A Cost-Effectiveness Analysis of Population-Level Dental Caries Prevention Strategies in US Children.

OBJECTIVE: To improve oral health disparities and outcomes among US children impacted by dental caries, there is a need to understand the cost-effectiveness of a targeted, risk-based versus universal-based approach for caries prevention. METHODS: Health and economic outcomes were simulated in a cohort of 50,000 US children aged 1-18 years, comparing current practice (CP) to risk-based-prevention (RBP) and prevention-for-all (PFA) strategies using health care sector and limited societal perspectives. Prevention included biannual oral health exams and fluoride varnish application, and one-time dental sealant placement. The primary outcome is the cost-effectiveness ratio (ICER), defined as the additional cost per quality-adjusted life year (QALY) gained when comparing each strategy to the next least costly one. RESULTS: For RBP compared to CP, the ICER was US$83,000/QALY from the health care sector perspective; for PFA compared to RBP the ICER was US$154,000/QALY. Using a limited societal perspective that includes caregiver time spent attending dental or medical setting visits, RBP compared to CP yielded a ratio of $119,000/QALY and PFA compared to RBP was $235,000/QALY. Results were most sensitive to changes in the probability of pain from an episode of dental caries, costs for prevention and restoration, and the loss in health-related quality of life due to dental caries pain. Scenario analyses evaluating a reduced intensity of prevention services yielded lower ICERs. CONCLUSION: Using a risk-based approach that identifies and targets children at increased risk for dental caries to guide the delivery of prevention services represents an economic value similar to other pediatric prevention programs.

Economic Evaluations of Preventive Interventions for Dental Caries and Periodontitis: A Systematic Review.

OBJECTIVES: To critically examine the methods used for full economic evaluations of preventive interventions for dental caries and periodontitis. METHODS: Published literature post-2000 was searched to April 2021. Based on a developed intervention classification framework for dental caries and periodontitis, only universal, selective or indicated interventions were included in this review. The Drummond 10-point checklist was used for quality appraisal. RESULTS: Of 3,007 unique records screened for relevance, 73 studies were reviewed. Most model-based studies (61/73) used cost-effectiveness analysis (49%) or cost-benefit analysis (28%). Trial-based studies (16/73) commonly used cost-effectiveness analysis (59%). Four studies used both economic evaluation methods. Sixty-four papers (88%) were on dental caries, eight papers (11%) focused on periodontitis, and one paper (1%) included both oral diseases; 72% of model-based and 82% of trial-based studies were of good quality. The most frequently investigated dental caries preventive interventions were water fluoridation (universal intervention; cost-saving or cost-effective), fissure sealant and fluoride varnish (selective and indicated interventions; cost-effectiveness outcomes were inconsistent). Supportive periodontal therapy with oral health education (indicated intervention; cost-effective) was the most frequently evaluated preventive intervention for periodontitis. Thirty percent of studies with a time horizon > 1 year did not apply an appropriate discount rate and 26% did not comprehensively discuss other important considerations beyond the technical analysis. CONCLUSIONS: Generic health outcome measures should be incorporated for economic evaluations on preventive interventions for dental caries and periodontitis, and an increased focus to prevent periodontitis using economic evaluation methods is needed to inform resource allocation and policy decision-making.

Systematic Review of Economic Evaluations of Primary Caries Prevention in 2- to 5-Year-Old Preschool Children.

OBJECTIVES: To describe and summarize evidence on economic evaluations (EEs) of primary caries prevention in preschool children aged 2 to 5 years and to evaluate the reporting quality of full EE studies using a quality assessment tool. METHODS: A systematic literature search was conducted in several databases. Full and partial EEs were included. The reporting quality of full EE studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. RESULTS: A total of 808 studies were identified, and 39 were included in the review. Most papers were published between 2000 and 2017 and originated in the United States and the United Kingdom. The most common type of intervention investigated was a complex multicomponent intervention, followed by water fluoridation. Cost analysis and cost-effectiveness analysis were the most frequently used types of EE. One study employed cost-utility analysis. The proportion of full EEs increased over time. The parameters not reported well included study perspective, baseline year, sensitivity analysis, and discount rate. The CHEERS items that were most often unmet were characterizing uncertainty, study perspective, study parameters, and estimating resources and costs. CONCLUSIONS: Within the past 2 decades, there has been an increase in the number of EEs of caries prevention interventions in preschool children. There was inconsistency in how EEs were conducted and reported. Lack of preference-based health-related quality-of-life measure utilization in the field was identified. The use of appropriate study methodologies and greater attention to recommended EE design are required to further improve quality.

