Iniquidades raciais em saúde bucal e no acesso a serviços odontológicos: uma análise do papel do racismo

Abstract

Evidence shows that marginalized racial groups face a higher burden of oral diseases and greater barriers in accessing dental care, but the role of racism in these iniquities remains underexplored. This dissertation investigated the role of racism in the production of racial iniquities in oral health and in access to dental services. Three studies were conducted. The first was a systematic review on the relationship between racism and oral health, focusing on the Black population. Of the 1,034 articles retrieved, 6 met the eligibility criteria. Most studies investigated interpersonal racism, while two addressed structural racism. The outcomes analyzed—self-perceived oral health, tooth loss, and edentulism—indicated an association between racism and worse oral health indicators. Furthermore, a notable scarcity of research on the topic was identified. The second study analyzed racial iniquities in oral health in the Brazilian population using data from the 2019 National Health Survey, based on a complex sample of 64,830 individuals. Outcomes included self-rated oral health, tooth loss, use of dentures, and recent use of dental services. Poisson regression models adjusted for sociodemographic variables showed that Black and Brown individuals had a lower prevalence of positive oral health self-assessment (Black: PR = 0.90; 95%CI 0.87– 0.93; Brown: PR = 0.94; 95%CI 0.92–0.96) and recent use of dental services (Black: PR = 0.93; 95%CI 0.89–0.97; Brown: PR = 0.95; 95%CI 0.92–0.98), as well as a higher prevalence of tooth loss (Black: PR = 1.32; 95%CI 1.18–1.47; Brown: PR = 1.23; 95%CI 1.14–1.34) compared to white individuals, highlighting racial iniquities in the Brazilian population. The third study, with a cross-sectional design, involved 686 undergraduate students. It assessed the association of oral health outcomes (selfperception, oral health impairment, and tooth loss) and access to dental services (access, recent use, and service evaluation) with experiences of interpersonal racial discrimination, the Racial Interaction Index (RII) of the municipality of residence, and neighborhood environment characteristics. Poisson regression models guided by Directed Acyclic Graphs (DAGs) indicated that experiences of interpersonal racial discrimination were associated with lack of access to dental services (PR = 4.86; 95%CI 1.67–14.10), absence of recent use (PR = 1.73; 95%CI 1.30–2.30), and negative evaluation of dental care (PR = 1.66; 95%CI 1.12–2.46). Living in a municipality with a high RII was associated with negative self-perception of oral health (PR = 1.57; 95%CI 1.04–2.37) and a lower probability of reporting lack of access to dental services (PR = 0.38; 95%CI 0.18–0.81). Conversely, living in neighborhoods with better physical and social conditions reduced the probability of negative selfperception (PR = 0.66; 95%CI 0.51–0.85), oral health impairment (PR = 0.87; 95%CI 0.76–0.99), lack of access (PR = 0.34; 95%CI 0.15–0.75), and negative evaluation of dental services (PR = 0.51; 95%CI 0.37–0.72). These findings reinforce racism as a determinant of oral health, operating through both structural and interpersonal pathways. The dissertation highlights the significant impact of racism, at different levels, on oral health and access to dental care, underscoring the urgent need to expand scientific research on the subject, deepen the understanding of racial iniquities in oral health, and inform the development of effective strategies for their mitigation.