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系統識別號 U0026-0602201422534800
論文名稱(中文) 牙科醫療利用率與根管治療成功率之流行病學研究
論文名稱(英文) An epidemiological study of dental service utilization and rate of success in root canal treatment.
校院名稱 成功大學
系所名稱(中) 公共衛生研究所
系所名稱(英) Graduate Institute of Public Health
學年度 102
學期 1
出版年 103
研究生(中文) 溫珮君
研究生(英文) Pei-Chun Wen
學號 t86004047
學位類別 碩士
語文別 中文
論文頁數 87頁
口試委員 指導教授-李中一
口試委員-季麟揚
口試委員-陳弘森
口試委員-古鯉榕
中文關鍵字 預防性牙科醫療利用率  治療性牙科醫療利用率  根管治療成功率  橡皮障防濕裝置  流行病學  全民健康保險  城鄉差距  Cox迴歸模式  卜瓦松迴歸 
英文關鍵字 preventive dental treatment  operative dental treatment  success rate of root canal treatment  rubber dam application  epidemiology  national health insurance  urban-rural difference  Cox regression  Poisson regression 
學科別分類
中文摘要 背景:台灣的牙科醫療狀況,在東西部與城鄉之間,有明顯的地區性差異,但過去研究多數偏向立意取樣研究的範疇,鮮少有以具代表性的全國性樣本為研究對象之研究探討口腔衛生與牙科醫療使用率。歐洲研究將牙科醫療分為預防性與治療性兩大分類,提供我們一個新的分類探討方向。根管治療為將牙齒保留的最後一道防線,過去研究顯示首次根管治療五年成功率統計多可高達九成以上,但可能會有相關因素影響其治療成功率。台灣過去研究顯示根管治療五年成功率與國外結果類似,也發現當根管治療失敗時最常見的後續治療為拔牙,但並未有研究探討重新根管與手術的比率,也未進一步探討影響國內民眾接受根管治療失敗的因素。
目的:本研究包括以下兩個研究目的:(一)將牙科醫療分為預防性與治療性兩部分,探討台灣民眾牙科醫療利用率,以及該利用率與人口變項及都市化程度間之相關性。(二)探討台灣民眾根管治療之成功率,以及影響此成功率之因素包含病人本身之差異、醫師、與醫療機構、共病等相關因素。
方法:本研究利用次級資料進行分析,採用健保資料庫2005年百萬人歸人檔,第一部分討論牙科醫療利用率分析,使用門診處方及治療明細檔、門診處方醫令明細檔以及原始承保資料(ID),並根據醫令代碼將牙科治療區分為預防性治療及治療性治療,分析其利用率,並以多變項卜瓦松迴歸模式探討其與人口學變項及地區都市化程度間的關聯性。第二部分則為根管治療成功率相關因素探討,從2005~2010之門診處方及治療明細檔與門診處方醫令明細檔中擷取首次接受根管治療的牙齒(n=458,557),並追蹤至2010年底前,檢視,樣本牙齒發生重新根管、手術、或拔牙事件發生的風險,並以生命表法計算樣本牙齒的累積成功率,並進一步以Cox迴歸模式探討影響此成功率之因素,包含:病人本身之特性、治療方法、醫師與醫療機構、以及共病等相關。
結果:第一部分的結果為:預防性牙科治療利用率以55-64歲族群最高(579.2/1,000人年),<15歲族群最低(178.6/1,000人年);治療性利用率則是以<15歲族群最高(1592.0/1,000人年),35-44歲族群最低(757.2/1,000人年)。不論何種利用率,女性都較男性高。高度都市化市鎮民眾的預防性最高(528.7/1,000人年),高齡及農業市鎮最低(313.5、315.9/1,000人年);但相較於預防性利用率,治療性利用率在最高(高度都市化市鎮)與最低(高齡及農業市鎮)之間的差距較小。多變量迴歸分析指出:年齡、性別、與都市化程度與預防性疾治療性的牙科醫療利用率均有顯著相關。第二部份的結果為:當根管治療失敗時,最常做的後續治療為拔牙(70.65%),接著為重新根管治療(26.59%),最少的是手術性治療(2.76%);就整體成功率而言,年紀越高其根管治療成功率越低,而男性根管治療成功率較女性低,都市化程度與成功率間無明顯的相關性;此外,於診所接受治療根管治療的牙齒其成功率最高,醫學中心成功率則是較低;服務量越高的院所及醫師其治療成功率越高;而有牙周共病的牙齒其後續治療成功率較低。本研究也發現相較於一般治療,使用橡皮障防濕裝置之根管治療,其成功率較比未使用之病例成功率顯著增加,校正危害比為0.85(95%CI=0.82-0.89)。
結論:在台灣,預防性牙科醫療利用的比率以45-64歲民眾最高,而以<15歲兒童利用率最低;相反的,治療性牙科利用卻是以<15歲以下兒童利用率最高,35-44歲民眾利用率最高;此外,女性是在預防性牙科醫療利用方面明顯高於男性,而都市化程度也是對預防性牙科醫療利用率影響較大。在根管治療成功率部分,整體根管治療5年成功率為89.29%,而影響整體的成功率之原因,包含年紀較長者、男性、有牙周共病者、醫學中心治療、醫師/機構服務量低者均與較低的成功率有關。另外,根管治療成功率與治療中是否使用橡皮障防濕裝置有顯著的關係,使用橡皮障防濕裝置的牙齒日後發生根管治療失敗的風險降低近15%。
英文摘要 Background:There are apparent differences in dental care services between Eastern and Western areas; as well as between urban and rural areas in Taiwan. Majority of previous studies rested on purposive sampling to reach their conclusions, and only few utilized nationally representative sample to explore issues on oral health and dental service utilization rate. European studies distinguished operative from preventive dental treatments, providing us with an insight toward classification of dental care utilization. Root canal treatment (RCT) is the last alternative of tooth preservation. Past research suggested that the five-year success rate for RCT exceeds 90%, which is likely to be associated with certain factors. Previous Taiwanese studies found that the success rate of RCT was comparable with that reported in foreign countries, and that extraction is the most common practice once the RCT failed. However, no study to my knowledge attempts to exam the prevalence of re-RCT and apical surgery after RCT failure; and also no study attempts to investigate the factors associated with RCT failure in general Taiwanese public.

