摘要：Objectives. We compared the incremental cost-effectiveness of 2 primary molar sealant strategies—always seal and never seal—with standard care for Medicaid-enrolled children. Methods. We used Iowa Medicaid claims data (2008–2011), developed a tooth-level Markov model for 10 000 teeth, and compared costs, treatment avoided, and incremental cost per treatment avoided for the 2 sealant strategies with standard care. Results. In 10 000 simulated teeth, standard care cost $214 510, always seal cost $232 141, and never seal cost $186 010. Relative to standard care, always seal reduced the number of restorations to 340 from 2389, whereas never seal increased restorations to 2853. Compared with standard care, always seal cost $8.12 per restoration avoided (95% confidence interval [CI] = $4.10, $12.26; P ≤ .001). Compared with never seal, standard care cost $65.62 per restoration avoided (95% CI = $52.99, $78.26; P ≤ .001). Conclusions. Relative to standard care, always sealing primary molars is more costly but reduces subsequent dental treatment. Never sealing costs less but leads to more treatment. State Medicaid programs that do not currently reimburse dentists for primary molar sealants should consider reimbursement for primary molar sealant procedures as a population-based strategy to prevent tooth decay and reduce later treatment needs in vulnerable young children. Oral health disparities are an indication of social injustice. 1 Tooth decay is the most common pediatric disease in the United States and is a significant public health problem. 2,3 When untreated, tooth decay leads to pain, systemic infections, hospitalization, and, in rare cases, death. Untreated tooth decay has social and health consequences manifesting as missed school days, poor grades, underemployment, poor quality of life, and life-threatening systemic diseases. 4–8 Children from low-income households, including Medicaid-enrolled children, are at risk for tooth decay. 9 National data indicate that decay rates in primary teeth for US children aged 2 to 5 years increased from 24.2% in 1988–1994 to 27.9% in 1999–2004. 10 Twice as many children from poor households (< 100% federal poverty level [FPL], defined annually by the US Census Bureau) had any or untreated tooth decay (41.8% and 31.3%, respectively) than did children from nonpoor households (> 200% FPL; 27.8% and 12.9%, respectively). 10 Healthy primary molars are important because they help children chew food, serve as placeholders before the permanent teeth erupt, and prevent orthodontic problems. Tooth decay on primary teeth is one of the strongest predictors of tooth decay in permanent teeth. 11 Decayed primary teeth harbor bacteria that can be transmitted to permanent teeth. The rise in decay rates in primary teeth has motivated public health strategies that protect the oral health of young socioeconomically vulnerable children. 12 Tooth decay is the consequence of a multifactorial disease process in which oral bacteria metabolize dietary carbohydrates and produce acids that demineralize tooth structure. Topical fluorides and pit-and-fissure sealants are the 2 most common preventive strategies available. Topical fluorides prevent decay by remineralizing tooth enamel and are found in fluoridated drinking water, fluoride toothpastes, and prescription fluoride drops or tablets. Also, health professionals provide patients with fluoride in the form of gels, foams, and varnish. Pit-and-fissure sealants are plastic coatings that protect the grooves of molars from developing tooth decay. Dentists and other oral health professionals provide sealants in dental offices, at community health centers, and through school-based programs. 13 The American Academy of Pediatric Dentistry recommends dental sealants as part of a comprehensive caries prevention strategy for children aged 3 years and older. 14 This recommendation is derived, in part, from a 2008 American Dental Association evidence-based review, which concluded that sealants prevent caries in children. 15 However, the American Dental Association review has 2 limitations. First, the specific recommendation to seal primary teeth is derived from a single study that evaluated primary molar sealant retention rates. 16 Second, the review broadly extrapolates from studies on permanent teeth, which may not be warranted because primary and permanent teeth differ in pit-and-fissure anatomy, enamel demineralization susceptibility, and dentin microstructure. 17,18 Studies suggest permanent molar sealants are cost-effective, particularly in children at increased risk for tooth decay, 19,20 but there are no such studies focusing on primary molar sealants. The lack of empirical data is a concern from an evidence-based dentistry 21 and public health perspective, especially for Medicaid-enrolled children. Only 1 in 3 state Medicaid programs reimburse dental providers for primary molar sealants. 22 State budget cuts have left Medicaid programs with limited resources. Findings from cost-effectiveness analyses could help policymakers prioritize funding decisions and devote additional resources to increase use of preventive dental services for vulnerable children. 23,24 In this study, we evaluated the cost-effectiveness of primary molar sealants in Medicaid-enrolled children. We compared the cost-effectiveness of standard care with 2 alternative strategies: always sealing versus never sealing primary molars. We tested 3 hypotheses: (1) always sealing primary molars is more costly than is standard care but prevents subsequent treatment; (2) never sealing primary molars is less costly but leads to more subsequent treatment than does standard care; and (3) compared with standard care, the incremental cost and treatment avoided for always sealing are less than are the incremental cost and treatment avoided for never sealing.
