The results, which were published in Health Affairs, provide useful information for comparing school-based sealant programs with other alternatives. These programs typically provide sealants at little or no cost to children attending schools with a large population of low-income families who do not receive regular dental care.
"Increasing sealant prevalence among low-income children could save society money and decrease toothaches and their sequelae," the study authors wrote (Health Affairs, December 2016, Vol. 35:12, pp. 2233-2240).
The study was led by Susan Griffin, PhD, a health economist in the division of oral health at the U.S. Centers for Disease Control and Prevention (CDC), and included other researchers from the CDC and U.S. universities.
Running the numbers
The authors noted that 27% of low-income children in the U.S. have untreated cavities by adolescence. However, sealants are used in only 38% of lower-income children compared with 47% of those from higher-income families. School-based sealant programs have been shown to increase the number of students receiving sealants and prevent cavities.
The Community Preventive Services Task Force, an independent panel of public health experts, has recommended school-based sealant programs since 2002. Nonetheless, in 2013 only 15 states had such programs in more than half of schools serving low-income populations, defined as those in which most students participated in the free and reduced-cost meal program.
This study is believed to be the first to estimate the net cost for a school-based sealant program to prevent a disability-adjusted life year (DALY), a commonly used measure of activity limitations caused by disease, injury, or disability. This allows the results of the program to be compared to other ones.
The investigators analyzed the cost-effectiveness of school-based sealant programs using data from 14 states from 2013 through 2014 on children's cavity risk, including the effects of untreated cavities on a child's quality of life. They estimated net costs and increased quality of life by applying sealant to a child's four permanent first molars.
The researchers created a model for a program that targets children for sealant placement soon after their first molars erupt but does not require reapplication. The analysis was limited to four years, since sealants are believed to be strongest during that period, but a nine-year period was included in the sensitivity analysis.
The researchers included the following factors in their model:
- First molar cavity attack rate
- Probability that a cavity remains untreated
- Effectiveness of school-based sealant
- Probability of a toothache in a child with an untreated cavity
- Loss of health and well-being caused by toothache
- School-based sealant program resource costs
- Cost per filling
- Productivity losses
They found that net costs for school-based sealant programs saved money: Costs were $8.43 less per student than the money saved in treatment and productivity costs. This was based on their calculations of $63.33 in costs per child in a school-based sealant program and $71.76 in averted treatment and productivity costs due to their participation in the program.
The researchers also found that providing sealants through school-based programs to 1,000 children would prevent 485 fillings, 133 toothaches for a year, and save 1.59 DALYs.
Increasing access to restorative care
The investigators noted the following limitations of their study:
- Estimates of averted treatment costs and productivity losses were conservative.
- Treatment options were limited to a basic filling.
- Travel costs associated with a dental visit or future treatment costs and productivity losses associated with maintaining or replacing a filling were not included.
- Loss of quality of life associated with untreated first-molar cavities may have been overestimated.
- The comparison group was children who were not receiving sealants as opposed to children in a school without a sealant program.
The authors pointed out that reducing labor costs, which account for two-thirds of program costs, would lower the expenses for the sealant program. This would involve reducing labor time per child or cost per labor unit. Programs in states that require a dentist to be present during sealant placement or assessment for sealants have higher hourly labor costs and may use more labor time per child.
The authors also noted that returning signed consent forms for receiving sealants can be a barrier to treatment. They suggested that policies designed to increase oral health literacy among low-income caregivers might increase the number of high-risk children receiving sealants. School staff may also be unaware of the potential benefits of sealants, they wrote.
The authors added that baseline screening data from the school-based sealant programs in the states included in their analysis found that the programs were serving children at high risk for cavities who were unlikely to use clinical dental services. A third of them had at least one cavity needing treatment in a permanent or primary tooth, compared with the national average of 20%.
"In the absence of access to restorative care, prevention becomes even more critical to long-term dental health," they concluded.
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