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International Journal for Equity in Health logoLink to International Journal for Equity in Health
. 2016 Apr 5;15:58. doi: 10.1186/s12939-016-0347-3

Utilization of tooth filling services by people with disabilities in Taiwan

Ming-Chuan Chen 1,2,3, Pei-Tseng Kung 4, Hsun-Pi Su 5, Suh-May Yen 6, Li-Ting Chiu 2, Wen-Chen Tsai 2,✉
PMCID: PMC4820987  PMID: 27044476

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 [2–4]; hence, they generally have poor oral conditions and several periodontal diseases [5–7]. Oral health conditions generally influence various aspects of life, such as nutritional status, quality of life, and personal perceptions and feelings [8–10]. 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
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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*
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*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.

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.

Abbreviations

CI

confidence interval

DMFT

decayed, missing, or filled teeth

NT$

New Taiwan Dollar

OR

odds ratio

SAS

statistics analysis system

SD

standard deviation

Footnotes

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

Conception and design was done by WCT, MCC, PTK, SMY, HPS; collection and assembly of data was conducted by WCT, MCC, PTK, LTC; data analysis and interpretation was performed by WCT, MCC, SMY, PTK, HPS, LTC; manuscript writing was finished by MCC, SMY, WCT, LTC, HPS; final approval of manuscript was done by all authors.

Contributor Information

Ming-Chuan Chen, Email: mccchen@yahoo.com.

Pei-Tseng Kung, Email: ptkung@asia.edu.tw.

Hsun-Pi Su, Email: subihtw@yahoo.com.tw.

Suh-May Yen, Email: suhmayyen@yahoo.com.tw.

Li-Ting Chiu, Email: u9775851@cmu.edu.tw.

Wen-Chen Tsai, Phone: +886 4 22073070, Email: wctsai2011@gmail.com.

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