Study protocol of the cost-effectiveness comparison of two preventive methods in the incidence of caries: A randomized, controlled clinical trial.

INTRODUCTION: Dental caries is the most frequent oral disease worldwide and the main cause of tooth loss in children and young adults. One of the most frequently affected areas is the occlusal surfaces of the first permanent molars (FPM) due to their morphological complexity. At present, several preventive treatments can reduce the incidence of this disease in school populations. In Mexico, the most commonly used technologies are those derived from some presentation of fluoride; on the other hand, research on this topic has been limited. OBJECTIVE: To determine the cost-effectiveness of two different methods for preventing the incidence of caries on the FPM of schoolchildren (6-8 years of age) from public primary schools. MATERIAL AND METHODS: This is a randomized experimental design. Participants will be assigned to two treatment groups of 114 each. In the first group, pit and fissure sealants will be applied, whereas the second group will receive a fluoride varnish. The work will be carried out in schoolchildren that attend public elementary schools in the state of Hidalgo, Mexico. The result variable will be the incidence of caries and the total cost of each of the interventions will be calculated in order to calculate the intervention's cost-effectiveness. CONCLUSION: This work will allow us to compare the cost-effectiveness of the pit and fissure sealants and the fluoride varnish in order to determine which offers the best results.

Private Practice Pricing in the Birmingham Region.

This study was carried out to evaluate the difference in prices for dental treatments carried out privately in general dental practice within the Birmingham area. Ten different practices were chosen at random, which were spread across Birmingham, in order to get a better insight into the differences across the districts. Their prices for pre-determined dental procedures were procured off the practices' respective websites or through telephoning. The findings of this study have shown a wide variation in prices for each dental procedure, with the greatest variation in prices between practices being ?850 for dental implants. The procedures with the lowest average cost were fissure sealants at ?23.14. The procedure with the highest average cost was dental implants at ?2,261.11. This study also showed that as more dental treatment was required, the mean cost for the dental intervention increased, regardless of the tooth being treated.

Economic evaluation of an expanded caries-preventive program targeting toddlers in high-risk areas in Sweden.

OBJECTIVE: To economically evaluate a caries-preventive program "Stop Caries Stockholm" (SCS) where a standard program is supplemented with biannual applications of fluoride varnish in toddlers and compared it with the standard preventive program. MATERIAL AND METHODS: Data from the cluster randomized controlled field trial SCS including 3403 children, conducted in multicultural areas with low socioeconomic status was used. The difference in mean caries increment between the examinations; when the toddlers were 1 and 3 years old, was outcome measure of the intervention. The program was evaluated from a societal as well as a dental health care perspective. The incremental cost-effectiveness ratio (ICER) was calculated as the incremental cost for each defs prevented. RESULTS: Average dental health care costs per child at age 3 years were EUR 95.77 for the supplemental intervention and EUR 70.52 for the standard intervention. The ICER was EUR 280.56 from a dental health care perspective and EUR 468.67 and considered high. CONCLUSIONS: The supplemental caries intervention program was not found to be cost-effective. The program raised costs without significantly reducing caries development. A better alternative use of the resources is recommended. TRIAL REGISTRATION: www.controlled-trials.com (ISRCTN35086887).

The cost-utility of school-based first permanent molar sealants programs: a Markov model.

BACKGROUND: Evidence of the cost-effectiveness of school-based first permanent molar sealants programs is not yet fully conclusive. The aim of this study was to determine the incremental cost-utility ratio (ICUR) of school-based prevention programs for the application of sealants in molars of schoolchildren compared with non-intervention. METHODS: A cost-utility analysis based on a Markov model was carried out using probability distribution. The utility was measured in quality-adjusted tooth years (QATY). The assessment was carried out from the public payer's perspective with a six-year time horizon. Costs and benefits were discounted at 3% per year. Only direct costs were evaluated, expressed in Chilean pesos (CLP) at 7th May at 2019 values (exchange rate USD = CLP 681.09). Univariate deterministic sensitivity analysis and probabilistic analysis were carried out. RESULTS: After a six-year follow up, the cost of sealing all first permanent molars was found to be higher than non-intervention, with a mean cost difference of USD 1.28 (CLP 875) per molar treated. The "seal all" strategy was more effective than non-intervention, generating 0.2 quality-adjusted tooth years more than non-intervention. The ICUR of the "seal all" strategy compared to non-intervention was USD 6.48 (CLP 4,412) per quality-adjusted tooth years. The sensitivity analysis showed that the increase in caries was the variable which most influenced the ICUR. CONCLUSIONS: A school-based sealant program is a cost-effective measure in populations with a high prevalence of caries.

