Having health and oral health services available and making them affordable and of a good quality are some of the most important attributes for a developed society. Although it remains unknown whether universal access to health care can reduce social and health inequities, a fair society must guarantee universal access, including access to dental care as part of the health system. This must be a goal for social development as stated in the SDG 20301⁠.

One of the most important policies in the context of the Brazilian Unified Health System (SUS) has been the National Oral Health Policy-PNSB called “Brasil Sorridente” (Smiling Brazil) published in 20042⁠. Among the many advances that the policy produced, there was an exponential increase in the number of primary oral health teams in the family health strategy, with more than 25,000 teams implemented, together with the establishment of more than 1,000 Dental Specialties Centers – DSC – throughout the country.

The DSC are secondary care facilities in oral health. They are considered an innovative part of the PNSB policy and should constitute reference units for Primary Care Teams, integrated into the regional planning process, which use a referral system between primary and secondary care. The innovative concept called “matrix support” and permanent education are instruments to ensure comprehensive care.3, 4

Within this perspective and with a commitment to maintain the continuous improvements produced by these initiatives, the Quality and Access Improvement Program (PMAQ) was established in 2014. The PMAQ has two versions, one focused on primary care (PMAQ-AB) and the other exclusively on secondary dental care (PMAQ-CEO). The PMAQ-CEO has been carried out in two waves, Wave 1 in 2014 and Wave 2 in 2018. One important component is the external evaluation of the PMAQ-CEO. This external evaluation has been carried out under the coordination of the Collaborating Centre for Health Surveillance (CECOL) at the Federal University of Pernambuco. The CECOL has worked with the Ministry of Health, in addition to the following institutions: Federal Universities of Maranhão (UFMA), Paraíba (UFPB), Minas Gerais (UFMG), Rio Grande do Sul (UFRGS) and University of São Paulo (USP). These institutions macro-regionally coordinated the data collection locally by another 18 higher education institutions and around 100 trained evaluators across the country. As Brazil is a continental country, the partnership established between all these institutions allowed for the verification – “in loco” – of the access to and quality of approximately 1089 CEO services authorized by the Ministry of Health.

The theoretical-methodological framework that guided the external evaluation of the PMAQ-CEO was a systemic approach with the triad: structure-process-results5-7(Donabedian, 1986). The aspects of the structure involve the physical structure, as well as material and human resources. The process involves the actions of governance, organization and planning of health services at the local level. The results were measured by user satisfaction in a sample of people attending the centre being evaluated. The methodology for Wave 1 of the PMAQ CEO has been previously reported.8

Within the field of Dental Public Health, whilst there have been marked developments in terms of oral epidemiology and the effectiveness and efficacy of dental public interventions, areas such as the planning, management and evaluation of public health policies remain under researched. This special issue will act to open a debate and offer insights and expertise as to the importance of dental public health quality evaluation for an international audience.

