Cost-effectiveness of pit-and-fissure sealants on primary molars in Medicaid-enrolled children

Abstract

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.

FIGURE 1—

Markov model for pit-and-fissure sealants on primary molar teeth: Iowa Medicaid, 2008–2011. Note. Initial state in standard care: natural tooth; initial state in all sealed: sealed tooth. A primary molar can move to adult tooth from any of the other 4 states. The model ends when all primary molars have moved to adult tooth.

FIGURE 2—

Deterministic Markov model for relative cost-effectiveness of 3 primary molar pit-and-fissure sealant strategies: Iowa Medicaid, 2008–2011. Note. AS = always sealed; ICER = incremental cost-effectiveness ratio; NS = never sealed; SC = standard care. We estimated ICERs by calculating the slope of each line connecting 2 pit-and-fissure sealant strategies for a given outcome (restoration or extraction avoided; e.g., in the AS strategy, there is a 96% likelihood that a tooth avoids a restoration). The mean cost of the AS strategy is about $23.25/tooth. The ICER of AS compared with SC (76% likelihood that a tooth avoids a restoration and $21.50/tooth) is about $9.00/restoration avoided ($23.21 − $21.45/0.96 − 0.76 ∼ $9.00/restoration avoided). The ICER of SC compared with NS is about $61.00/restoration avoided ($21.45 − $18.61/0.76 − 0.72 ∼ $61.00/restoration avoided).