Do you know who’s referring to you? We asked two pediatric dentists to discuss
For quite some time, the line between the specialties of orthodontics and pediatric dentistry has been a blurry one. The amount of orthodontic knowledge among the pediatric dental community—as well as their desire to refer cases to an orthodontist—varies greatly, because of the dentists’ training programs, personal experiences and patient expectations.
But no matter how you look at it, confidence in orthodontic services by a pediatric dentist is an essential pillar in the referral network that we orthodontists need.
Some pediatric dentists feel compelled to manage certain orthodontic issues, believing that the service they provide is best accomplished while under their care, then refer to an orthodontist only after their “limited treatment” has been completed. But what if the recommended treatment plans are different? What if treatment can be accomplished in one rather than two phases? What if the orthodontist doesn’t believe in early treatment, based on research or anecdotes that have been published indicating that most orthodontic care can be completed in one phase?
Whatever the reason, renewed interest in Phase I or early care has been happening, due in part to cone beam radiography and visualization of airways and the transverse dimension. Functional orthopedics is being revitalized with the reintroduction of positioner-type devices designed to encourage forward posturing of the mandible, proper placement of the tongue and advancement of teeth often at a very young age. All in the name of the airway and sleep disorders!
Also, “cosmetic” orthodontics is making a comeback, or being introduced as the key to a great smile, emphasizing the smile arc or the 12-tooth (or “wide”) smile.
I quizzed two pediatric dentists to ask their views on a multitude of orthodontic topics, with the goal of uncovering the trend in the pediatric dentistry profession that will ultimately affect us as orthodontists through referrals.
One pediatric dentist, Dr. Candace Veneberg, has a solo practice that’s located amid several progressive as well as traditional orthodontists. The other, Dr. Robert Matthews, is my new business partner. He’s been in practice for several years, working closely with an established orthodontic practice before he ventured out on his own, ultimately to partner with me.
How much did you learn in your pediatric residency about orthodontics? Or, put another way, how much time was devoted to orthodontics?
Dr. Candace Veneberg: I graduated from Baylor College of Dentistry Pediatric Dental Residency in 2008. Emphasis was on orthodontic diagnosis, treatment planning and collaborating with orthodontists. We had limited orthodontic clinical exposure. Residents could elect to have more clinical cases.
Dr. Robert Matthews: In my pediatric residency, we had minimal interceptive orthodontic training. I would say that our main focus was on space maintenance due to early loss of primary dentition, but we did have a handful of lectures from a practicing orthodontist in the area, who discussed orthodontic considerations and eruption timelines. During my second year, I was able to fabricate a push-spring appliance to correct a single-tooth crossbite and assisted in placing a few brackets on a patient. (So, in other words, not much.)
Were you allowed or encouraged to “do your own” orthodontics, or to refer it to other specialists?
CV: We were encouraged to provide Phase I orthodontics such as correction of crossbites, or limited Phase I for aesthetics.
RM: In my residency program, we mainly referred patients out for orthodontic care. We were required to select one patient our second year to treat, under the supervision of an orthodontist, but it had to be a very simple case or interceptive treatment. Mine consisted of correcting a single-tooth crossbite of #8.
At what point or age in the development of the child dentition did you refer?
CV: Age 7.
RM: We typically referred out toward the late mixed dentition, or when patients were in their early teens with permanent dentition. Generally, it was due to crowding or the patients’ concern with their appearance.
What are your top concerns today?
CV: Crowding, smiles, airway function and stable joints.
RM: Spacing/crowding, followed by the aesthetics of the smile. Airway and function will come into play when you see a patient who’s truly struggling with one of these aspects.
Do you believe you learned enough about the basics of orthodontics?
RM: I didn’t learn enough about the basics of orthodontics during residence, so most of what I know today was learned while in practice. As an associate, the office I worked in for the first several years worked closely with a neighboring orthodontic group, and I was able to ask a lot of questions and learn some through the osmosis of practicing. Now, Dr. Grob and I are able to look at cases together and discuss different treatments, topics, etc.
[Editor’s note: Is it proper or expected for orthodontics to be discussed in a pediatric dental practice? We’ll let you decide after reading the answers to this next question.]
At what age do you bring up the topic of orthodontics to your patients?
CV: I start discussing spacing and arch development as early as 1, particularly if there’s a non-nutritive habit. If the patient has a crossbite, narrow palate or primary-tooth crowding, I start the discussion about early intervention as young as 3, to “plant the seed” of the importance of early intervention.
RM: I bring up the topic of orthodontics at a very young age with my patients and their families. In the primary dentition when I see little to no spacing, I will subtly bring up the fact that when there is no extra space for the baby teeth, the adult teeth will likely be tight or even crowded. I’ll often emphasize that when we are reviewing early occlusal X-rays or the panos after the age of 6.
Do you refer everyone for orthodontics?
RM: I will refer when either the parents or I am concerned with crowding, appearance, etc. I do discuss spacing and development for all of my patients, but not everyone is referred to an orthodontist—more than half of them are referred at some point, though.
Do you believe orthodontics is an elective service, or a necessary part of treatment?