Objectives:This study has two objectives: (1). To examine the utilization rates of preventive and operative treatments in Taiwanese people, and to explore whether the utilization rates are associated with social demographic variables and urbanization. (2). To investigate the success rate of RCT treatment, and to discover the factors determining the success rate, including characteristics of patients’ social demographics, dentists, institutions, and co-morbidity.

Methods:This study was a secondary data analysis that adopted the sample of 1-million beneficiaries retrieved from Taiwan’s National Health Insurance Research Database (NHIRD) in 2005. In the part of dental service utilization, we used data of ambulatory care visit, medical orders, and registry of beneficiaries. We further separated dental treatments, based on medcial orders, into preventive and operative practices, and analyzed the utilization rates of both practices. Poisson regression models were used to explore the associations of utilization rates with patient’s socioeconomic characteristics and urbanization. The second part is the analysis of success rate of RCT. We identified the teeth receiving RCT (n=458,557) from 2005 to 2010, and followed these teeth to the end in 2010 for the occurrence of endo re-treatment, surgery, and extractions. We also used the life table mehod to calculate the cumulative success rate, and employed Cox regression model to explore the factors that effected success rate of RCT. These factors assessed included the characteristics of patients, treatment modality, dentists, institutions, and co-morbidity.

Results:Results from the first part of sudy: The rate of preventive dental service utilization was highest in people aged 55-64 y/o (579.2/1,000 person-year), and was lowest in those aged <15 y/o (178.6/1,000 person-year). The corresponding figures for rate of operative dental utilization were <15 y/o (1592.0/1,000 person-year), and 35-44 y/o (757.2/1,000 person-year). The utilization rate is higher for females than for males regardless of treatment modality. When considers geographic regions, preventive utilization rate achieved its highest value in highly urbanized areas (528.7/1,000 person-year), and were lowest in areas with older population and agricultural activities (313.5/1,000 person-year). Nonetheless, the difference in utilization rate of operative practices between the highest (highly urban areas) and the lowest utilization rate (senior and agricultural areas) was smaller compared to the figures for preventive practices. Multivariate regression analysis indicated that age, sex, and geographic regions are significantly correlated with preventive and operative dental service utilizations. The results in the second part of study: Following the failure of RCT, the most common subsequent event is extraction (70.65%), followed by re-endodontic treatment (26.59%) and surgery (2.76%). In addition, the overall success rate of RCT was negatively associated with older ages and male gender; and was unrelated to urbanization. Additionally, the success rate was highest in dental clinics and lowest in medical centers. The success rate was also positively associated with service volumes of dentisits and medical institutions; and negatively associated with history of periodontitis. We also noted that teeth with rubber dam application experienced significantly elevated success rate, with an adjusted hazard ratio of 0.85 ( 95% CI = 0.82-0.89).

