Commonwealth of Massachusetts Subchapter Number and Title Page Appendix W. EPSDT Services Medical MassHealth W-7 and Dental Protocols and Periodicity Provider Manual Series Schedules Transmittal Letter Date All Provider Manuals ALL-219 07/01/14 The Dental Schedule The Dental Protocol and Periodicity Schedule (The Dental Schedule) consists of procedures arranged according to the intervals or age levels at which each procedure is to be provided. The Dental Schedule is based on the Preventive Pediatric Oral Health Care recommendations from the American Academy of Pediatric Dentistry (AAPD) Reference Manual 2007-2008. See 130 CMR 450.140 through 450.150 for more information about Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services and Preventive Pediatric Health-Care Screening and Diagnosis (PPHSD) services. Recommendations for Preventive Pediatric Oral Health Care (AAPD Reference Manual 2007-2008) 6 - 12 12 -24 2 6 6 - 12 12 - 20 – Months Months Years Years Years Clinical oral examination (1, 2) x x x x x Assess oral growth and x x x x x development (3) Caries-risk assessment (4) x x x x x Radiographic assessment (5) x x x x x Prophylaxis and topical x x x x x fluoride (4, 5) Fluoride supplementation (6, 7) x x x x x Anticipatory x x x x x guidance/counseling (8) Oral counseling (9) Parent Parent Patient/parent Patient/parent Patient Dietary counseling (10) x x x x x Injury prevention counseling (11) x x x x x Counseling for nonnutritive habits x x x x x (12) Counseling for x x x speech/language development Substance-use disorder x x screening Screening for intraoral/perioral x x piercing Assessment and treatment of x x x developing malocclusion Assessment for pit and fissure x x x sealants (13) Assessment and/or removal of x third molars Transition to dental care x
Commonwealth of Massachusetts MassHealth Provider Manual Series All Provider Manuals Subchapter Number and Title Appendix W. EPSDT Services Medical and Dental Protocols and Periodicity Schedules Page W-7 Transmittal Letter ALL-219 Date 07/01/14 The Dental Schedule The Dental Protocol and Periodicity Schedule (The Dental Schedule) consists of procedures arranged according to the intervals or age levels at which each procedure is to be provided. The Dental Schedule is based on the Preventive Pediatric Oral Health Care recommendations from the American Academy of Pediatric Dentistry (AAPD) Reference Manual 2007-2008. See 130 CMR 450.140 through 450.150 for more information about Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services and Preventive Pediatric Health-Care Screening and Diagnosis (PPHSD) services. Recommendations for Preventive Pediatric Oral Health Care (AAPD Reference Manual 2007-2008) 6 - 12 Months 12 -24 Months 2 – 6 Years 6 - 12 Years 12 - 20 Years Clinical oral examination (1, 2) x x x x x Assess oral growth and development (3) x x x x x Caries-risk assessment (4) x x x x x Radiographic assessment (5) x x x x x Prophylaxis and topical fluoride (4, 5) x x x x x Fluoride supplementation (6, 7) x x x x x Anticipatory guidance/counseling (8) x x x x x Oral counseling (9) Parent Parent Patient/parent Patient/parent Patient Dietary counseling (10) x x x x x Injury prevention counseling (11) x x x x x Counseling for nonnutritive habits (12) x x x x x Counseling for speech/language development x x x Substance-use disorder screening x x Screening for intraoral/perioral piercing x x Assessment and treatment of developing malocclusion x x x Assessment for pit and fissure sealants (13) x x x Assessment and/or removal of third molars x Transition to dental care x
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