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«Thank you to the North Dakota Department of Human Services and North Dakota Department of Health staff members who assisted in the development of ...»

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The North Dakota Department of Human Services Medical Services Division and the North

Dakota Department of Health’s Oral Health Program wish to thank the following entities for

granting permission to adapt their photos into this guide.

Jesperson Orthodontics


BioMed Central

www.biomedcentral.com Delta Dental Corporation www.deltadentalid.com Thank you to the North Dakota Department of Human Services and North Dakota Department of Health staff members who assisted in the development of this guide.

This manual is also available online at:

 www.ndhealth.gov/oralhealth  www.nd.gov/dhs/services/medicalserv/medicaid/provider.html This publication was supported with funding from the U.S. Centers for Disease Control and Prevention, Cooperative Agreement grant number 5U58DP001577-04.




Training Objectives

Orthodontic Treatment Options Under Health Tracks

Cleft Lip or Cleft Palate

Interceptive Orthodontic Treatment

Comprehensive Orthodontic Treatment

Orthodontic Screening

When To Start Screening Children for Orthodontic Referral

When To Refer Children for Orthodontic Evaluation

Use of Screening Results

Understanding Malocclusions

Cleft Lip or Cleft Palate

Positioning of Teeth for Classifying Malocclusions

Interceptive Orthodontic Screening Malocclusions

Anterior cross bite

Posterior cross bite

Ectopic central incisor

Comprehensive Orthodontic Screening Malocclusions

Over jet

Over bite

Mandibular protrusion

Anterior open bite

Impacted teeth


Cross bite

Habits that affect arch development

Infection Control Procedures for Screening


Appendix A – Glossary

Appendix B – Screening Supplies

Appendix C – Reference Guide for Health Tracks Orthodontic Screening

Appendix D – Orthodontic Screening Tools

Appendix E – Health Tracks Orthodontic Screening Form Sample


  Page 1 PREFACE This guide was written to assist Health Tracks nurses in understanding orthodontic terminology and to establish basic guidelines for screening and referral of children. The information presented in the guide covers only the malocclusions used in the North Dakota Health Tracks (EPSDT) inceptive and comprehensive orthodontic indexes. The guide includes basic suggestions for orthodontic screening procedures.

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Orthodontic treatment includes the diagnosis, prevention and treatment of dental and facial irregularities. These irregularities often take the form of malocclusions (or problems with the way the teeth fit together).

In most cases, malocclusion is hereditary, caused by differences in the size of the teeth and jaw that cannot be prevented. Sometimes malocclusion is the result of habits such as finger or thumb sucking, tongue thrusting, mouth breathing or losing baby teeth too soon.

More than half of children 12 to 17 years of age suffer from malocclusions that can be corrected with orthodontic treatment. In some cases, mild malocclusions primarily affect appearance. More severe cases of malocclusion can interfere with chewing ability, create tension and pain in jaw joints, and result in facial deformities leading to emotional problems. Crowded or crooked teeth are more difficult to clean and can lead to increased tooth decay or periodontal disease. Health Tracks (EPSDT) screening for orthodontic problems is important so referral for treatment can be accomplished.

There is a lack of uniformly acceptable standards defining the degree of deviation from ideal occlusion severe enough to be considered an orthodontic problem. The North Dakota Department of Health’s Oral Health Program developed this guide to assist in training Health Tracks (EPSDT) screeners, as well as to standardize oral screening procedures performed statewide. The information outlined in this guide is provided for screening and referral information purposes only and should not be interpreted as a diagnosis or treatment plan. This information is not meant to be a substitute for the advice of a licensed dentist and should not be used for diagnosing a dental condition.

Training Objectives

 Understand basic orthodontic terminology  Understand basic treatment options under the Health Tracks Program  Recognize normal occlusion and malocclusions  Estimate the degree of abnormality measured in millimeters  Given an abnormal condition, estimate if the client meets the eligibility criteria set forth in the orthodontic indexes  Recognize attitudes and behaviors that may contraindicate orthodontic treatment

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Orthodontic treatment under the North Dakota Medicaid Program includes the following

treatment options:

1. Cleft Lip or Cleft Palate – immediate referral

2. Interceptive Orthodontic Treatment – early treatment of developing malocclusions

3. Comprehensive Orthodontic Treatment – improvement of craniofacial (head, skull or facial bone) dysfunction and/or dentofacial (face, teeth and jaw) abnormalities Cleft Lip or Cleft Palate Cleft lip or cleft palates are automatically referred under interceptive phase.

Interceptive Orthodontic Treatment Interceptive orthodontic treatment is the early treatment of developing malocclusions. The purpose of interceptive orthodontic treatment is to lessen the severity of the developing malocclusion. Interceptive treatment does not preclude the need for further treatment at a later age.

The presence of complicating factors such as skeletal disharmonies, overall space deficiency, or other conditions requiring present or future comprehensive therapy is beyond the realm of interceptive therapy. Early phases of comprehensive therapy may utilize some procedures involved in the interceptive phase in otherwise normally developing dentition, but such procedures are not considered interceptive.

Interceptive treatment under the North Dakota Medicaid Program will include only treatment of anterior and posterior cross bites and minor treatment for tooth guidance in the transitional dentition. This may include treatment for an ectopic (severely mal-positioned) incisor. Points are not necessary in the interceptive screening process.

Comprehensive Orthodontic Treatment

Comprehensive orthodontic treatment under the North Dakota Medicaid Program includes treatment of handicapping malocclusions in the transitional or adolescent dentition leading to improvement in the patient’s craniofacial (head, skull or facial bone) dysfunction and /or dentofacial (teeth, jaw or face) abnormalities. Treatment may incorporate several phases with specific objectives at various stages of dentofacial (teeth, jaw or face) development. Treatment usually includes fixed orthodontic appliances (braces) and may also include procedures such as extractions and maxillofacial surgery.

