Handicapping malocclusion assessment record in direct mouth examination

Handicapping malocclusion assessment record in direct mouth examination Norman New

Rochelle,

D. Allen,

D.D.S.

N. P.

M

uch has been written recently about the impending flood of orthodontic patients expected when the various third-party programs of dental care are in full operation. Many states which provide dentistry under Title XIX legislation have already experienced an increased public demand for orthodontics. At the present time a cutback in federal funds has caused a reduction in most state dental programs under Medicaid. This condition is no doubt temporary, since it would be almost impossible to permanently curtail a social program so popular with the voting public. As economic conditions permit, we must expect a re-establishment and even an expansion of federally funded dental programs. In addition to Medicaid, there is another potential source of orthodontic patients which, over the near term, may prove even more expansive. This is the field of private prepaid dental plans. In this category are the commercial insurance companies, Blue Cross and Blue Shield, and the dental service corporations. It has been estimated that by 19’75, more than 50,000,OOO persons will be covered by some form of dental health insurance, which probably will include orthodontic treatment. Faced with the prospect of an increasing demand for orthodontic care, and realizing that funds for treat,mcnt as well as professional personnel may be inndeqnate, dental administrators have been searching for dependable ways to tncasu~u~‘c, record, ii~alyzc, i~~tl classify tlcntofaeial deviations on an epidemiologic basis. If predictions rclgardirig orthodontic dcmand are accurate, a priority system of treat.ment will be necessary. Obviously, it would be impossible to provide qualit,g orthodontic care for such vast numbers of children, even if adequate funds were available. The task of setting ol*thodontic treat,rnent priorities requires a system of measurement. or assessment of malocclusion which, for large-scale use, must be as objective as possible with clearly defined terms. It should furnish the necessary data without being so complex that t.raining examiners in its use t,akes long 67

68

Amer.

Allen

J. Orthodont. July 1970

periods of time, and it must show a small degree of interexaminer error. Several indices are currently proposed, and all purport to satisfy the above requirements. The index accepted by the American Association of Orthodontists and the Council on Dental Health of the American Dental Association is the Handicapping Malocclusion Assessment Record developed by the AA0 Council on Orthodontic Public Health Service under the chairmanship of J. A. Salzmann.l This index has one distinct advantage over others in that assessments may be made quickly without the need of millimeter measurements. index

advantages

and

indications

Radiographs, study models, and other orthodontic diagnostic aids are time consuming and would involve considerable expense in any large-scale screening program. Thus, assessments of malocclusion would probably be made by direct mouth examination and might conceivably be conducted by dental personnel who have not been orthodontically trained.2 The mechanics involved in any index of dentofacial deviations should anticipate such use by auxiliary personnel through the employment of criteria easily recognized and understood outside the specialty of orthodontics. The purpose of the present study was to test the feasibility of the AAOSalzmann Index in direct mouth assessment of malocclusion and to determine the accuracy of such assessments. The AA0 Index was chosen because it does not require millimeter measurements and because the criteria upon which it is based involve recognizable dentofacial deviations. 3 Millimeter measurements made in the mouth are subject to considerable error due to the angle at which the measuring device is held, the tendency of patients to move the mandible during the measuring process, and personal errors in reading measurements. In this study examinations were conducted on a series of 110 patients ranging in age from 10 to 19 years. These patients were examined in a public health facility as part of the screening process for orthodontic care under the New York State Medicaid program. All cases recorded were in the permanent dentition stage. Examination

of

patients

The procedure employed consisted of seating the patient in a dental chair with the head tipped back sufficiently to permit a clear view of the dentition. The patient was asked to open the mouth wide and, with the assessor standing beside the chair and viewing the mouth from in front, the first part of the assessment form was filled out (Fig. 1). An assistant marked each score on the record form as called out by the assessor. This procedure is highly desirable, since it speeds the assessment and minimizes distraction of the assessor. Occasionally it is necessary to readjust the headrest during this phase of assessment for children who are taller or shorter than average. For accuracy, the assessor must be able to view each of the dental arches at a right angle to the occlusal plane. The patient was asked to “bite on the back teeth.” The occlusion was checked to ascertain that the mandible had not been thrust forward or to one side. Overbite and overjet were assessed in two positions-with the patient’s head level

