Abstract
Background/purpose
Patients with disabilities usually have difficulties in communication and mobility, and the quality of the dental treatments are often inferior. This study uses the Taiwan National Health Insurance Database to analyze the quality of dental treatment for patients with disabilities who receive intravenous sedation (IVS).
Materials and methods
This study selected patients with disabilities who received dental treatment under IVS. Their oral cavity was divided into three major sections: anterior teeth, upper posterior teeth, and lower posterior teeth. Self-matching of the same section was conducted to observe whether operative dental treatment (OD) with or without IVS affected the occurrence of dental retreatment. This study observed the occurrence of refilling and the duration from the end of treatment until retreatment to compare treatment differences with or without IVS.
Results
After self-matching, this study found 158 patients who received dental treatment within the same section with and without IVS. During a follow-up period of 17 years, 75.18% of the patients who received OD treatment required refilling, 10.87% required endodontic treatment, and 5.67% required tooth extraction. After OD treatment with IVS, the risks of refilling, endodontic treatment, and tooth extraction were 0.71 (95% CI: 0.58–0.87, P < 0.001), 0.77 (95% CI: 0.48–1.23, P = 0.28), and 0.64 (95% CI: 0.32–1.27, P = 0.20), respectively.
Conclusion
For patients with disabilities, OD treatment with IVS significantly reduces the risk of refilling compared with OD treatment without IVS. IVS can be ideal for people with disabilities who receive dental treatment.
Keywords: National health insurance database, Patients with disabilities, Intravenous sedation
Introduction
In 2021, the number of Taiwanese citizens with disabilities exceeded 1.2 million, accounting for 5.12% of the total Taiwanese population and increasing by 0.02%–0.03% per annum.1 Although people with disabilities continue to experience varying degrees of physical, mental, behavioral, or physical injury and subsequently insufficient self-care of oral hygiene, advances in both medical technology and health care have extended the life expectancy of people with disabilities.2,3 Therefore, the oral health-care system of people with disabilities requires further analysis to prevent and eliminate oral disease, eradicate oral infections and microorganism invasions, and maintain basic chewing function.
People with disabilities are more likely to be restricted by difficulties in communication and mobility, and the quality of dental treatment is often inferior to that of the general population. In 2016, Lin et al. conducted quality assessments of dental services provided to patients with specific disabilities by using a Taiwanese nationwide population-based database and found that both the refilling rate and unfinished endodontic rate were higher than those of the general population.4 Because patients with disabilities experience difficulties when cooperating with medical personnel and procedures, medical sedation such as general anesthesia (GA) and intravenous sedation (IVS) were introduced to reduce unintended movements.5 Most IVS is performed using midazolam, which is safe and suitable for pediatric patients and people with disabilities. Compared with general anesthesia, IVS procedures are simple and require fewer medical resources; therefore, routine oral examinations and dental treatments can be performed more quickly.6,7
As an alternative to general anesthesia, IVS has become more commonplace for treating patients with disabilities. In 2010, Capp et al. performed IVS on patients with neurological or behavioral interruptions during dental treatment and found that the IVS was effective for 89% of the patients.8 Ransford et al. performed dental examinations and treatment on patients with severe disabilities and found that 78.8% (241 out of 316 sedation cases) exhibited acceptable outcomes without major interferences, which supported the effectiveness, safety, and acceptability of IVS.9 Although IVS is commonly used and likely to benefit disabled patients, it is important to monitor the quality of dental treatment and the actual benefits need to be supported by researches. This study assesses the first dental restoration therapy on people with disabilities under IVS by using data from a nationwide population-based database.
Materials and methods
Study population
The analysis and use of the database in this study passed the review of the Institutional Review Board of the National Yang Ming Chiao Tung University (approval number: YM105087E-5). Dental medical data from the Taiwan National Health Insurance Database before 2016 were used for analysis. This study first selected individuals with disabilities by using the specific codes under the National Health Insurance Research Database. Second, we searched for individuals with disabilities who received dental treatment under intravenous or intramuscular anesthesia. Third, we identified individuals with disabilities who received operative dental treatment (OD) with and without IVS and the type of dental treatment received. Finally, self-matching was performed to divide the interior of patients' oral cavity into three sections: the anterior teeth (#13–23, #33–43), upper posterior teeth (#14–17, #24–27), and lower posterior teeth (#34–37,#44–47). Self-matching of the anterior teeth was conducted within the same section to observe whether OD treatment with or without IVS affected the occurrence of dental retreatment, which served as an indicator of treatment quality (Figure 1, Figure 2).
Figure 1.