The impact of national health insurance coverage on pit and fissure sealing experience.

INTRODUCTION: The purpose of this study was to review the change of supplied amount of oral pit and fissure sealing (PFS) in urban and rural areas of South Korea after including PFS into the list of treatments covered by the National Health Insurance (NHI), and to check whether there is a difference in supplied amount in areas where the dental treatment accessibility is different based on the data of the Korean National Health and Nutritional Examination Survey (KNHANES). METHODS: The KNHANES data year used for 'before coverage' was 2007, and that of 'after coverage' was 2012. Data analysis was done using STATA software. RESULTS: Areas were classified as urban or rural. Reduction of out-of-pocket expenses, according to the NHI coverage PFS experience of children aged 6-14 years, increased from 28.7% before coverage to 34.9% after coverage. PFS experience of children aged 6-14 years in the urban area was increased from 29.2% before coverage to 35.6% after coverage. The increase in rural areas was from 27.2% before coverage to 31.5% after coverage. CONCLUSIONS: Although PFS supplying was increased after inclusion in NHI coverage, it is still insufficient to reduce the decayed, missing, filled teeth index effectively. To reduce inequality, supply of PFS in rural area by community oral health program should be strengthened. And also, waiving out-of-pocket money for PFS in NHI should be considered.

Efetividade de selantes de fossas e fissuras aplicados por estudantes de Odontologia na prevenção de cárie / Effectiveness of pit and fissure sealants applied by Dental students for dental caries prevention

Objetivo: avaliar a efetividade dos selantes aplicados por estudantes do curso de graduação em Odontologia da Universidade do Sul de Santa Catarina (Unisul), Grande Florianópolis, após 6 meses da aplicação, e estimar a prevalência de cárie dos participantes. Sujeitos e método: estudo observacional descritivo com indivíduos das clínicas de Odontologia. A efetividade dos selantes oclusais foi avaliada por roteiro validado na literatura, e a prevalência de cárie, dicotomizada. Os dados foram analisados por estatística descritiva e as associações pelo teste Qui-Quadrado. Resultados: a taxa de resposta do estudo foi de 94,7% (n=18), 2/3 da amostra eram do sexo feminino (72,2% IC 95% 49,1;87,5), 60% dos pacientes recebiam 3 salários mínimos ou menos, maiores proporções de indivíduo tinham selados seus dentes há pelo menos 9 meses. Pouco menos de 2/3 da amostra receberam Fluroshield como material restaurador em seus dentes. Dentre os 57 dentes avaliados, 70,2% apresentavam retenção to-tal. Os dentes mais acometidos pela perda de retenção foram os segundos molares superiores (40%). Mais de 2/3 da amostra não apresentaram cárie (88,9% IC 95% 67,2; 96,9). O isolamento relativo foi o mais prevalente (72,2% IC 95% 49,1;87,5). Conclusão: sob a perspectiva das práticas dos estudantes de Odontologia, metade da amostra de pacientes apresentou alguma perda de retenção dos selantes, mesmo que um número maior de retenções totais e a ausência de recidiva de cárie tenham sido observados. Isso reflete a importância da relação professor-aluno no planejamento e na correta aplicação das técnicas de selamento por estudantes de Odontologia. (AU)

Objective: to evaluate the effectiveness of pit and fissure sealants applied by undergraduate dental students of the University of Southern Santa Catarina (Unisul), SC, Brazil, after 6 months, and to estimate the prevalence of caries in the participants. Subjects and method: observational and descriptive study with individuals from the dental clinics. The effectiveness of pit and fissure sealants was evaluated using a script validated in the literature, and the prevalence of caries was dichotomized. The data were analyzed by descriptive statistics and the associations were made using the chi-square test. Results: the response rate of the study was 94.7% (n=18), 2/3 of the sample consisted of women (72.2% 95%CI 49.1, 87.5), 60% of the patients received three Brazilian minimum wages or less, and a great portion of the participants had sealed their teeth at least 9 months earlier. A little under 2/3 of the sample received Fluroshield as restorative material for their teeth. Among the 57 teeth evaluated, 70.2% presented complete retention. The teeth most affected by loss of retention were maxillary left second molars (40%). More than 2/3 of the sample did not present dental caries (88.9% 95%CI, 67.2, 96.9). Relative isolation was the most prevalent (72.2% 95%CI 49.1, 87.5). Conclusion: from the perspective of the practices of dental students, half of the sample of patients presented some loss of sealant retention, despite the greater number of complete retentions and absence of recurrent caries. This reflects the importance of the teacher-student relationship in the planning and correct application of sealing techniques by dental students. (AU)

Economic evaluation of dental sealants: A systematic literature review.