Eligibility for treatment is determined by use of an orthodontic index. Children must have 20 or more points to be eligible for treatment. Special consideration may be given if the index is between 18 and 20 points, and if x-rays and a narrative description are submitted to the North Dakota Medicaid Program Dental Consultant for review. The child must be North Dakota Medicaid eligible at the beginning of the treatment phase.

  Page 3


An orthodontic screening is a visual inspection aided by this guide, use of a tongue blade and orthodontic ruler or gauge. The screening identifies children with occlusion abnormalities and is not considered a diagnostic examination. Based on the eligibility criteria set forth by the North Dakota Medicaid Health Tracks Program (EPSDT) outlined in this guide, children will be referred to an enrolled dental provider for a complete orthodontic evaluation.

When To Start Screening Children for Orthodontic Referral Cleft Lip or Cleft Palate No need to screen children of all ages. Refer to an orthodontist immediately.

Interceptive Children ages 7 through 10 should be screened for an interceptive orthodontic referral.

Conditions to be referred are anterior cross bite, posterior cross bite, and ectopic (malpositioned) incisor.

Comprehensive Children should be screened for a comprehensive orthodontic referral beginning at age 10. By this age, a majority of the permanent teeth have erupted. Since the criteria in the current orthodontic index will allow only the most severe cases for treatment, it is most efficient to begin screening when this determination can most easily be made. This procedure will save time for both the screener and the enrolled provider. The screener will not complete the orthodontic screening on children too young to make a complete determination since the permanent teeth have not erupted. The enrolled provider will not complete orthodontic evaluations on children who may never come close to meeting the criteria for eligibility (20 points or more), even though they may have some degree of malocclusion.

Children being treated in phases do not need to be rescreened at the beginning of Phase II if they have been previously approved for Phase I. However, the child must be North Dakota Medicaid eligible at the beginning of Phase II, or arrangements must be made with the family as with any other private pay patients.

–  –  –

Cleft Lip or Cleft Palate Children with cleft lip or cleft palate should be referred immediately to an orthodontist.

Interceptive Children who have anterior or posterior cross bites, or ectopic (mal-positioned) incisors should be referred for further orthodontic evaluation. Points are not used in the interceptive screening process. If any of the conditions covered under the interceptive treatment program are present, a referral to a participating dental provider can be made by checking the appropriate condition(s) identified on the referral form.


The orthodontic index sets 20 points as the minimum necessary to be eligible for orthodontic treatment. Since there will be some variability in the measurements and some malocclusions which non-dental professionals may miss, an index with 18 points should be referred along with x-rays and a narrative description. In cases requiring special consideration for unique circumstances, the screener should consult with the enrolled provider in the area and the North Dakota Medicaid Health Tracks administrator.

Use of Screening Results  Based on eligibility criteria established by the North Dakota Medicaid Health Tracks (EPSDT) program, referrals should be made to participating dental providers only. A provider may be obtained by contacting the North Dakota Medicaid Health Tracks administrator.

 Screening results should be shared with parents, even if the child does not meet the eligibility criteria for a referral.

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Classification of malocclusion(s) is a complex undertaking. In defining a screening procedure, a normal occlusion is defined and deviations are recorded for evaluation as possible orthodontic problem(s). Some of the most common malocclusions used in the North Dakota Medicaid Health Tracks orthodontic indexes are illustrated and described in further detail on the following pages.

Normal: All teeth in the maxillary (upper) arch are in maximum contact with the mandibular (lower arch.) The upper teeth slightly overlapping the lower teeth. The mesiofacial cusp of the maxillary permanent first molar occludes in the facial groove of the mandibular (lower) first molar.

–  –  –

1. Cleft Lip or Cleft Palate. Children with cleft lip or cleft palate should be referred immediately to an orthodontist. No points are necessary for interceptive referrals.

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The child should position his/her teeth in centric relation – the most unstrained and functional position of the jaws or how the child normally bites his/her teeth together. Some children have difficulty doing this when asked and may have a tendency to bite the front teeth edge-to-edge.

To assist the child in positioning his/her teeth in centric relation, have the child place the tip of their tongue on the roof of the mouth and bite together.


Referral for an interceptive treatment evaluation is based on the conditions listed below. No points are necessary for an interceptive referral.

1. Anterior cross bite. Any of the upper anterior (front) teeth are lingual (inside) the lower front teeth.

–  –  –

How to Measure: Record the largest horizontal overlap of the most protruding upper incisor (front tooth) with the metric ruler. Round off to the nearest millimeter.

2. Over bite. The upper front teeth come down too far over the lower front teeth, sometimes causing the lower front teeth to touch the gum tissue behind the upper front teeth (upper teeth may also hit lower gums).

–  –  –

How to measure: Record the largest overlap by measuring how far down the upper front teeth overlap or cover the lower front teeth. This is a vertical measurement.

–  –  –

How to measure: Record the largest over jet of the most protruding lower incisor (lower front tooth) with the metric ruler. This is a horizontal measurement.

4. Anterior open bite. The anterior (front) teeth cannot be brought together and an open space remains. There is a lack of incisal (biting surface of teeth) contact between the upper teeth and lower teeth.

–  –  –

How to measure: Record the largest open bite with the metric ruler. This is a vertical measurement.

5. Impacted teeth (anterior only). Teeth which have developed but have not erupted properly in the mouth.

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