Cost-Effectiveness Analysis of a School-Based Dental Sealant Program for Low-Socioeconomic-Status Children: A Practice-Based Report

38 Brief communication COST-EFFECTIVENESS ANALYSIS OF A SCHOOL-BASED DENTAL SEALANT PROGRAM FOR LOW-SOCIOECONOMIC-STATUS CHILDREN: A PRACTICE-BASED REPORT The decline in dental caries prevalence among school-age children during the last decade was masked by increased disparities of caries patterns between segments of the U.S. population. As caries rates decreased among school-age children, the burden of dental disease and untreated caries shifted to minority and low-socioeconomic-status (SES) groups.1"3 The need for greater preventive interventions, such as school-based sealant programs, should be implemented as a means of targeting such high-risk populations. It is very timely to evaluate the cost-effectiveness of dental sealants in public health programs that reach populations at highest risk for caries. Furthermore , the mid-decade assessment of Healthy People 2000 Oral Health Objectives illustrated increasing use of dental sealants yet reaffirmed that chüdren highest at risk for caries fail to receive adequate preventive services.4 The significance of cost-effectiveness analysis has been demonstrated in several articles dealing with allocation of resources in health care.5"7 This report presents a cost-effectiveness analysis of a successful school-based dental sealant program for low-SES children. The Peekskill Area Health Center (PAHC)'s School-based Caries Preventive Program was born of a traditional outreach effort to increase utilization of primary oral health care (POHC) services among low-SES children in the public schools. Oral health screenings, referrals, and follow-up efforts via phone and mail were offered during four years (1983-87). Analysis of the follow-up data produced dismal results: less then 10 percent of the children referred to the PAHC received comprehensive POHC. Numerous barriers to care were identified, including the high rate of broken appointments due to dysfunctional , distressed families, whose priorities did not include comprehensive POHC. Alternatives were considered, and the decision was made to take caries prevention directly to where the children were, that is, to the schools. In 1986, a weekly fluoride mouth rinse program was initiated, followed by the dental sealant program for children age 6 to 14, supported by a New York State Department of Health Maternal and Child Health Block Grant. This clinical preventive program included oral hygiene instructions, weekly NaFl rinses, dental sealants, and referrals to the students' family dentists or the PAHC for comprehensive dental care. It is crucial to note the high caries prevalence in Journal of Health Care for the Poor and Underserved · Vol. 13, No. 1 · 2002 Zabos et al. 39 Peekskill schoolchildren, which was 30 percent higher than among similar children in surrounding communities, and the high proportion of untreated dental caries among these children (54 percent). Only 36 percent were cariesfree , a very dismal figure in the United States.8 Reasons included a high proportion of low-income families, lack of fluoridated water, and difficulty finding needed dental care due to low Medicaid participation rates among private dentists. The PAHCs School-Based Caries Preventive Program offered services at no cost to aU children. Portable equipment was used to contain program costs. A team consisting of a dental hygienist and dental assistant deUvered the sealants under the general supervision of the dental director. The school-based service delivery system removed financial and social barriers to preventive care. Using New York State Department of Health (NYSDOH) practice guidelines ,9 first and sixth graders were targeted to have their first and second permanent molars sealed. Yearly foUow-up examinations were conducted and indicated services offered (repair of lost sealants, sealing of newly erupted teeth, and referrals for comprehensive dental care to the PAHC or to a private family dentist). This school-based preventive program was designed as a service project; the interventions were offered to all children. However, due to an initial delay in offering sealants to chüdren in one of the elementary schools, it became possible to evaluate clinical outcomes and their cost-effectiveness using students from the second school as controls where implementation of the sealants was delayed by five years (the time lag from first to sixth grade). Method Data avaüable for evaluation from both elementary schools where chüdren were initially screened included demographic information...