This special issue covers a wide range of areas within nine papers. The first paper aimed to verify racial differences in the performance of Dental Specialities Centers in Brazil, according to the presence of active health ombudsman on four primary outcomes: (1) access and dental appointment, (2) reception services, (3) bond and responsibility and (4) social participation and concluded that Dental Specialities Centers that use health ombudsman for planning have attenuated racial inequities in all analysed dimensions.9⁠ The second paper assessed the association between the structure and process of Brazilian Dental Specialty Centers (CEO, in Portuguese) and user satisfaction with secondary dental care services. Characteristics of the process and structure were associated with user satisfaction, but a quality of care was perceived by users, mainly due to structural characteristics.10 The third paper analysed the provision of oral cancer (OC) care services in the Dental Specialties Centers (Centros de Especialidades Odontológicas-CEO) in Brazil and identify changes over two cycles of external evaluation of the Program for the Improvement of Access and Quality-PMAQ, in 2014 and 2018 and concluded that there are regional inequities in the provision of OC care in CEO. Most services improved their work process or remained stable. However, the biopsies and the referral to hospital care for confirmed cases declined, indicating that CEO need to improve planning and care provision to reduce OC morbimortality.11 The fourth paper assessed the performance and changes in the number of clinical procedures in secondary dental care in Brazil. Pay for performance in the PMAQ/CEO scheme can favour the production of secondary dental care. Besides, as expected, the increase in the number of dentists is associated with the increase in specialized production.12⁠ The fifth paper aimed at the assessment of the association between the structure and process of Brazilian Dental Specialty Centers (CEO, in Portuguese) and user satisfaction with secondary dental care services. Characteristics of the process and structure were associated with user satisfaction, but the quality of care was perceived by users, mainly due to structural characteristics.13 The sixth paper verified which factors that enable the goals achievement of endodontic procedures contextual and local determinants are associated with the achievement of goals in the endodontic specialty in the Dental Speciality Centers in Brazil. Factors such high level of patients’ not ateendance of their appointmets, availability of endodontists for more than 40 hours a week, a waiting time for endodontic procedures greater than 45 days, type of CEO, the number of endodontic instruments in sufficient number and have a preventive program in the primary care.14⁠ The seventh paper investigated the satisfaction of users of Dental Specialty Centers (CEO) in Brazil employing the Service Satisfaction Index (SSI) and identifying associated factors. The maximum satisfaction with the service was influenced by age, education, waiting time, not having treatment interrupted and considering CEO clean and hygienic environment.15⁠ The eighth paper analysed the factors associated with the waiting time for access to specialized care at Specialized Dental Care Centers (SDCCs) – a secondary level of assistance in the Brazilian Healthcare System, which concluded that different factors related to the service, management and a form of relationship with primary health care secondary influenced the waiting time for specialized care in SDCCs. The contact between professionals in the oral health network (primary care and SDCCs) was associated with a shorter waiting time, regardless of the specialty.16⁠ And finally, the ninth paper identified changes in the provision of dental services to people with disabilities (PD) in the Dental Specialties Centers (acronym CEO in Portuguese – Centro de Especialidades Odontológicas) between the first and second cycles of the Program for the Improvement of Access and Quality of Dental Specialties Centers and analysed factors associated with changes. We can observe advances in the provision and more significant transitions to the “Better” class, with improvements mainly in the interface with primary and tertiary care. However, some deteriorations were noted, such as providing professionals with exclusive care for patients with disabilities.17⁠

Community Dentistry & Oral Epidemiology has been the leading journal in Dental Public Health with an international perspective having the most cited papers in the field18⁠. Approximately 90% of all papers in core journals have some connection to health policy, planning and health service research.19⁠ The journal understands that local context makes a difference in the implementation process and outcome of any policy and so, country-specific papers have an important contribution to make. Therefore, in this special issue, we present a series of papers from the Brazilian perspective on the assessment of secondary dental care, and authors were challenged to give an international perspective to the readers to export a successful program. Any local experience is unique in the field of health policy and planning, but we believe that this special issue provides sufficient information about the Brazilian experiences for policy-makers to adapt and apply them in new settings. Our experience contributes to other initiatives to establish evidence of quality in dental care evaluation. In addition, there have been international entities promoting this discussion,20 including the dissemination of Guides21 and, above all, for the importance of establishing proper quality attributes in oral health.22, 23

We acknowledge the National Health Fund for funding the project; The General Coordination of Oral Health Policy from Ministry of Health of Brazil for technical partnership; The research board of PMAQ CEO that includes: Nilcema Figueiredo, Gabriela da Silveira Gaspar and Petrônio José Martelli from Federal University of Pernambuco (UFPE); Edson Hilan Gomes de Lucena and Wilton Wilney Nascimento Padilha from Federal University of Paraíba (UFPB); Erika Bárbara Abreu Fonseca Thomaz from Federal University of Maranhão (UFMA); Marcos Azeredo Furquim Werneck from Federal University of Minas Gerais (UFMG); Fernando Neves Hugo from Federal University of Rio Grande do Sul (UFRGS); Maria Ercília de Araújo And Fernanda Campos de Almeida Carrer from University of São Paulo (USP). There was no conflict of interest.