Flowchart of study design and case selection.
Figure 2.
Example of self-matching process.
Repeated operative dental treatment (re-OD): If a patient received OD treatment, in the same section after a OD treatment. Endodontic treatment after OD treatment: If a patient received endodontic treatment in the same section after a OD treatment. Tooth extraction after OD treatment: If a patient received tooth extraction in the same section after a OD treatment.
Statistical analyses
Descriptive statistics, McNemar test, and a paired t-test were performed to compare the correlations between treatments with and without IVS. Subsequently, a Cox proportional hazard model was used. In said models, potential variables such as sex, age, disability type, and degree of disability were adjusted to compare dental treatments with and without IVS, which determined the correlations between survival times or the survival probabilities of patients treated using the two treatment methods.
Results
This study analyzed the 2000–2016 population data obtained from the Taiwan National Health Insurance Research Database, and revealed that 138,224 patients received dental treatment. In the first stage, 700 patients were selected if they received dental treatment with IVS. In the second stage, patients were excluded if they only received treatment for deciduous teeth, had a medical record that did not specify the teeth sections that underwent treatment, or only received dental treatment before disability. Consequently, 669 patients underwent self-matching. The self-matching required that OD be conducted within one intraoral section with and without IVS, to observe the outcomes under IVS. A total of 158 patients (teeth = 1022) were included, 41.77% of whom were women, 46.84% of whom were aged 18–34 years, and 75.32% of whom had severe disabilities (Table 1).
Table 1.
General characteristics of patients using intravenous sedation during dental treatment (after self-matching, N = 158).
| General characteristics | Dental treatment under IVSa (N = 158) | |
|---|---|---|
| Gender | Female | 66 (41.77) |
| Male | 92 (58.23) | |
| Age | <18 | 57 (36.08) |
| 18–34 | 74 (46.84) | |
| 35–44 | 15 (9.49) | |
| ≧ 45 | 12 (7.59) | |
| Dental treatment | ODb | 139 (87.97) |
| Endoc | 58 (36.71) | |
| Disability level | Mild | 3 (1.90) |
| Moderate | 36 (22.78) | |
| Severe | 119 (75.32) | |
IVS, intravenous sedation.
OD, operative dental treatment.
Endo, endodontic treatment.
Concerning the incidence of retreatment within the same section of the mouth, the refilling risk was 75.18% for patients who received OD treatment with IVS compared with 75.65% of patients who received OD treatment without IVS (P = 0.76). After further observation, 10.87% of patients who received OD treatment with IVS required root canal retreatment, which was slightly higher those who received OD treatment without IVS (P = 0.57). Additionally, 5.67% and 5.91% of patients who received OD treatment with and without IVS required tooth extraction retreatment, respectively (P = 0.88). Overall, when IVS was combined with OD treatment, the risks of refilling, endodontic treatment, and tooth extraction were lower than OD treatment without IVS (Table 2).
Table 2.
Treatment of tooth after dental treatment with and without intravenous sedation.
| Variable | OD → re-ODa |
OD → Endob |
OD → Extc |
||||||
|---|---|---|---|---|---|---|---|---|---|
| IVSd | non-IVSe | P-value | IVSd | non-IVSe | P-value | IVSd | non-IVSe | P-value | |
| Anteriorf | 125 (81.70) | 122 (79.74) | 0.66 | 14 (9.15) | 13 (8.50) | 0.84 | 6 (3.92) | 5 (3.27) | 0.76 |
| Upper posteriorg | 110 (74.32) | 112 (75.68) | 0.79 | 12 (8.11) | 19 (12.84) | 0.18 | 13 (8.78) | 10 (6.76) | 0.51 |
| Lower posteriorh | 83 (68.03) | 86 (70.49) | 0.68 | 20 (16.39) | 9 (7.38) | 0.03∗ | 5 (4.10) | 10 (8.20) | 0.18 |
| Total | 318 (75.18) | 320 (75.65) | 0.76 | 46 (10.87) | 41 (9.69) | 0.57 | 24 (5.67) | 25 (5.91) | 0.88 |
∗ P-value<0.05.
OD → re-OD, patient received operative dental treatment (OD) in the same section after an OD treatment, repeated operative dental treatment (re-OD).
OD → Endo, patient received endodontic treatment (Endo) in the same section after an OD treatment.
OD → Ext, patient received tooth extraction (Ext) in the same section after an OD treatment.
IVS, received dental treatment under intravenous sedation.
non-IVS, received dental treatment without intravenous sedation.
Anterior, upper and lower anterior teeth (#13–23, #33–43).