Conclusion:In Taiwan, the highest utilization rate of preventive dental treatment was noted for people aged 45-64 y/o, while the lowest noted in those aged <15 y/o. In contrast, the highest utilization rate of operative dental treatment was observed for people in <15 y/o population, and the lowest was in 35-44 y/o population. Additionally, the preventive utilization rate was signifciantly higher in female than in male populations. Moreover, urbanization associated more with preventive than with operative practices. In the part of RCT success rate, the 5-year overall success rate was estimated at 89.29%. Regarding the factors related to RCT success rate, older age, male gender, history of periodontal disease, treated in centers, lower dentist/institution service volumes were all significantly associated with lower RCT success rate. Additionally, rubber dam application was significantly associated with RCT success rate, in which utilization of rubber dam was associated with a 15% reduction of RCT failure rate.
論文目次 目次
摘要.................................................i
Abstract...........................................iv
致謝...............................................vii
目次..............................................viii
圖目錄...............................................xi
表目錄..............................................xii
第1章 緒論............................................1
1.1 研究背景..........................................1
1.2 研究目的..........................................3
第2章 文獻探討.........................................5
2.1牙科醫療利用率......................................5
2.1.1口腔的健康與疾病..................................5
2.1.2牙科醫療服務不平等.................................5
2.2 根管治療成功率.....................................8
2.2.1 根管治療概論.....................................8
2.2.2 根管治療成功率概論................................9
2.3 文獻小結..........................................11
第3章 研究材料與方法....................................13
3.1 都市化程度與牙科醫療利用率分析........................13
3.1.1 資料來源........................................13
3.1.2 研究變項定義.....................................14
3.1.3 研究世代建立流程..................................16
3.1.4 統計方法........................................16
3.2 根管治療成功率相關因素探討............................17
3.2.1 資料來源.........................................17
3.2.2 研究變項定義......................................17
3.2.3 研究世代建立流程...................................22
3.2.4 統計方法..........................................24
第4章 研究結果...........................................26
4.1 牙科醫療利用率之研究結果...............................26
4.1.1 樣本特性描述.......................................26
4.1.2 預防性與治療性牙科醫療利用率..........................27
4.2 根管治療成功率之研究結果...............................28
4.2.1 樣本特性描述.......................................29
4.2.2 根管治療牙齒,後續接受重新根管治療的牙齒其變項特性........30
4.2.3 根管治療牙齒,後續接受手術性治療的牙齒其變項特性..........31
4.2.4 根管治療牙齒,後續接受拔牙的牙齒其變項特性...............32
4.2.5 根管治療牙齒,總體根管治療失敗率與其結果之變項特性........33
4.2.6 根管治療失敗與其相關因素之多變量迴歸分析結果.............35
4.2.7 根管治療後各年累積存活率之分析結果.....................37
第5章 討論..............................................38
5.1 本研究主要結果........................................38
5.2 與相關研究比較........................................39
5.2.1 牙科醫療利用率......................................39
5.2.2 根管治療成功率......................................41
5.3 研究的優勢與限制......................................47
5.3.1 研究優勢...........................................47
5.3.2 研究限制...........................................48
第6章 結論與建議............................................50
參考文獻...................................................52

圖目錄
圖一:牙科醫療利用率資料擷取過程...............................59
圖二:根管治療成功率概論資料擷取過程............................60

表目錄
表1:牙科醫療利用率研究樣本之社會人口學變項......................61
表2:特性別牙科預防性醫療利用率................................62
表3:特性別牙科治療性醫療利用率................................63
表4:牙科預防性醫療利用率與年齡、性別及投保地區都市化程度間的相關性...64
表5:牙科治療性醫療利用率與年齡、性別及投保地區都市化程度間的相關性...65
表6:2005~2010年首次接受根管治療的牙齒共病以及牙齒所屬病人與治療機構之
特性分佈...............................................66
表7:接受根管治療牙齒世代於追蹤期間接受重新根管治療之總發生率及牙齒/病人/
治療機構特性別發生率.....................................68
表8:接受根管治療牙齒世代於追蹤期間接受手術性治療之總發生率及牙齒/病人/治
療機構特性別發生率.......................................70
表9:接受根管治療牙齒世代於追蹤期間接受拔牙治療之總發生率及牙齒/病人/治療
機構特性別發生率.........................................72
表10:接受根管治療牙齒世代於追蹤期間發生根管治療失敗事件之總發生率及牙齒/
病人/治療機構特性別發生率.................................74
表11:牙齒/病人/治療機構特別之重新根管治療危害比..................76
表12:牙齒/病人/治療機構特別之手術性治療危害比...................78
表13:牙齒/病人/治療機構特別之拔牙治療危害比.....................80
表14:牙齒/病人/治療機構特別之根管治療失敗事件發生危害比...........82
表15:根管治療牙齒發生重新根管治療事件之存活(成功)率分析..........84
表16:根管治療牙齒發生手術性治療事件之存活(成功)率分析............85
表17:根管治療牙齒發生拔牙事件之存活(成功)率分析.................86
表18:根管治療牙齒發生整體治療失敗事件之存活(成功)率分析..........87




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