Purpose: Since properly placed and retained sealants can reduce the incidence of caries lesions and save subsequent restorative costs, the purpose of this study was to compare the subsequent restorative cost in a group of predominantly African American Medicaid children who received prior sealants to that of a group of children who did not receive sealants. Methods: Dental claims of 2 cohorts of 5- to 7-year-old children who were continuously enrolled in Alabama Medicaid from 1990 to 1997 (N=9, 549) and who either did or did not receive sealants were analyzed using basic descriptive statistics, chi-square and t tests, and regression analysis. The subsequent restorative care costs related to 1-surface posterior amalgam or resin restorations were evaluated in relation to sealant status and selected independent variables. Results: Only 10% of the children with at least 1 prior sealant claim obtained subsequent 1-surface posterior amalgam or resin restorations. This proportion was 33% among children without a prior sealant claim (OR=4.2, 95% CI=3.6-4.9). On average, total Medicaid reimbursement per child for sealants, plus subsequent restorative care was $56 in the sealant group compared to $72 for subsequent care alone in the nonsealant group. This difference was independent of the child's race, gender, or age. Conclusions: As expected, children who do not receive sealants are more likely to obtain subsequent restorative care and cost more money to the health care system. However, the modest sealant-related subsequent restorative cost savings observed among Alabama Medicaid children may be an underestimate of the real cost-benefits of sealants.