Upper posterior, upper premolars and molars (#14–17, #24–27).
Lower posterior, lower premolars and molars (#34–37, #44–47).
Regarding the amount of time before re-OD treatment was required, the outcomes of OD treatment with and without IVS lasted 2.14 ± 1.80 and 1.77 ± 1.46 years, respectively. OD treatment with IVS produced significantly longer-lasting outcomes (P = 0.00). Concerning the amount of time before endodontic treatment was required, the outcomes of OD treatment with and without IVS lasted an average of 2.65 ± 1.52 and 1.86 ± 1.45 years, respectively (P = 0.02). With respect to the amount of time before tooth extraction was required, the outcomes of OD treatment with and without IVS lasted 2.64 ± 2.11 and 1.85 ± 1.79 years, respectively (Table 3).
Table 3.
Duration of outcomes after dental treatment with and without intravenous sedation.
| Variable | OD → re-ODa |
OD → Endob |
OD → Extc |
||||||
|---|---|---|---|---|---|---|---|---|---|
| IVSd | non-IVSe | P-value | IVSd | non-IVSe | P-value | IVSd | non-IVSe | P-value | |
| Anteriorf | 2.21 ± 2.06 | 1.89 ± 1.64 | 0.48 | 2.60 ± 1.17 | 2.04 ± 1.37 | 0.26 | 2.46 ± 0.40 | 0.73 ± 0.40 | 0.02 |
| Upper posteriorg | 2.27 ± 1.66 | 1.67 ± 1.35 | 0.00∗ | 2.74 ± 2.02 | 1.32 ± 1.10 | 0.04 | 3.06 ± 2.50 | 2.37 ± 1.23 | 0.39 |
| Lower posteriorh | 1.89 ± 1.52 | 1.73 ± 1.32 | 0.48 | 2.63 ± 1.47 | 2.75 ± 1.82 | 0.85 | 1.75 ± 1.84 | 1.90 ± 2.44 | 0.91 |
| Total | 2.14 ± 1.80 | 1.77 ± 1.46 | 0.00∗ | 2.65 ± 1.52 | 1.86 ± 1.45 | 0.02 | 2.64 ± 2.11 | 1.85 ± 1.79 | 0.16 |
∗ P-value<0.05.
OD → re-OD, patient received operative dental treatment (OD) in the same section after an OD treatment, repeated operative dental treatment (re-OD).
OD → Endo, patient received endodontic treatment (Endo) in the same section after an OD treatment.
OD → Ext, patient received tooth extraction (Ext) in the same section after an OD treatment.
IVS, received dental treatment under intravenous sedation.
non-IVS, received dental treatment without intravenous sedation.
Anterior, upper and lower anterior teeth (#13–23, #33–43).
Upper posterior, upper premolars and molars (#14–17, #24–27).
Lower posterior, lower premolars and molars (#34–37, #44–47).
A Cox proportional hazard model was subsequently used, in which potential variables such as sex, age, disability type, and degree of disability were adjusted to compare dental treatments with and without IVS, thereby determining the correlations between survival times or survival probabilities of the patients treated using the two methods. The hazard ratios were 0.71 for re-OD treatment (95% CI: 0.58–0.87, P < 0.001), 0.77 for endodontic treatment (95% CI: 0.48–1.23, P = 0.28), and 0.64 for tooth extraction (95% CI: 0.32–1.27, P = 0.20) after OD treatment. The hazard ratio for retreatment was negatively correlated with the invasiveness and recoverability of dental treatment and tooth preservability (Table 4). Overall, for patients with disabilities who received OD treatment with IVS, re-OD treatment was less necessary, the treatment outcomes lasted longer before re-OD treatment, and the hazard ratios were lower compared with those who received OD treatment without IVS.
Table 4.
Hazard ratios (HR) for various dental retreatments in dental treatment with and without intravenous sedation (IVS).
| Parameter | HRa | Confidence Limits |
P-value | |
|---|---|---|---|---|
| Lower 95%CI | Upper 95%CI | |||
| OD → re-ODb | 0.71 | 0.58 | 0.87 | <0.001∗ |
| OD → Endoc | 0.77 | 0.48 | 1.23 | 0.28 |
| OD → Extd | 0.64 | 0.32 | 1.27 | 0.20 |
∗ P-value<0.05.
HR, Hazard ratios of Cox proportional hazards model, adjust for gender, age, disability category and disability level.
OD → re-OD, patient received operative dental treatment (OD) in the same section after an OD treatment, repeated operative dental treatment (re-OD).
OD → Endo, patient received endodontic treatment (Endo) in the same section after an OD treatment.