Handicapping DEFINITION

malocclusion

AND CRITERIA FOR ASSESSING HANDICAPPING PERMANENT DENTITION

DEFINITION: Handicapping malocclusion and handicapping tute o hazard to the maintenance of oral health, and interfere fecting dentofacial esthetics, mandibular function, or speech.

HANDICAPPING

MALOCCLUSION

A.

INTRA-ARCH

Ant. = anterior teeth (4 incisors); Post. = posterior (include canine, premolars and first molar). No. = number

of teeth

No.

maxillary

= number

OVERJET

ore conditions that constiof the child by adversely of-

RECORD

teeth

INTER-ARCH

DEVIATION

affected;

Segment

OVERBITE IS

3’

or mandibular of teeth

ASSESSMENT

MALOCCLUSION

DEVIATION

1. Anterior

+Score

dentofaciol deformity with the well-being

CHOSSBITE 39

OPENBITE

) NO.

P.V.

P.V.

40

x2

incisors.

Total : point

score

value. 2. Posterior

Segment

1 St Premolar

1 st Molar No. = number; P.V. = point value; *Add 8 points,when intro-ond inter-arch maxillary incisor score is 6 or more to denote esthetic handicap. REMARKS: Fig.

1

69

affected.

B.

SCORE MAXILLARY TEETH AFFECTEDONLY, EXCEPT OVERBITE*

assessment record

Total

Score

----------+ GRAND

TOTAL*

SCORE

’

Case

No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55

Fig. 2

&fe6!ic&d screening Approved Not approved Approved Not approved Not approved Approved Approved Approved Approved Approved Approved Not approved Not approved Not approved Approved Approved Not approved Not approved Approved Approved Not approved Not approved Not approved Approved Approved Not approved Approved Approved Approved Approved Approved Approved Approved Not approved Not approved Not approved Approved Not approved Approved Approved Not approved Approved Approved Approved Approved Approved Approved Approved Approved Approved Approved Approved Approved Approved Not approved

AA0 Index 20 17 21 15 7 20 37 22 18 18 23 9 3 6 21 21 27 9 22 17 3 6 6 22 36 3 21 19 21 22 16 24 30 7 6 6 5 4 20 8 4 21 9 9 23 10 28 38 26 34 28 7 30 22 7

Case

AA0 Index

No. 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110

Approved Approved Approved Not approved Approved Not approved Not approved Approved Not approved Approved Approved Not approved Approved Not approved Not approved Not approved Approved Not approved Approved Not approved Approved Approved Approved Approved Not approved Approved Approved Approved Approved Approved Not approved Not approved Not approved Not approved Not approved Approved Approved Not approved Not approved Not approved Not approved Approved Approved Not approved Not approved Approved Approved Approved Approved Approved Approved Not approved Approved Approved Approved

21 22 27 4 14 3 3 22 25 20 24 5 25 4 2 3 42 5 36 7 18 24 18 21 24 24 24 18 25 28 4 18 23 18 19 21 34 7 5 5 7 17 22 7 2 38 28 22 21 22 27 7 24 19 26

