The HLD (CalMod) index and the index question.

The malocclusion index problem arises because of the need to identify which patient's treatments will be paid for with tax dollars. Both the civilian (Medicaid) and military (Champus) programs in the United States require that "need" be demonstrated. Need is defined as "medically necessary handicapping malocclusion" in Medicaid parlance. It is defined by Champus as "seriously handicapping malocclusion." The responsible specialty organization (the AAO) first approved the Salzmann Index in 1969 for this purpose and then reversed course in 1985 and took a formal position against the use of any index. Dentistry has historically chosen a state of occlusal perfection as ideal and normal and declared that variation was not normal hence abnormal and thus malocclusion. This "ideal" composes from 1% to 2% of the population and fails all statistical standards. Many indexes have been proposed based on variations from this "ideal" and fail for that reason. They are not logical. The HLD (CalMod) Index is a lawsuit-driven modification of some 1960 suggestions by Dr. Harry L. Draker. It proposes to identify the worst looking malocclusions as handicapping and offers a cut-off point to identify them. In addition, the modification includes two situations known to be destructive to tissue and structures. As of Jan. 1, 1998, the California program has had 135,655 patients screened by qualified orthodontists using this index. Of that number, 49,537 patients have had study models made and screened by qualified orthodontists using the index. Two separate studies have been performed to examine results and to identify problems. Necessary changes have been made and guidelines produced. The index problem has proven to be very dynamic in application. The HLD (CalMod) Index has been successfully applied and tested in very large numbers. This article is published as a factual review of the situation regarding the index question and one solution in the United States.