OD → Ext, patient received tooth extraction (Ext) in the same section after an OD treatment.
Discussion
Patients with disabilities require more accommodations during dental treatment than people without disabilities. Also, their poor behavioral control or communication difficulty increase the difficulty of treatment and may impede successful dental care. For patients with disabilities, seeking medical treatment and cooperating during treatment are more challenging for doctors, patients, and caregivers. In this study, the mean age of the population observed was 15–34 years old, and most patients had severe disabilities. For young patients with mental and physical disabilities, OD treatment with IVS produced superior results, required less retreatment, and yielded longer-lasting outcomes than OD treatment without IVS. Wallace et al.7 investigated the application of IVS in dental treatment for children with dental anxiety and dentophobia, and found that IVS led to better dental treatment and a better medical experience. Dixon et al.10 examined the safety and postoperative complications of IVS for 49 adolescents (mean age = 14.67 years old) with dentophobia and determined that IVS is an effective and potentially safe alternative to general anesthesia. Moreover, IVS can improve the quality of treatment for patients with greater dental needs.
General anesthesia has long been applied in dental treatment of patients with disabilities and usually requires more medical resources than sedative treatment or anesthesia. Sometimes, the patient's oral cavity is suitable for sedation and allows dentists to perform regular oral examinations and some short-term dental treatments. Patients can wake up quickly after IVS termination, and dentists can thoroughly perform treatment and improve the quality of dental care.11
Manley et al.12 argued that sedation is effective for relieving anxiety and fear of dental treatment and is especially effective among patients with intellectual disabilities. For complex dental treatments that require multiple dental visits, such as periodontal therapy and endodontic therapy, sedative anesthesia is more appropriate and accessible than general anesthesia. Curl13 reported that inhalational sedation with nitrous oxide and IVS with midazolam can reduce unwanted movements in patients with movement disorders during dental treatment.
In early dental treatment, OD treatment prevents further tooth decay, preserves tooth roots, reduces the possibility of severe cavities, and decreases the need for additional medical services. Therefore, receiving OD treatment is the main indicator used to evaluate the oral health of patients with disabilities.14 The survey of this study revealed that dental treatment with IVS can reduce the re-OD treatment rate with relatively long-lasting effects. Dental treatment with IVS did not significantly reduce the need for endodontic treatment or tooth extraction. These results are different from our original expected quality factors. One possible reason is that dental treatment for patients with disabilities is usually more aggressive; therefore, endodontic treatment or tooth extraction after OD treatment might not be suitable indicators. Future researches are warranted to identify more precise dental quality indicators for patients with disabilities.
Patients under IVS have better behavioral control, which provides dentists with more options when treating teeth with severe caries. IVS can increase the chances of successful treatment. Moreover, this study discovered no significant differences between OD treatment with and without IVS for requiring retreatments. Nonetheless, the results of OD treatment with IVS lasted significantly longer than those of OD treatment without IVS. In this study, each individual's oral cavity was divided into three major sections based on dental anatomy and morphology. Self-matching was conducted within the same section to observe the results of OD treatment with and without IVS. The self-matching method adopted in this study compared the intraoral conditions between individuals, and oral health-related factors, such as sex, age, disability type, and degree of disability, were controlled.
This study had some limitations. The retrospective database study could not fully consider the difficulty of OD treatment or the treatment criteria of dentists, which may vary according to the dentists' treatment plans and affect the length that treatment outcomes last. However, these effects were minimized by comparing the self-matchings within the same section of teeth. Self-matching involves comparing the outcome risks of the same individual at different times to assess the effects of intermittent exposure. Self-matching can eliminate confusion caused by fixed and gradual factors such as the effects of sex, race, and medical history.15,16 For successful self-matching, the patients must have a high rate of caries and have received OD treatment for at least two teeth within the same section. To increase the chances of successful self-matching, this study only divided patients' oral cavity into three sections, which reduced the generalizability of this study. Future research can further explore the choice and difficulty of dental treatment.
Therefore, applying IVS during OD treatment to accommodate the needs of patients can be an ideal treatment option and produce greater results.
Declaration of competing interest
The authors have no conflicts of interest relevant to this article.
Acknowledgments
This project was supported by National Yang Ming Chiao Tung University Far Eastern Memorial Hospital Joint Research Program (grant number: NYCU-FEMH 106DN07) and Taipei City Hospital (grant number: TPCH-111-19).
Contributor Information
Ping-Yi Lin, Email: rhyne.lin@gmail.com.
Lin-Yang Chi, Email: chily9@gmail.com.
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