Volume Number

58 1

Handicapping

maloccZusion

assessment record

71

and with the head tipped back. This made it possible to check both the vertical and horizontal relations of the incisor teeth, especially with regard to overbite. Cross-bite and open-bite present,ed no particular difficulties in direct mouth assessment. With a tongue blade retracting the cheeks, the posterior segment was scored for mesial or distal positioning of the mandibular teeth, for cross-bite, and for open-bite. It quickly became evident that the angle from which the posterior segment was viewed made a tremendous difference in scoring. It is essential that the patient’s cheek be retracted far enough that the assessor’s line of vision is at a right angle to the buccal teeth. After one or two practice sessions, the assessor was able to complete the record form in approximately one minute. If additional dental chairs are available, together with enough auxiliary personnel, one assessor could easily screen thirty-five to forty patients per hour. The time consumed in seating patients in a single-chair facility would cut the above figure to approximately twenty-five patients per hour. In addition to assessments on the AA0 form, each child was assessed for severity of malocclusion according to the subjective criteria employed by the Bureau of Dental Health of the State of New York. The results obtained from the subjective examinations were compared with scores on the AA0 Index for the same children (Fig. 2). Of the 110 cases examined, sixty-nine were approved for treatment while forty-one were judged not severe enough to come within the scope of the state Medicaid program. This represents an approval rate of 62.7 per cent. It should be pointed out that the children examined in this study did not constitute a random population sample but were referred for screening on the basis of some obvious dentofacial defect. Many were referred by school dental hygienists, public health nurses, general dentists, and orthodontists. Thus, the ratio of acceptance in this study was highor than one would expect to find in a random population sample. It is estimated that the incidence of handicapping malocclusion among children of high school age is approximately 14 per cent.4 Comparison

of

results

On the basis of Index scores, two general groupings were evident; thirtyeight cases fell into the 0 to 10 range, while fifty-nine cases were between 17 and 28. An arbitrary dividing line set between 16 and 17 would have resulted in sixty-nine cases with scores of 17 and over and forty-one cases with scores under 17. Despite the fact, that not a11 cases arceptcd for tr&mrnt under the Medicaid program scored over 1’7 on the AA0 form, a significant correlation between Dhe two assessment procedures exist.ed and is indicative of the practical value of the Index. Six patients who scored ten points or less on the Index were approved for Medicaid treatment by the examiners because their problems involved rotations and/or crowding of maxillary incisors judged to be handicapping. Often only one or two incisors were rotated, producing low assessment scores, and yet, in the opinion of the examiners, the degree of rotation was sufficiently handicapping

Amer.

Allen

72

J. Orthodont. July 19iO

to rate sceeptancc for treatment. Much of this apparent lack of consistency can be explained by the subjective viewpoints of the examiners brought into play by the Medicaid screening procedures. It is extremely difficult for an orthodontist with practical experience not to inject his thoughts regarding etiology, treatment, and prognosis into a subjective assessment. Of the eight children with scores of 17 or over rejected for treatment, two had maxillary lateral incisors missing for which prosthetic appliances were advised. The remaining six cases were judged not severe enough to come within the scope of the Medicaid program. At the present time a separate study is underway to test the reproducibility of assessment scores by different examiners. This is a prime requirement for any index, whether it is concerned with the prevalance or the severity of malocclusion. Summary

and

Conclusions

One hundred ten children were examined to determine the feasibility of direct mouth examination in completing the Handicapping Malocclusion Assessment Record as developed by Dr. Salzmann and The Council on Orthodontic Public Health Service of the American Association of Orthodontists. Results indicate that direct mouth examination is a valid and practical method of assessment using the AA0 Index. Such examinations could be used in epidemiologic surveys of malocclusion or the assessment of large numbers of children for third-party orthodontic care programs. REFERENCES

1. Salzmann, J. A.: Malocclusion severity assessment, AMER. J. ORTHOD~NT. 53: 109-119, 1967. 2. Byrne, John J.: Assessment of malocclusion: Implications for dental prepayment programs, AMER. J. ORTHODONT.~~: 766-768,1968. 3. Salzmann, J. A.: Handicapping malocclusion assessment to establish treatment priority, AMER. J. ORTHODONT.~~: 749-765,196s. and characteristics 4. Ast, David B., Carlos, James P., and Cons, Naham C.: The prevalence of malocclusion among senior high school students in upstate New York, AMER. J. ORTHODONT. 51: 437-445, 1965. 650

Vain

St.