OBJECTIVES: To systematically review the literature on economic evaluations of dental sealants and examine the costs and effectiveness of caries prevention using sealants. METHODS: Of 21 full-text articles examined, a total of 13 were included in this study. These studies are grouped by the type of intervention as follows: (i) sealants compared with no sealants; (ii) sealants compared with other forms of caries prevention; (iii) resin-based sealants compared with glass-ionomer sealants; (iv) different sealing strategies in primary teeth; (v) different sealing strategies in permanent teeth; and (vi) sealants based on school- or clinic-based setting of delivery. All currency is reported in constant 2010 US$. RESULTS: Cost-effectiveness analyses differed due to varying study designs, assumptions, sealant delivery settings, outcomes, caries risk assessment and study durations. Findings varied on the cost-effectiveness of sealants compared with other caries-preventive strategies. Under the assumption of equal caries risk, always sealing primary molars appeared to be the most effective strategy, whereas risk-based sealing was the optimal strategy with differing caries risk. Studies that assessed sealing strategies in permanent teeth reported that risk-based sealing was more cost-effective than not sealing, but they differed on the cost-effectiveness of risk-based seal compared with non-risk-based seal. Sealants delivered in school settings had mixed results on costs but were as equally effective as sealants delivered in private practices. CONCLUSIONS: The cost-effectiveness of sealants is dependent on the conditions of delivery. The list of cost-effectiveness ratios for each intervention can support policy makers to estimate expected returns on their investments in dental sealants.

Seal or Varnish? A randomised controlled trial to determine the relative cost and effectiveness of pit and fissure sealant and fluoride varnish in preventing dental decay.

BACKGROUND: Fissure sealant (FS) and fluoride varnish (FV) have been shown to be effective in preventing dental caries when tested against a no-treatment control. However, the relative clinical effectiveness and cost-effectiveness of these interventions is unknown. OBJECTIVE: To compare the clinical effectiveness and cost-effectiveness of FS and FV in preventing dental caries in first permanent molars (FPMs) in 6- and 7-year-olds and to determine their acceptability. DESIGN: A randomised controlled allocation-blinded clinical trial with two parallel arms. SETTING: A targeted population programme using mobile dental clinics (MDCs) in schools located in areas of high social and economic deprivation in South Wales. PARTICIPANTS: In total, 1016 children were randomised, but one parent subsequently withdrew permission and so the analysis was based on 1015 children. The randomisation of participants was stratified by school and balanced for sex and primary dentition baseline caries levels using minimisation in a 1 : 1 ratio for treatments. A random component was added to the minimisation algorithm, such that it was not completely deterministic. Of the participants, 514 were randomised to receive FS and 502 were randomised to receive FV. INTERVENTIONS: Resin-based FS was applied to caries-free FPMs and maintained at 6-monthly intervals. FV was applied at baseline and at 6-month intervals over the course of 3 years. MAIN OUTCOME MEASURES: The proportion of children developing caries into dentine (decayed, missing, filled teeth in permanent dentition, i.e. D4-6MFT) on any one of up to four treated FPMs after 36 months. The assessors were blinded to treatment allocation; however, the presence or absence of FS at assessment would obviously indicate the probable treatment received. Economic measures established the costs and budget impact of FS and FV and the relative cost-effectiveness of these technologies. Qualitative interviews determined the acceptability of the interventions. RESULTS: At 36 months, 835 (82%) children remained in the trial: 417 in the FS arm and 418 in the FV arm. The proportion of children who developed caries into dentine on a least one FPM was lower in the FV arm (73; 17.5%) than in the FS arm (82, 19.6%) [odds ratio (OR) 0.84, 95% confidence interval (CI) 0.59 to 1.21; p = 0.35] but the difference was not statistically significant. The results were similar when the numbers of newly decayed teeth (OR 0.86, 95% CI 0.60 to 1.22) and tooth surfaces (OR 0.85, 95% CI 0.59 to 1.21) were examined. Trial fidelity was high: 95% of participants received five or six of the six scheduled treatments. Between 74% and 93% of sealants (upper and lower teeth) were intact at 36 months. The costs of the two technologies showed a small but statistically significant difference; the mean cost to the NHS (including intervention costs) per child was £500 for FS, compared with £432 for FV, a difference of £68.13 (95% CI £5.63 to £130.63; p = 0.033) in favour of FV. The budget impact analysis suggests that there is a cost saving of £68.13 (95% CI £5.63 to £130.63; p = 0.033) per child treated if using FV compared with the application of FS over this time period. An acceptability score completed by the children immediately after treatment and subsequent interviews demonstrated that both interventions were acceptable to the children. No adverse effects were reported. LIMITATIONS: There are no important limitations to this study. CONCLUSIONS: In a community oral health programme utilising MDCs and targeted at children with high caries risk, the twice-yearly application of FV resulted in caries prevention that is not significantly different from that obtained by applying and maintaining FSs after 36 months. FV proved less expensive. FUTURE WORK: The clinical effectiveness and cost-effectiveness of FS and FV following the cessation of active intervention merits investigation. TRIAL REGISTRATION: EudraCT number 2010-023476-23, Current Controlled Trials ISRCTN17029222 and UKCRN reference 9273. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 21. See the NIHR Journals Library website for further project information.

