Inequalities in the use of public oral health services among older adults in Brazil: a national population-based study, 2023

ABSTRACT Objective: To analyze individual and contextual factors associated with the use of public dental services among Brazilian older adults, using data from SB Brasil 2023. Methods: A total of 9,745 older adults were included in this cross-sectional study. The outcome was the use of public oral health services versus private services. Analyses accounted for the complex sampling design and applied multilevel logistic regression with a random intercept at the municipal level, guided by Andersen's Behavioral Model. Independent variables included predisposing factors (race/skin color, sex, and level of education), enabling factors (per capita income and oral health coverage in Primary Health Care) and need factors (edentulism and perceived need for dental treatment and prostheses). Results: The weighted prevalence of public dental service use was 39.2% (95%CI 35.7–42.9). After adjustment, higher odds of using the public system were observed among Black (OR 1.97; 95%CI 1.60–2.40), mixed-race (OR 1.38; 95%CI 1.19–1.61), and Indigenous older adults (OR 5.16; 95%CI 2.01–13.21), as well as among those with edentulism (OR 1.44), perceived need for dental treatment (OR 1.26), and need for prostheses (OR 1.39). Living in municipalities with oral health coverage above 70% was associated with greater use of public services (OR 2.47; 95%CI 1.83–3.31). The proportion of variance attributable to the municipal level decreased from 28.3% in the null model to 16.7% in the final model. Conclusion: Public dental service use among older adults in Brazil is socially stratified and strongly associated with social vulnerability and oral health needs, highlighting the pro-equity role of the Brazilian Unified Health System.