Open Access

Utilization of tooth filling services by people with disabilities in Taiwan

  • Ming-Chuan Chen1, 2, 3,
  • Pei-Tseng Kung4,
  • Hsun-Pi Su5,
  • Suh-May Yen6,
  • Li-Ting Chiu2 and
  • Wen-Chen Tsai2Email author
International Journal for Equity in HealthThe official journal of the International Society for Equity in Health201615:58

https://doi.org/10.1186/s12939-016-0347-3

Received: 31 October 2015

Accepted: 1 April 2016

Published: 5 April 2016

Abstract

Background

The oral condition of people with disabilities has considerable influence on their physical and mental health. However, nationwide surveys regarding this group have not been conducted. For this study, we used the National Health Insurance Research Database to explore the tooth filling utilization among people with disabilities.

Methods

Using the database of the Ministry of the Interior in 2008 which included people with disabilities registered, we merged with the medical claims database in 2008 of the Bureau of National Health Insurance to calculate the tooth filling utilization and to analyze relative factors. We recruited 993,487 people with disabilities as the research sample.

Results

The tooth filling utilization was 17.53 %. The multiple logistic regression result showed that the utilization rate of men was lower than that of women (OR = 0.78, 95 % CI = 0.77–0.79) and older people had lower utilization rates (aged over 75, OR = 0.22, 95 % CI = 0.22–0.23) compared to those under the age of 20. Other factors that significantly influenced the low tooth filling utilization included a low education level, living in less urbanized areas, low economic capacity, dementia, and severe disability.

Conclusion

We identified the factors that influence and decrease the tooth-filling service utilization rate: male sex, old age, low education level, being married, indigenous ethnicity, residing in a low urbanization area, low income, chronic circulatory system diseases, dementia, and severe disabilities. We suggest establishing proper medical care environments for high-risk groups to maintain their quality of life.

Keywords

Tooth filling utilization Disability Dental services

Background

Oral diseases are crucial health concerns for people with disabilities [1]. Because of their physical and mental limitations, the activities of daily living of people with disabilities are restricted. Moreover, people with disabilities have limited self-care abilities, relatively poor health conditions, and a low utilization of medical services [24]; hence, they generally have poor oral conditions and several periodontal diseases [57]. Oral health conditions generally influence various aspects of life, such as nutritional status, quality of life, and personal perceptions and feelings [810]. In addition, oral health is a critical factor influencing overall health. Therefore, the oral health and treatment of people with disabilities require further attention.

Regarding the number of decayed, missing, or filled teeth (i.e., the DMFT index), studies have indicated that the total DMFT score for people with disabilities is higher than that for people without disabilities [6]. Despite the high proportion of decayed or missing teeth, people with disabilities have a low rate of tooth fillings [11]. Tooth decay can induce pain and cause difficulty in food consumption and chewing; in severe cases, infection-caused sepsis can endanger patients’ lives [12, 13]. Missing teeth may alter teeth arrangement, affect chewing ability [14], and trigger periodontal diseases. Moreover, malocclusion caused by missing teeth can induce temporomandibular pain and affect the facial appearance [15].

According to dental early-treatment concepts, tooth fillings can prevent teeth from further decay, preserve the original tooth root, reduce the possibility of severe decay or cavities, and reduce the utilization of additional medical services. Therefore, the utilization of the tooth-filling services is a major indicator of the oral healthcare status for people with disabilities. In addition, the utilization of preventive health services was associated with gender, marital status [16], educational level, age, income, health status, severity of disability, and urbanization level of residence area [17].

This study used a nationwide survey to investigate the tooth-filling service utilization rate among approximately 0.93 million Taiwanese people with disabilities and to explore the factors that influence tooth-filling utilization. Moreover, we present a population-based statistical analysis that could serve as a reference or foundation for future studies.