The cost-effectiveness of three interventions for providing preventive services to low-income children.

OBJECTIVE: We evaluated the impact of loan repayment programmes, revising Medicaid fee-for-service rates, and changing dental hygienist supervision requirements on access to preventive dental care for children in Georgia. METHODS: We estimated cost savings from the three interventions of preventive care for young children after netting out the intervention cost. We used a regression model to evaluate the impact of changing the Medicaid reimbursement rates. The impact of supervision was evaluated by comparing general and direct supervision in school-based dental sealant programmes. RESULTS: Federal loan repayments to dentists and school-based sealant programmes (SBSPs) had lower intervention costs (with higher potential cost savings) than raising the Medicaid reimbursement rate. General supervision had costs 56% lower than direct supervision of dental hygienists for implementing a SBSP. Raising the Medicaid reimbursement rate by 10 percentage points would improve utilization by <1% and cost over $38 million. Given one parameter set, SBSPs could serve over 27 000 children with an intervention cost between $500 000 and $1.3 million with a potential cost saving of $1.1 million. Loan repayment could serve almost 13 000 children for a cost of $400 000 and a potential cost saving of $176 000. CONCLUSIONS: The three interventions all improved met need for preventive dental care. Raising the reimbursement rate alone would marginally affect utilization of Medicaid services but would not substantially increase acceptance of Medicaid by providers. Both loan repayment programmes and amending supervision requirements are potentially cost-saving interventions. Loan repayment programmes provide complete care to targeted areas, while amending supervision requirements of dental hygienists could provide preventive care across the state.

Evaluation of School-Based Dental Sealant Programs: An Updated Community Guide Systematic Economic Review.

CONTEXT: A recently updated Community Guide systematic review of the effectiveness of school sealant programs (SSPs) still found strong evidence that SSPs reduced dental caries among schoolchildren. This follow-up systematic review updates SSP cost and benefit information from the original 2002 review. EVIDENCE ACQUISITION: Using Community Guide economic review methods, the authors searched the literature from January 2000 to November 20, 2014. The final body of evidence included 14 studies-ten from the current search and four with cost information from the 2002 review. Nine studies had information on SSP costs; six on sealant benefit (averted treatment costs and productivity losses); four on SSP net cost (cost minus benefit); and three on net cost to Medicaid of clinically delivered sealants. The authors imputed productivity losses and discounted costs/outcomes when this information was missing. The analysis, conducted in 2015, reported all values in 2014 U.S. dollars. EVIDENCE SYNTHESIS: The median one-time SSP cost per tooth sealed was $11.64. Labor accounted for two thirds of costs, and time to provide sealants was a major cost driver. The median annual economic benefit was $6.29, suggesting that over 4 years the SSP benefit ($23.37 at a 3% discount rate) would exceed costs by $11.73 per sealed tooth. In addition, two of four economic models and all three analyses of Medicaid claims data found that SSP benefit to society exceeded SSP cost. CONCLUSIONS: Recent evidence indicates the benefits of SSPs exceed their costs when SSPs target schools attended by a large number of high-risk children.

Cost-Effectiveness Analysis of Dental Sealants versus Fluoride Varnish in a School-Based Setting.

