This is a cross-sectional study carried out at the Jardim das Palmas Basic Health Unit (BHU), located in the southern region of the city of São Paulo, with 5 FHS teams and 3 OHS teams, consisting of Dental Surgeon, Oral Health Technician and Oral Health Assistant, providing care to 19,136 people distributed in approximately 5,638 families. The population is mostly composed of young adults aged 20–39 (n = 6738) and adults aged 40–49 (n = 2506), totaling 9,242 (48%) individuals, the remainder being divided into the age groups: less than 1 year old (n = 298), from 1 to 4 years old (n = 1117), from 5 to 6 years old (n = 587), from 7 to 9 years old (n = 911), from 10 to 14 years old (n = 1442), from 15 to 19 years old (n = 1647), and 50 years old or older (n = 3,890). Of the total, 59.02% do not have water treatment at home, 16.05% live near open sewers and 88% of the individuals are dependents of the Brazilian Unified Health System (SUS).
Until 2016, the access to oral health services occurred through priority groups, family screening with classification of biological risk and spontaneous demand. The spontaneous dental demand in this BHU was met on a first-come, first-served basis, and no instrument was used to prioritize access. Since April 2016, the BHU began using risk assessment instruments to meet the spontaneous demand: color risk classification scale , family risk assessment , caries risk and periodontal risk , as can see on Fig. 1. Dental health service flow chart.
In color risk classification scale, non-acute situations are identified by the color BLUE and acute situations by the colors: RED (immediate care – high risk of death), YELLOW (priority care – moderate risk), GREEN (sporadic care – low risk or no risk with significant vulnerability). In addition, “Acute” is considered priority, immediate or sporadic care, and “Non-acute” are scheduled interventions . Most of the time, from the perspective of oral health complaints, pain situations are not life-threatening. Therefore, only the colors blue, yellow and green were used in this research to classify spontaneous dental demand, excluding red.
The color risk classification scale used to prioritize care adopted the colors yellow (pulpitis, edema, dental fracture, uncontrolled bleeding, joint dislocation, painful oral lesions), green (pain on probing, tenderness, trauma without acute symptoms, non-spontaneous bleeding, lesion suspected of malignancy) and blue (history of pulp or periodontal pain, history of lesions on the oral mucosa, history of bleeding without acute symptoms).
The family risk assessment instrument proposed by Coelho and Savassi  was also used, divided into 3 categories: R1 – low risk (score lower than 5), R2 – moderate risk (score between 7 and 8), R3 – high risk (score above 9). In the BHU where the study was conducted, Coelho’s scale is applied by the Oral Health Team, according to sociodemographic and socioeconomic data collected by the Community Health Agent (ACS), used as an instrument for organizing access.
In addition, the classification of biological risk was used to assess the risk of caries and periodontal disease, along with the soft tissue assessment proposed by the Municipal Health Secretariat of São Paulo . Caries risk was classified as: Low risk (A – no caries lesion, no plaque, no gingivitis and/or no stain), Moderate risk (B – history of dental restoration, no plaque, no gingivitis and/or no active white spot, C – one or more chronic caries lesions, but no plaque, no gingivitis and/or no active white spot), and High risk (D – absence of caries lesion or history of dental restoration, but with presence of plaque, gingivitis and/or active white spot), (E – one or more acute caries lesions), (F – presence of pain and/or abscess) .
Periodontal risk was assessed by sextant, according to the Municipal Health Guidelines of São Paulo, and classified as: Low risk (0 – healthy periodontium), (X – absence of teeth in the sextant), Moderate risk (1 – gingivitis), (2 – supragingival calculus), (B – sequelae of previous periodontal disease), High risk (6 – supragingival calculus visible due to gingival retraction and with reversible or no mobility), (8 – irreversible mobility and loss of function) .
The soft tissues were classified as: no risk (0 – normal tissues) and presence of risk (1 – soft tissue abnormalities) .
color risk classification scaleIn the first appointment, color risk classification scale (BLUE, YELLOW and GREEN) and Coelho and Savassi’s scale were used to prioritize spontaneous demands, as well as the number of patients treated. In the second appointment, the classification of biological risk was used in association with Coelho and Savassi’s scale to prioritize the access to continued dental treatment, based on the first appointment.
Coelho and Savassi’s scale was applied by the OHS after calibration and collection of information from File A.
Secondary data were extracted from the medical records of the patients who accessed the dental service through spontaneous demand in the period prior to (from April 2015 to March 2016) and one year after the implementation of risk assessment (from April 2016 to March 2017), corresponding to a total of (n = 1215) cases.
As inclusion criteria, the records of patients who sought the service through spontaneous demand from April 2015 to March 2017 were evaluated, and the records of cases with no information on more than 70% of the variables were excluded from the study.
The main explanatory variables analyzed were the use of color risk classification scale and Coelho and Savassi’s family risk scale  as instruments for organizing and prioritizing spontaneous demands. The data on caries risk, periodontal disease, soft tissue, age and sex, adopted as independent variables for adjustment, were obtained from the spontaneous demand monitoring worksheet.
So, this study analyzed the influence of the implementation of color risk classification scale , Coelho and Savassi’s scale  and the biological risk scale  on the access to dental services through spontaneous demand, first scheduled appointment and the resolvability of treatment based on the number of completed treatments (CT).
The study’s dependent variables were access and resolvability. The following variables were used as proxy for Access: 1) first scheduled dental appointment (yes and no), and 2) sporadic care (yes and no), referring to patients who sought the service through spontaneous demand and were seen on the same day. Resolvability was analyzed based on the number of Completed Treatments (CT) (yes and no).
The clinical complaint and diagnostic hypothesis (DH) variables were grouped into the following categories: Clinical complaint – Broken tooth (broken filling and decayed tooth); Pain (toothache and tenderness); Swelling (swollen tooth and face); Gum inflammation (bleeding and loose tooth); Trauma; Others (crooked teeth, stain on teeth, broken dentures, wants to remove tooth or stitches, mouth sore and lip sore); Shedding of deciduous teeth. The diagnostic hypothesis variable was grouped into the following categories: Caries/pulp-related disease (abscess, infection, fistula, apical injury, endodontics, pulpitis, extraction, residual root, pericementitis, restoration and caries); Periodontal disease (gingivitis, hyperplasia, periodontitis, inflammation, mobility, periodontics, scraping, gingival retraction, abfraction, tenderness, pericoronitis, impacted teeth); Eruption; Exfoliation; Trauma (facial trauma, dental trauma, intrusion, dislocation, fracture; Other (occlusal adjustment, bruxism, cementation, TMD, pigmentation, partial dentures, X-ray, suture removal, no abnormalities, oral lesions). The color risk classification scale variable is represented by the colors yellow, green and blue.
The associations between the study’s variables were analyzed according to the implementation of the demand organization instruments (color risk classification scale and Coelho and Savasse’s scale), using chi-square tests. The association between independent variables (socioeconomic and demographic variables) and dependent variables (first appointment, type of access and resolvability with the risk scales’ implementation) was analyzed using Logistic Regression. Moreover, bivariate analyses were performed using the chi-square test to evaluate the associations between each risk assessment instrument, e.g., between color risk classification scale and the other variables, and Fisher’s exact test was used to evaluate the association between Coelho and Savassi’s scale and the other variables. The significance level adopted was 5%. The analyses were performed on software R version 3.2.2.
The research project was approved by the Research Ethics Committee of School of Dentistry of Piracicaba, São Paulo, Brazil (CEP-FOP/UNICAMP), according to Resolution 466/12 of the Brazilian National Health Council.