Fluoride and fissure sealants: Matching insurance claims with evidence

South African health insurance sector costs have risen rapidly over the past few years with little concern for the efficacy of treatments provided. Evidence-based dentistry provides a way to review whether spending patterns represent optimal use of dental care resources. Objective: To determine the extent to which medical aid schemes are funding evidence-based dental care by assessing claims patterns for topical fluoride and fissure sealants to beneficiaries of a large South African medical aid scheme. Method: The 2005 claims and membership data (N=181,039) were analysed. National Health Reference Price List (NHRPL) procedure codes were used to create a dental claims data set by isolating claims with procedure codes 8101 to 9300. Topical fluoride claims were identified by codes 8161 and 8162 and fissure sealants by code 8163. The data was analysed by age category. Results: 43% of all beneficiaries visited a dentist in 2005 and 30% of these received fluoride treatment. This ranged from 10% of those aged 0-5 to 38% in children aged 10-15 years. Of almost 27,000 fluoride treatments provided, only 18% were provided to children aged 0-15 years and 64% were provided to patients 25 or older. Few patients (3%) received at least one fissure sealant and most (75%) were provided to children aged 5-15 years. Only 12% of children aged 5-10 who visited a dentist, received at least one sealant. Fluoride treatment costs constituted 1.6% and fissure sealant costs 0.4% of total dental claims for 2005. Conclusions: The claims data reveal a substantial under-provision of an evidence-supported intervention (fissure sealants) to children who could benefit, and enthusiastic provision of a procedure with doubtful effectiveness (topical fluoride). The cost implications for consumers and the insurance industry are significant if procedures with limited or no evidence-base continue to be provided to patients.