CV: I have a culturally diverse patient population, so I’m sensitive to the fact that some cultures aren’t as concerned about aesthetics or orthodontics. In this situation, I’ve found that informing them of potential issues can help: Most patients will benefit from orthodontics for function, aesthetics or airway, so giving parents information, showing them my concerns, and describing possible long-term effects is an effective way to communicate and build trust. Most of the time, this informative approach and encouragement to seek an orthodontic evaluation typically results in accepting treatment.
RM: For the most part, I believe that orthodontics is an elective service of our treatment. There are, of course, certain cases where I feel it’s more of a need due to impacted teeth, functional issues or other factors.
Do you regularly refer to a single orthodontist or offer several options?
CV: I refer to several.
RM: Because an orthodontist is a part of my practice, I refer in-house. In cases where siblings or other family members have been seen by another orthodontist in town, I’ll ask if they’ve been happy with the treatment they received; if they are, I typically encourage them to consult with that doctor. In cases where families would like a second opinion, I encourage that as well and will refer to some other orthodontists in the area whom I know and respect.
Do you read the referral letter or report that follows?
RM: I glance at it, but typically will not really read it unless it’s a case that has something out of the ordinary going on. At the point that they’re being tracked by the orthodontist, he or she is now the one making the call on that treatment.
What if anything bothers you about orthodontic referrals?
CV: Keep the referral pad simple!
RM: Not all orthodontists practice the same or have the same treatment philosophies, and I will commonly let parents know that. If parents have taken their child to multiple evaluations and ask my opinion on that matter, I’ll typically tell them that they’re best suited going with the opinion that makes the most sense to them on how to get from Point A to Point B, and once they start, to stay the course. Too often I’ve seen parents get frustrated because they start talking to other parents whose kids are receiving treatment elsewhere under different philosophies, and begin to second-guess their decisions.
And what bothers you about orthodontic treatment?
CV: When comprehensive orthodontics is complete, but position and occlusion of second molars were not addressed. Particularly maxillary second molars can be difficult to keep clean if they are rotated. I love when orthodontists have a system to ensure patients are maintaining preventive dental visits during orthodontic treatment. When there’s a lack of emphasis on preventive visits, many times the patient or parent will assume the orthodontist is checking to make sure the patient is disease-free. I appreciate orthodontists who encourage a three-month recall system, and removal of wires for patients with poor oral hygiene.
Do you have any thoughts regarding removal of primary teeth?
CV: This often can be beneficial to prevent permanent tooth impaction, particularly maxillary canines. If the patient requires deep sedation or general anesthesia to tolerate primary teeth extractions, I often consult with the orthodontist to see if an alternate treatment plan is an option. Early orthodontic intervention can usually prevent removal of permanent teeth. I prefer treatment plans with no removal of permanent teeth, but I also understand there are situations where removal is needed.
RM: I think that in certain situations, the removal of primary teeth has its place in facilitating the eruption and spacing of permanent teeth. That is a talk I’ll commonly have with parents when reviewing the panos when I see severe crowding or canines that aren’t lining up well. I always make sure to let them know that removing baby teeth is in conjunction with braces in the future. For permanent teeth removals, I’d say there are times that it seems appropriate, but I have definitely seen far fewer premolar extractions with the increase of early expansion.
How about occlusion? Have you been schooled on what to look for in a finished orthodontic treatment?
CV: Yes, but also with continuing education.
RM: Over time, you get a good sense of occlusion and how teeth should work together. It’s pretty easy to tell which orthodontists pay attention to that detail and which ones don’t.
How about lingual and labial frenectomy?
CV: Yes—address before and during orthodontic intervention, then refer to therapist.
RM: In my experience, this is something that’s becoming more important in a pediatric practice and in orthodontics. We’re starting to do more early evaluations for tongue/lip restrictions in infants to not only help with nursing and feeding but also in other areas. As kids get older, we then assess for speech patterns and will work with myofunctional therapists to help facilitate.
How about airway and sleep issues? Do you screen?
RM: I don’t screen for airway directly, but it is a conversation I have with parents if their kids are excessive grinders, have inflamed tonsils or some other underlying concerns that arise. Our orthodontist can use the 3D cone beam in our office to screen for airways, and I have seen the benefits that can come from it.
Do you think orthodontics may benefit some of these patients? Do patients bring up the topic of orthodontics?
RM: Every day, with a different way to approach it with each individual. With that said, everyone has their own view of orthodontics and when they think kids should have or not have braces. I have parents who are concerned about braces on their 4-year-olds, while others fight the idea for a teenager who has severe crowding with impacted teeth. Orthodontics is something I bring up at an early age in a general concept, and then gauge the parents over time to find the best solution.
[Editor’s conclusion: This Q&A was eye-opening and encouraging. It’s apparent that both pediatric dentists take their duty and obligation to refer to orthodontists very seriously. I found it interesting that some little things, like the design of a referral pad, could be a factor or tipping point in the decision to refer for orthodontics!
It behooves us as orthodontists to do what we can to meet the demands and expectations of our pediatric dental colleagues, to help keep the discussion open.]