Methods

Data source and processing

We used the database of the Ministry of the Interior (Taiwan) for 2008, which included information of the registered people with disabilities. In 2008, Taiwan had 1,040,585 people with disabilities, accounting for 4.52 % of the population. Additionally, we merged the medical claims database of the Bureau of National Health Insurance of Taiwan for 2008. In 2007, 22.60 million (98.43 %) of Taiwan’s total population (22.96 million) was enrolled in the NHI program. This NHI research database includes the details of all medical services utilized by the enrollees.

We recruited 933,487 participants in 2008. Among the participants, 14,558 (1.56 %) had undergone endodontic therapy, 101,905 (10.92 %) had received amalgam or composite resin tooth fillings, 47,155 (5.05 %) had received both procedures, and 769,869 (82.47 %) did not receive tooth fillings. This study was approved by the institutional review board of China Medical University and Hospital (IRB No. CMUH102-REC3-076).

Description of variables

The independent variables were (a) personal characteristics, such as sex, age, education level, marital status, and indigenous ethnicity; (b) economic status, such as premium-based monthly salary (seven levels based on income) and low-income households; (c) health condition, such as catastrophic injuries or illnesses, chronic diseases, disability categories, and disability degrees; and (d) environmental factors, such as the degree of urbanization (levels 1–7 for highly urbanized cities and townships, moderately urbanized cities and townships, emerging cities and townships, average cities and townships, aging cities and townships, agricultural cities and townships, and remote cities and townships, respectively).

Study participants

The study participants encompassed people with disabilities of all ages. Disabilities considered in this study were visual impairment, hearing impairment, speech impediment, limb impairment, mental illness, multiple impairments, major organ malfunction, facial disfigurement, dementia, autism, chromosomal abnormalities, congenital metabolic disorders, congenital defects, mental illness, impaired balance, refractory epilepsy, and disabilities caused by rare diseases. We excluded chronically unconscious patients because they are unsuitable for evaluating the tooth-filling service utilization rate.

Statistical analyses

We used descriptive statistics to analyze the utilization of tooth-filling services by people with disabilities. By exploring tooth-filling service utilization rates and its correlation with several variables through a bivariate analysis, we summarized all variables as distinguishable-category data. Furthermore, we used SAS software, chi-square test, Fisher exact test, and univariate logistic regression to examine the correlation between variables and tooth-filling service utilization rates. In addition, we used logistic regression to examine the potentially independent effect of demographic and clinical variables on utilization. We also performed the Likelihood Ratio Test to evaluate the validity of the adjusted logistic regression model. The value of -2LL (i.e., -2 times the log likelihood) was used to assess the significance of logistic regression model. The test was significant and implied the validity of the adjusted logistic regression model in our study.

Results

Basic characteristics of people with disabilities

Males comprised 58.6 % (N = 547,017) of the participants. The average age of the participants was 49.98 years (SD = 18.97). The majority of the participants were either illiterate or possessed an elementary school level education (42.36 %, N = 395,409). The urbanization degree of nearly 80 % of the participants ranged from 1 to 4. The dependent-population (i.e., children and older adults) were the largest group when stratified by premium-based monthly salary (33.47 %, N = 312,480).

People with catastrophic injuries or diseases accounted for 31.17 % (N = 290,971). People with chronic diseases such as endocrine and congenital metabolic disorders, mental disorders, circulatory system diseases, digestive system diseases, and musculoskeletal system disorders and connective tissue diseases comprised the majority, with each disease accounting for approximately 30 % of the total. Limb impairment was the largest disability category (37.47 %, N = 349,790), followed by mental illness, major organ malfunction, and mental illness (approximately 10 % each). Regarding the disability degree, participants with mild and moderate disabilities accounted for 72.04 % (N = 672,409) of the study population (Table 1).
Table 1

The tooth filling utilization among people with disabilities: basic characteristics and bivariate analysis

     

Did not use

Used

 

Variables

Total

%

N

%

N

%

p-value

Overall rate of use

933,487

 

769,869

82.47

163,618

17.53

 

Gender

      

<0.001*

 

Female

386,470

41.40

312,284

80.80

74,186

19.20

 
 

Male

547,017

58.60

457,585

83.65

89,432

16.35

 

Age

      

<0.001*

 

<20 years

79,290

8.49

58,567

73.86

20,723

26.14

 
 

20–24 years

30,235

3.24

23,740

78.52

6,495

21.48

 
 

25–29 years

41,815

4.48

33,296

79.63

8,519

20.37

 
 

30–34 years

44,714

4.79

36,249

81.07

8,465

18.93

 
 

35–39 years

53,901

5.77

44,191

81.99

9,710

18.01

 
 

40–44 years

73,354

7.86

60,246

82.13

13,108

17.87

 
 

45–49 years

97,836

10.48

80,184

81.96

17,652

18.04

 
 

50–54 years

98,301

10.53

80,820

82.22

17,481

17.78

 
 

55–59 years

92,438

9.90

76,513

82.77

15,925

17.23

 
 

60–64 years

73,382

7.86

61,112

83.28

12,270

16.72

 
 

65–69 years

81,554

8.74

68,799

84.36

12,755

15.64

 
 

70–74 years

82,694

8.86

71,648

86.64

11,046

13.36

 
 

≥75 years

83,973

9.00

74,504

88.72

9,469

11.28

 

average age (mean, SD)

49.98

18.97

50.76

18.73

46.27

19.66

 

Educational level

      

<0.001*

 

Elementary school and under

395,409

42.36

339,179

85.78

56,230

14.22

 
 

Junior high school

160,067

17.15

132,981

83.08

27,086

16.92

 
 

Senior (vocational) high school

170,568

18.27

134,799

79.03

35,769

20.97

 
 

Junior college and university or above

78,672

8.43

57,953

73.66

20,719

26.34

 
 

Unclear

128,771

13.79

104,957

81.51

23,814

18.49

 

Marital status

       

<0.001*

 

Married

 

421,340

45.14

348,931

82.81

72,409

17.19

 
 

Unmarried

 

235,128

25.19

189,964

80.79

45,164

19.21

 
 

Divorced or widowed

31,110

3.33

25,891

83.22

5,219

16.78

 
 

Unclear

 

245,909

26.34

205,083

83.40

40,826

16.60

 

Aboriginal status

      

<0.001*

 

No

 

915,624

98.09

754,092

82.36

161,532

17.64

 
 

Yes

 

17,863

1.91

15,777

88.32

2,086

11.68

 

Urbanization of residence areaa

      

<0.001*

 

Level 1

 

171,415

18.36

134,078

78.22

37,337

21.78

 
 

Level 2

 

239,908

25.70

192,884

80.40

47,024

19.60

 
 

Level 3

 

178,416

19.11

147,534

82.69

30,882

17.31

 
 

Level 4

 

178,728

19.15

151,507

84.77

27,221

15.23

 
 

Level 5

 

36,456

3.91

32,053

87.92

4,403

12.08

 
 

Level 6

 

66,598

7.13

58,017

87.12

8,581

12.88

 
 

Level 7

 

61,966

6.64

53,796

86.82

8,170

13.18

 

Premium-based monthly salary (NT$)

      

<0.001*

 

Dependent population

312,480

33.47

257,249

82.32

55,231

17.68

 
 

≤17,280

262,965

28.17

220,503

83.85

42,462

16.15

 
 

17,281–22,800

253,096

27.11

212,029

83.77

41,067

16.23

 
 

22,801–28,800

35,726

3.83

27,978

78.31

7,748

21.69

 
 

28,801–36,300

24,772

2.65

19,049

76.90

5,723

23.10

 
 

36,301–45,800

26,214

2.81

19,857

75.75

6,357

24.25

 
 

≥45,801

18,234

1.95

13,204

72.41

5,030

27.59

 

Low-income household

      

<0.001*

 

No

 

877,491

94.00

722,409

82.33

155,082

17.67

 
 

Yes

 

55,996

6.00

47,460

84.76

8,536

15.24

 

Catastrophic injury or disease

      

<0.001*

 

No

 

642,516

68.83

534,430

83.18

108,086

16.82

 
 

Yes

 

290,971

31.17

235,439

80.91

55,532

19.09

 

Relevant chronic diseases

       
 

Cancer

      

<0.001*

  

No

884,359

94.74

730,664

82.62

153,695

17.38

 
  

Yes

49,128

5.26

39,205

79.80

9,923

20.20

 
 

Endocrine and metabolic disease

      

0.001*

  

No

664,445

71.18

547,440

82.39

117,005

17.61

 
  

Yes

269,042

28.82

222,429

82.67

46,613

17.33

 
 

Mental illness

      

<0.001*

  

No

668,022

71.56

557,214

83.41

110,808

16.59

 
  

Yes

265,465

28.44

212,655

80.11

52,810

19.89

 
 

Disease of the nervous system

      

<0.001*

  

No

789,656

84.59

652,148

82.59

137,508

17.41

 
  

Yes

143,831

15.41

117,721

81.85

26,110

18.15

 
 

Disease of the circulatory system

     

<0.001*

  

No

589,991

63.20

481,890

81.68

108,101

18.32

 
  

Yes

343,496

36.80

287,979

83.84

55,517

16.16

 
 

Disease of the respiratory system

     

<0.001*

  

No

782,423

83.82

649,470

83.01

132,953

16.99

 
  

Yes

151,064

16.18

120,399

79.70

30,665

20.30

 
 

Disease of the digestive system

     

<0.001*

  

No

682,929

73.16

568,242

83.21

114,687

16.79

 
  

Yes

250,558

26.84

201,627

80.47

48,931

19.53

 
 

Disease of the urinary system

     

<0.001*

  

No

869,390

93.13

716,469

82.41

152,921

17.59

 
  

Yes

64,097

6.87

53,400

83.31

10,697

16.69

 
 

Disease of the skeletal and muscular system and connective tissue

   

<0.001*

  

No

692,897

74.23

577,247

83.31

115,650

16.69

 
  

Yes

240,590

25.77

192,622

80.06

47,968

19.94

 
 

Disease of the eyes and auxiliary organs

     

<0.001*

  

No

856,755

91.78

709,338

82.79

147,417

17.21

 
  

Yes

76,732

8.22

60,531

78.89

16,201

21.11

 
 

Infectious diseases

      

<0.001*

  

No

905,982

97.05

747,844

82.55

158,138

17.45

 
  

Yes

27,505

2.95

22,025

80.08

5,480

19.92

 
 

Congenital malformation

     

<0.001*

  

No

912,276

97.73

753,770

82.63

158,506

17.37

 
  

Yes

21,211

2.27

16,099

75.90

5,112

24.10

 
 

Skin and subcutaneous tissue disorders

     

<0.001*

  

No

866,628

92.84

716,390

82.66

150,238

17.34

 
  

Yes

66,859

7.16

53,479

79.99

13,380

20.01

 
 

Diseases of the blood and blood-forming organs

     

<0.001*

  

No

902,629

96.69

744,849

82.52

157,780

17.48

 
  

Yes

30,858

3.31

25,020

81.08

5,838

18.92

 
 

Diseases of the ear and mastoid process

     

<0.001*

  

No

885,954

94.91

732,903

82.72

153,051

17.28

 
  

Yes

47,533

5.09

36,966

77.77

10,567

22.23

 
 

Others

       

<0.001*

  

No

821,048

87.95

681,738

83.03

139,310

16.97

 
  

Yes

112,439

12.05

88,131

78.38

24,308

21.62

 

Type of disability

     

<0.001*

 

Visual impairment

46,201

4.95

38,131

82.53

8,070

17.47

 
 

Hearing impediment

85,252

9.13

67,004

78.60

18,248

21.40

 
 

Speech impediment

12,539

1.34

10,210

81.43

2,329

18.57

 
 

Limb impediment

349,790

37.47

292,704

83.68

57,086

16.32

 
 

Mental retardation

94,627

10.14

78,660

83.13

15,967

16.87

 
 

Multiple impediments

90,649

9.71

78,549

86.65

12,100

13.35

 
 

Major organ malfunction

105,927

11.35

85,828

81.03

20,099

18.97

 
 

Facial disfigurement

4,349

0.47

3,505

80.59

844

19.41

 
 

Dementia

16,441

1.76

14,766

89.81

1,675

10.19

 
 

Autism

9,155

0.98

6,484

70.82

2,671

29.18

 
 

Chromosomal abnormalities

2,102

0.23

1,645

78.26

457

21.74

 
 

Congenital metabolic disorders

611

0.07

389

63.67

222

36.33

 
 

Congenital defect

1,106

0.12

836

75.59

270

24.41

 
 

Mental illness

106,442

11.40

84,672

79.55

21,770

20.45

 
 

Impaired balance

2,733

0.29

2,284

83.57

449

16.43

 
 

Refractory epilepsy

4,153

0.44

3,148

75.80

1,005

24.20

 
 

Rare diseases

1,410

0.15

1,054

74.75

356

25.25

 

Severity of disability

      

<0.001*

 

Mild

354,883

38.02

282,016

79.47

72,867

20.53

 
 

Moderate

317,526

34.02

262,009

82.52

55,517

17.48

 
 

Severe

158,648

17.00

137,106

86.42

21,542

13.58

 
 

Very severe

102,430

10.97

88,738

86.63

13,692

13.37

 

aLevel one: the most urbanized areas

*p < 0.05

Tooth-filling utilization among people with disabilities

In this study, 17.53 % (N = 163,618) of the participants used tooth-filling services (Table 1). The tooth-filling service utilization rate for males (16.35 %) was lower than that for females (19.20 %) (p <0.001). Younger participants (<20 years) demonstrated a high utilization rate (26.14 %), whereas older participants (>30 years) demonstrated a utilization rate of <20 % (p <0.001).

Participants with high education levels had a high tooth-filling service utilization rate, whereas illiterate participants and those with an elementary school level education had the lowest utilization rate of 14.22 % (p <0.001). Regarding marital status, unmarried people had a slightly higher utilization rate compared to that of other groups (p <0.001). The use of tooth-filling services was higher in highly urbanized areas (21.78 %) compared with that in other areas (<20 %). As the urbanization degree declined, the utilization rates decreased (p <0.001). Regarding economic status, participants with a high premium-based monthly salary had a high utilization rate (p <0.001), whereas participants from low-income households exhibited a low utilization rate (15.24 %) (p <0.001).

Participants with chronic diseases demonstrated a higher tooth-filling service utilization rate compared participants without chronic diseases. Notably, participants with circulatory and urinary system diseases exhibited low utilization rates (p <0.001). When stratified by disability categories, participants with congenital metabolic disorders and autism had high utilization rates (36.33 % and 29.18 %, respectively), whereas participants with multiple impairments and dementia exhibited low utilization rates (13.35 % and 10.19 %, respectively) (p < 0.001). Regarding disability degree, participants with mild disabilities exhibited higher utilization rate (20.53 %) than did other participants (p < 0.001) (Table 1).

Logistic regression models for tooth-filling service utilization among participants with disabilities

After adjustment for the variables, most correlating factors significant affected the utilization rate, except for (a) chronic diseases of the neural and urinary systems and blood and hematopoiesis diseases, and (b) the disability categories of facial disfigurement, congenital defects, impaired balance, and disabilities caused by rare diseases (Table 2).
Table 2

Logistic regression models for tooth filling utilization among people with disabilities

Variables

OR

95 % CI

p-value

Gender

 

Female

1

 

Male

0.78

0.77

0.79

<0.001*

Age

 

<20 years

1

 

20–24 years

0.70

0.67

0.72

<0.001*

 

25–29 years

0.59

0.57

0.61

<0.001*

 

30–34 years

0.49

0.48

0.51

<0.001*

 

35–39 years

0.44

0.42

0.45

<0.001*

 

40–44 years

0.42

0.41

0.43

<0.001*

 

45–49 years

0.41

0.40

0.43

<0.001*

 

50–54 years

0.40

0.38

0.41

<0.001*

 

55–59 years

0.38

0.37

0.39

<0.001*

 

60–64 years

0.37

0.36

0.39

<0.001*

 

65–69 years

0.35

0.34

0.36

<0.001*

 

70–74 years

0.29

0.28

0.30

<0.001*

 

≥75 years

0.22

0.22

0.23

<0.001*

Educational level

 

Elementary school and under

1

 

Junior high school

1.15

1.13

1.17

<0.001*

 

Senior (vocational) high school

1.38

1.35

1.40

<0.001*

 

Junior college and university or above

1.71

1.67

1.75

<0.001*

 

Unclear

1.20

1.18

1.22

<0.001*

Marital status

 

Married

1

 

Unmarried

1.16

1.14

1.18

<0.001*

 

Divorced or widowed

1.05

1.01

1.08

0.011*

 

Unclear

0.95

0.93

0.96

<0.001*

Aboriginal status

 

No

1

 

Yes

0.76

0.72

0.80

<0.001*

Urbanization of residence area

 

Level 1

1

 

Level 2

0.87

0.86

0.89

<0.001*

 

Level 3

0.79

0.77

0.80

<0.001*

 

Level 4

0.70

0.69

0.71

<0.001*

 

Level 5

0.58

0.56

0.60

<0.001*

 

Level 6

0.61

0.59

0.63

<0.001*

 

Level 7

0.63

0.61

0.64

<0.001*

Premium-based monthly salary (NT$)

 

≤17,280

1

-

 

Dependent population

1.00

0.98

1.02

0.989

 

17,281–22,800

1.10

1.09

1.12

<0.001*

 

22,801–28,800

1.28

1.24

1.31

<0.001*

 

28,801–36,300

1.34

1.29

1.38

<0.001*

 

36,301–45,800

1.42

1.37

1.46

<0.001*

 

≥45,801

1.48

1.43

1.54

<0.001*

Low-income household

 

No

1

 

Yes

0.97

0.95

0.99

0.038*

Catastrophic injury or disease

 

No

1

 

Yes

1.12

1.10

1.13

<0.001*

Relevant chronic diseases

    
 

Cancer

1.06

1.03

1.09

<0.001*

 

Endocrine and metabolic disease

1.02

1.01

1.03

0.024*

 

Mental illness

1.12

1.11

1.14

<0.001*

 

Disease of the nervous system

1.00

0.98

1.02

0.970

 

Disease of the circulatory system

0.95

0.93

0.96

<0.001*

 

Disease of the respiratory system

1.14

1.12

1.15

<0.001*

 

Disease of the digestive system

1.16

1.14

1.18

<0.001*

 

Disease of the urinary system

1.01

0.98

1.04

0.428

 

Disease of the skeletal and muscular system and connective tissue

1.29

1.27

1.31

<0.001*

 

Disease of the eyes and auxiliary organs

1.23

1.21

1.26

<0.001*

 

Infectious diseases

1.09

1.06

1.13

<0.001*

 

Congenital malformation

1.05

1.02

1.09

0.003*

 

Skin and subcutaneous tissue disorders

1.06

1.04

1.09

<0.001*

 

Diseases of the blood and blood-forming organs

1.01

0.98

1.04

0.500

 

Diseases of the ear and mastoid process

1.16

1.13

1.19

<0.001*

 

Others

1.35

1.32

1.37

<0.001*

Type of disability

 

Visual impairment

1

 

Hearing impediment

1.13

1.10

1.16

<0.001*

 

Speech impediment

1.43

1.40

1.46

<0.001*

 

Limb impediment

1.11

1.06

1.16

<0.001*

 

Mental retardation

0.89

0.87

0.91

<0.001*

 

Multiple impediments

0.94

0.91

0.96

<0.001*

 

Major organ malfunction

1.30

1.27

1.33

<0.001*

 

Facial disfigurement

0.97

0.89

1.05

0.391

 

Dementia

0.75

0.71

0.79

<0.001*

 

Autism

1.05

1.01

1.11

0.045*

 

Chromosomal abnormalities

0.81

0.73

0.91

0.001*

 

Congenital metabolic disorders

1.64

1.39

1.94

<0.001*

 

Congenital defect

1.04

0.90

1.20

0.588

 

Mental illness

1.04

1.02

1.07

0.001*

 

Impaired balance

0.92

0.83

1.02

0.122

 

Refractory epilepsy

1.11

1.03

1.19

0.008*

 

Rare diseases

0.96

0.84

1.08

0.470

Severity of disability

 

Mild

1

 

Moderate

0.87

0.85

0.88

<0.001*

 

Severe

0.66

0.65

0.67

<0.001*

 

Very severe

0.57

0.56

0.59

<0.001*

*p < 0.05

After controlling for other variables, the analysis revealed that males used tooth-filling services at 0.78 times the rate that females did (95 % CI [0.77, 0.79], p <0.001). Based on the reference group, which comprised participants <20 years, the adjusted odds ratio (OR) revealed a trend of declining tooth-filling service utilization rate with increasing age; participants ≥75 years exhibited a low utilization rate (0.22 times) compared with that of the reference group (95 % CI [0.22, 0.23], p <0.001). Utilization rate variation among the considered age groups was approximately 80 %.

The tooth-filling service utilization rate for participants from the least urbanized areas was lower (0.63 times) that that for participants from the most urbanized areas (95 % CI [0.61, 0.64], p <0.001). Furthermore, participants with a high premium-based monthly salary exhibited high tooth-filling service utilization rates. The tooth-filling service utilization rate for participants with the highest premium-based salary was higher (1.48 times; 95 % CI [1.43, 1.54], p <0.001) than that for the reference group comprised of participants with the lowest premium-based monthly salary (NT$ ≤17,280).

Compared with participants with visual impairment, those with mental retardation, multiple impairments, dementia, and chromosomal abnormalities exhibited significantly lower tooth-filling service utilization rate; service utilization was the lowest among participants with dementia (OR = 0.75, 95 % CI [0.71, 0.79], p <0.001). Participants with other disabilities exhibited higher utilization rates than did participants with visual impairment. Participants with congenital metabolic disorders exhibited the highest utilization rates compared with other participants (OR = 1.64, 95 % CI [1.39, 1.94], p <0.05). Participants with more severe disability levels exhibited low utilization rates, and the utilization rate for participants with extremely severe disabilities was lower (0.57 times) than that for participants with mild disabilities (95 % CI [0.56, 0.59], p <0.001; Table 2).

Discussion

Chalmers et al. (2011) conducted a survey in 2005 and reported that approximately 60 % of people with intellectual and developmental disabilities visit dentists. In addition, people aged 22–64 years exhibited high tooth-filling service utilization rates (approximately 64 %), and people ≥65 years exhibited the lowest utilization rate (45 %) compared with the other age groups [18]. However, studies have revealed that older people demonstrate a high rate of missing teeth and untreated decay or cavities [19], high total DMFT scores, and low tooth-filling rates [20, 21]. These results are consistent with our finding that older peoples’ tooth-filling service utilization rate is low.

We demonstrated that patients with dementia had the lowest tooth-filling service utilization rate. Dementia progressively increases in severity, gradually impairing cognitive function [22]. People with a low cognitive function score have a four-fold higher tendency of not regularly availing dental services [23].

Because people with extreme disabilities have physical or mental limitations, they face difficulty in availing medical care [24], thus developing poor oral health conditions [4, 25]. Participants with extreme disabilities in this study demonstrated a tooth-filling service utilization rate 43 % lower than that of patients with mild disabilities.

Sex, residential area, and economic status influence the medical services utilization rate. Kung, Tsai, and Li (2012) indicated that females utilize more preventive health services than do males. A study conducted in the United Kingdom [26] reported that females more readily seek consultation for illness. In the present study, we demonstrated that 19.20 % of the female participants used tooth-filling services, which is significantly higher than the utilization by male participants (16.35 %; OR = 0.78, 95 % CI 077, 0.79).

A high urbanization degree is indicative of denser population and higher government expenditures, higher density of hospitals and medical institutes, more media broadcasts of health information, and higher access to disease treatment and prevention resources [27, 28]. We revealed that the tooth-filling service utilization rate significantly increased with the degree of urbanization; by contrast, participants living in the least urbanized areas exhibited 40 % lower utilization rates. Furthermore, economic status influenced people’s medical assistance–seeking attitudes and behavior [29]. Participants with a low premium-based salary and those from low-income households demonstrated low tooth-filling service utilization rates.

The overall tooth-filling service utilization rate for participants in this study was only 17.53 %, whereas that for the general population is 54.7 % [30]. People with disabilities exhibit high tooth damage because of poor oral health conditions and oral hygiene compared with people without disabilities [31, 32]. However, the number of people with disabilities seeking dental services or undergoing early treatments is relatively low [3], worsening the tooth conditions until they visited a dentist. Thus, the probability of tooth extraction was higher than that for tooth filling. Similar results were reported in Rodriguez Vazquez et al. (2002), suggesting that when people with mental illnesses experience tooth decay or cavities, they receive destructive therapies, such as tooth extraction, instead of reforming the tooth appearance and function; this phenomenon causes a high rate of missing teeth among people with disabilities [33].

In this study, we focused only on tooth-filling service utilization in 2008 by people with disabilities. Because doctor visit rates, decay and cavity prevalence, other dental treatment conditions, and personal health behavior were not considered in out analyses, we could not determine the actual proportion of people who required tooth fillings, nor could we compare other risk factors; this is the primary limitation of our study. However, people with disabilities have exhibited a higher incidence rate of untreated tooth decay or cavities compared with those without disabilities [11, 34]. Therefore, our analysis of nationwide data substantially supports future research and additional investigations for identifying the risk factors, thus serving as a foundation for cohort studies. Moreover, this study was a population-based study with a substantial sample size. Because we recruited participants who cannot easily be recruited, such as people with extreme disabilities and communication impediments, our results are not biased by the presence of groups with superior functions.

Since this study had a large population-based sample, it had a high statistical power and might cause some weak-association factors to reach significant level (p < 0.05). Thus, we suggest readers to focus on the factors with bigger odds ratios and to interpret the factors with a borderline odds ratio in a more conservative way. We advise to use confidence intervals (CIs) instead of p values in terms of practical importance.

Conclusion

In this nationwide study, we investigated the tooth-filling service utilization rate among people with disabilities. We identified the factors that influence and decrease the tooth-filling service utilization rate: male sex, old age, low education level, being married, indigenous ethnicity, residing in a low urbanization area, low income, chronic circulatory system diseases, dementia, and severe disabilities.

The association between tooth-filling service utilization and maintenance of oral health among people with disabilities is extremely crucial. We should focus on and provide more assistance to people with disabilities. Moreover, we should establish appropriate welfare policies for protecting the health of people with disabilities, for example, improving accessible environment for dental care, or proving dentists with financial incentives for dental care giving to people with disabilities.

Abbreviations

CI: 

confidence interval

DMFT: 

decayed, missing, or filled teeth

NT$: 

New Taiwan Dollar

OR: 

odds ratio

SAS: 

statistics analysis system

SD: 

standard deviation

Declarations

Acknowledgements

This study was supported by grants (CMU102-ASIA-12) from China Medical University and Asia University, and grants (No.9805006A) from the Health Promotion Administration. We are grateful for the Health Insurance Research Database provided by the Ministry of Health and Welfare, and the Disabilities Registry Database provided by Ministry of the Interior.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Department of Public Health, China Medical University
(2)
Department of Health Services Administration, China Medical University
(3)
Department of Healthcare Administration, Central Taiwan University of Science and Technology
(4)
Department of Healthcare Administration, Asia University
(5)
Department of Dental Hygiene, China Medical University
(6)
Department of Chinese Medicine, Nantou Hospital

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Copyright

© Chen et al. 2016

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