While sealants are more effective than fluoride varnish in reducing the development of new carious lesions on occlusal surfaces, and a course of treatment requires fewer clinical visits, they are more expensive per application. This analysis assessed which treatment is more cost-effective. We estimate the costs of sealants and fluoride varnish over a 4-year period in a school-based setting, and compare this to existing estimates of the relative benefits in terms of caries reduction to calculate the relative cost-effectiveness of these two preventive treatments. In our base case scenario, varnish is more cost-effective in preventing caries. Allowing for caries benefits to nonocclusal surfaces further improves the cost-effectiveness of varnish. Although we found that varnish is more cost-effective, the results are context specific. Sealants become equally cost-effective if a dental hygienist applies the sealants instead of a dentist, while varnish becomes increasingly cost-effective when making comparisons outside of a traditional dental clinic setting.

TRICARE; Revision of Nonparticipating Providers Reimbursement Rate; Removal of Cost Share for Dental Sealants; TRICARE Dental Program. Final rule.

This final rule revises the benefit payment provision for nonparticipating providers to more closely mirror industry practices by requiring TDP nonparticipating providers to be reimbursed (minus the appropriate cost-share) at the lesser of billed charges or the network maximum allowable charge for similar services in that same locality (region) or state. This rule also updates the regulatory provisions regarding dental sealants to clearly categorize them as a preventive service and, consequently, eliminate the current 20 percent cost-share applicable to sealants to conform with the language in the regulation to the statute.

Effectiveness, cost-effectiveness and cost-benefit of a single annual professional intervention for the prevention of childhood dental caries in a remote rural Indigenous community.

BACKGROUND: The aim of the study is to reduce the high prevalence of tooth decay in children in a remote, rural Indigenous community in Australia, by application of a single annual dental preventive intervention. The study seeks to (1) assess the effectiveness of an annual oral health preventive intervention in slowing the incidence of dental caries in children in this community, (2) identify the mediating role of known risk factors for dental caries and (3) assess the cost-effectiveness and cost-benefit of the intervention. METHODS/DESIGN: The intervention is novel in that most dental preventive interventions require regular re-application, which is not possible in resource constrained communities. While tooth decay is preventable, self-care and healthy habits are lacking in these communities, placing more emphasis on health services to deliver an effective dental preventive intervention. Importantly, the study will assess cost-benefit and cost-effectiveness for broader implementation across similar communities in Australia and internationally. DISCUSSION: There is an urgent need to reduce the burden of dental decay in these communities, by implementing effective, cost-effective, feasible and sustainable dental prevention programs. Expected outcomes of this study include improved oral and general health of children within the community; an understanding of the costs associated with the intervention provided, and its comparison with the costs of allowing new lesions to develop, with associated treatment costs. Findings should be generalisable to similar communities around the world. The research is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR), registration number ACTRN12615000693527; date of registration: 3rd July 2015.

Effect of Family Income on the Relationship Between Parental Education and Sealant Prevalence, National Health and Nutrition Examination Survey, 2005-2010.

INTRODUCTION: We examined the association between sealant prevalence and parental education for different levels of family income, controlling for other covariates. METHODS: We combined data from 2005-2006, 2007-2008, and 2009-2010 cycles of the National Health and Nutrition Examination Survey. The study sample was 7,090 participants aged 6 to 19 years. Explanatory variables, chosen on the basis of Andersen and Aday's framework of health care utilization, were predisposing variables - child's age, sex, race/ethnicity, and parental education (high school diploma); enabling variables - family income (<100% of the federal poverty level [FPL]; 100%-200% of the FPL; and >200% of the FPL), health insurance status, and regular source of medical care; and a need variable - future need for care (perceived child health status is excellent/very good, good, fair/poor). We conducted bivariate and multivariate analyses and included a term for interaction between education and income in the multivariate model. We report significant findings (P ≤ .05). RESULTS: Sealant prevalence was associated with all explanatory variables in bivariate and multivariate analyses. In bivariate analyses, higher parental education and family income were independently associated with higher sealant prevalence. In the multivariate analysis, higher parental education was associated with sealant prevalence among higher income children, but not among low-income children (<100% FPL). Sealant prevalence was higher among children with parental education greater than a high school diploma versus less than a high school diploma in families with income ≥100% FPL. CONCLUSION: Our findings suggest that income modifies the association of parental education on sealant prevalence. Recognition of this relationship may be important for health promotion efforts.