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8 rev port estomatol med dent cir maxilofac . 2026;67(1):2-10

sonable program performance: most women who receive cation. An important limitation of this pilot study is the inabil-
vouchers do use them. However, when population coverage— ity to perform multivariate analyses due to sample size con-
the proportion of pregnant women who actually access the straints. Additionally, the dental voucher data analysis
program—is considered, a different picture emerges. Only 40- assumes that each pregnancy redeems all three allocated
46% of women who gave birth in 2022-2024 used at least one vouchers; however, some women use fewer than three, which
voucher, meaning the program fails to reach over half of eligi- probably leads to an underestimation of utilization and cover-
ble women. age. Additionally, coverage calculations are based on live births
This disconnect raises critical questions about program in the same calendar year, meaning pregnancies that result in
access and resource allocation. Crucially, this pattern rep- miscarriage or births in the following year are not captured.
resents significant resource inefficiency: vouchers are issued The complex decision-making process surrounding vouch-
but not redeemed, while simultaneously many pregnant wom- er utilization likely involves multiple factors that cannot be
en who could benefit from care never access it. Understanding adequately examined through descriptive statistics alone.
who uses the program, who does not, and critically, why Variables such as educational background, work status, prior
non-users do not engage was precisely the motivation for this dental experiences, and health insurance coverage may inter-
study. Without this knowledge, the system cannot differentiate act in ways that influence voucher uptake. However, our cur-
between women who opt not to participate and those who face rent analysis cannot control for the independent effects of
barriers — a distinction vital for effective intervention design. these relationships. Future research with larger sample sizes
Moreover, the persistent gap between voucher issuance and should employ advanced statistical methods to better under-
population reach suggests opportunities for resource realloca- stand the multifaceted determinants of participation in the
tion: unused vouchers could be redirected to women who re- Dental Voucher program for pregnant women.
quire additional care beyond the standard allocation, address-
ing unmet clinical needs while reducing waste. However,
implementing such reforms requires precisely the granular Conclusions
understanding of utilization determinants that current data
systems do not capture. The Dental Voucher program for pregnant women demon-
Finally, our experience also yields insights into systemic strates policy commitment, with voucher issuance quadru-
challenges and methodologies. Our difficulty recruiting par- pling since 2008. However, this expansion has not translated
ticipants (n=38 despite contacting all ULSs nationally) is itself into proportional population reach. Evidence-based reform
a finding that exposes fragmentation within the SNS. Portugal must operate at multiple levels simultaneously:
cannot improve what it does not measure. The last compre-
hensive national survey of oral health was published in 2015, • For individuals: integrate standardized oral health coun-
and routine data collection on determinants of voucher uptake seling and voucher information into first prenatal visits,
and oral health outcomes remains fragmented. These findings implement SMS reminder systems, and simplify re-
underscore the pressing need for improved data collection demption procedures.
within the SNS. Without standardized, high-quality data on • For providers: adjust voucher values to reflect actual
oral health behaviors and service utilization, policymakers costs with inflation indexing, streamline administrative
cannot effectively monitor program performance or tailor in- barriers, and expand networks in underserved regions.
terventions. Bureaucratic obstacles, exemplified by our expe- • For the system: establish unified data platforms for re-
rience in the need for repeated ethical approvals and limited al-time monitoring, mandate routine collection of oral
cooperation from the ULSs, further hinder research progress health metrics, and foster an organizational culture that
and maintain evidence gaps. Integrating a unified data plat- values implementation research.
form into the SNS infrastructure, supported by clear mandates
for routine oral health metrics, may establish the feedback Most urgently, the absence of updated and comprehensive
mechanisms necessary to refine and efficiently expand vouch- oral health burden-of-disease surveillance, along with frag-
er programs. Equally important is fostering a research culture mented data systems, prevents the continuous learning nec-
within ULSs, ensuring that frontline providers contribute to essary for program optimization. Without infrastructure to
and benefit from a continuous cycle of data-driven improve- measure, monitor, and learn from implementation, even
ment. Without these reforms, access will remain fragmented, well-designed interventions cannot achieve their potential.
and the burden of preventable oral disease will remain unnec- The program has demonstrated two decades of commitment;
essarily high. it now requires the evidence-based infrastructure and imple-
Strengths of this study include its focus on real-world be- mentation focus necessary to fully realize its potential in re-
haviors within a national context and its detailed mapping of ducing preventable oral disease among pregnant women in
system-level and informational barriers. However, its small Portugal.
sample size (n = 38) and reliance on self-reported data limit
external validity and may introduce recall and reporting bias-
es. Furthermore, we only reached pregnant women who used Acknowledgments
primary care services, excluding those who used only private
clinics or hospitals. Therefore, these preliminary findings do The authors would like to express their sincere gratitude to all
not allow for statistical inference or population-level stratifi- participating ULS.