(a) Dental care in the medical assistance program shall include only preventive, prophylactic and other routine dental care, services and supplies, and dental prosthetic and orthodontic appliances required to alleviate a serious health condition including one which affects employability.

1. (1) dental services required for emergency care and/or the relief of pain or acute infection;
2. (2) oral examination, including treatment plan, if necessary;
3. (3) periapical, bitewing, occlusal and extraoral radiographs, as required;
4. (4) oral prophylaxis, including cleaning, supra and subgingival scaling, and polishing of teeth;
5. (5) subgingival curettage and root planning;
6. (6) topical fluoride applications for persons 13 years of age and under;

7. (7) restoration of carious permanent and primary teeth with:

   1. (i) silver amalgam;
   2. (ii) silicate cement;
   3. (iii) plastic materials; or
   4. (iv) stainless steel crowns;
8. (8) pulpotomy for permanent or primary teeth;
9. (9) endodontic therapy for incisor or cuspid teeth;
10. (10) extraction of infected or nonrestorable teeth; and
11. (11) repair of full or partial dentures, recementing crowns and fixed bridges, or replacing facings on bridges.

(b) Definition of preventive, prophylactic and other routine dental care, services and supplies.

Preventive, prophylactic and other routine dental care, services and supplies shall mean dental care, services and supplies deemed essential to maintain an adequate level of dental health and shall include but need not be limited to: