita income and the scarcity of available services³⁴. In Brazil, there is an asymmetry in the distribution of dental services, which is reflected in the lower utilization of health services by socioeconomically vulnerable populations³⁵. At a regional level, the North and Northeast regions have reduced medical and dental care compared to other regions²⁹,³⁴. Notably, even among the most vulnerable population, an increase in the supply of health services does not automatically translate into greater production and utilization of these services, with a greater increase observed among those with lower healthcare needs rather than among those with greater ones³⁶. The lower recovery of endodontic access procedures observed in municipalities with lower HID may reflect reduced availability of specialized oral healthcare services, longer waiting times for referral, and socioeconomic barriers that delay access to conservative treatment¹⁶. Consequently, these factors may increase the likelihood of dental extraction as the definitive therapeutic option.

The findings also have important implications for the public health planning. Reducing regional disparities in oral healthcare requires strengthening the integration between primary and specialized care, expanding the availability and equitable distribution of Dental Specialty Centers, and improving referral and counter-referral pathways for endodontic treatment. Additionally, prioritizing investments in underserved regions, improving workforce allocation, and maintaining preventive and conservative oral healthcare polices may reduce avoidable dental extractions and contribute to more equitable access to specialized dental services.

As limitations of this study, informational bias related to data recorded in SISAB should be acknowledged, considering that the responsibility for correctly recording this data in the information systems of the Brazilian Ministry of Health lies with health professionals and municipal managers, therefore, there may be registration errors. It should be also considered that the COVID-19 pandemic may have affected the quality of routine administrative records. Furthermore, the dental extraction procedure is restricted to permanent teeth, and the COVID-19 pandemic may be linked to the worsening of children's oral health conditions³⁷. Thus, this research has a scope that does not include the entire population served in public health services, and future approaches to this procedure may cover both dentitions. The analyses were based on the absolute number of procedures rather than population-adjustment rates. Therefore, differences in municipal population size should be considered when interpreting the results. Future studies using standardized indicators may provide complementary evidence regarding regional inequalities in access to oral healthcare.

CONCLUSION

From the analysis and interpretation of data on dental extractions and endodontic access carried out in Brazilian public health services in the period from 2019 to 2022, a significant increase in dental extractions was identified, proportionally greater than the recovery observed in endodontic access procedures. Regional analysis revealed persistent disparities in access to dental services across Brazil.

DATA AVAILABILITY

The contents underlying the research text are included in the manuscript. The contents are already available.

How to cite:

Braga-Prado OE, Félix TR, Bulgareli JV, Herval AM. Endodontic access and dental extractions in brazilian primary health services: a cross-sectional study. Rev Odontol UNESP. 2026;55:e20260019. https://doi.org/10.1590/1807-2577.20260019

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CONFLICTS OF INTERESTS

The authors declare that there is no conflict of interest related to this study.

*

CORRESPONDING AUTHOR Otávio Enrico Braga-Prado, UFU - Universidade Federal de Uberlândia, Faculdade de Odontologia, Av. Pará 1720, Bloco 2G, Sala 1, Umuarama, 38405-320 Uberlândia, MG, Brasil, e-mail: [e-mail]

Edited by

Editor: Letícia Helena Theodoro

Publication Dates

• Publication in this collection
  21 Sept 2026
• Date of issue
  2026

History

• Received
  27 Apr 2026
• Accepted
  14 Aug 2026