The pediatric dental trauma patient:

Interdisciplinary collaboration between

the orthodontist and pediatric dentist
Courtney H. Chinn

Oral trauma in children and adolescents remains a significant health issue

that can benefit from an interdisciplinary approach between the orthodontist
and the pediatric dentist. The purpose of this article is to review the
opportunities for coordinated interdisciplinary care between the specialties
of orthodontics and pediatric dentistry through a case example of oral
trauma. In order to be successful, interdisciplinary care requires all parties
involved to have clear communication on roles and expectations and the
ability to resolve differences in treatment goals and values. When properly
executed, interdisciplinary care between the dental specialties holds great
potential to improve patient satisfaction and health outcomes. (Semin
Orthod 2016; 22:205–210.) & 2016 Elsevier Inc. All rights reserved.

T he growing complexity and multi-

dimensionality of health problems man-
dates the need for interdisciplinary collaboration
traumatic dental injury. Of all, 11% of patients
have reported having sustained a dental injury
before the onset of their orthodontic treatment.8
to achieve better patient care and health out- The pediatric or adolescent patient with a
comes.1 Within dentistry, the use of an history of dental trauma adds a level of com-
interdisciplinary approach has been found to plexity to the orthodontist’s plan of treatment
be of critical importance in achieving treatment already challenged with traditional issues of
success for individuals with complicated oral home care, caries risk status, and patient will-
health conditions and medical or behavioral ingness or ability to comply. Further, children are
challenges.2–4 Children and adolescents who also considered to be an inherently vulnerable
experience oral trauma can particularly benefit population. The clinician cannot assume that a
from team of dental specialists who are coordi- child can serve as a reliable health historian and
nating care, maintaining constant communica- may not have the physical faculty or legal
tion, and sharing decision-making in order to authority to make decisions regarding their own
maximize available treatment options and attain care and well being. All of these considerations
an optimal health result.5 The frequency of oral necessitate the need for coordinated patient care
trauma in US child and adolescent populations between pediatric and orthodontic specialties in
has been documented as high as 30%.6 Trauma order to achieve safer and more effective care.
to the oral region accounts for 5% of all injuries The purpose of this article is to review the
overall with dental injuries being the most opportunities for coordinated interdisciplinary
common in injuries that involve the face.7 care between the specialties of orthodontics and
Orthodontic patients are at increased risk as pediatric dentistry through a case example of
both excessive over jet and inadequate lip oral trauma.
coverage are predisposing risk factors to The common pitfalls of patient care coordi-
nation that involve multiple specialties are a lack
of clarity in specific roles and responsibilities and
New York University College of Dentistry, New York, NY. improper timing in which care is provided. This
Address correspondence to Courtney H. Chinn, DDS, MPH,
can be especially true in the management of
New York University College of Dentistry, 345 East 24th St, 9th Floor,
9W, New York, NY 10010. E-mail: [email protected]
patients involving pediatric dentistry and ortho-
& 2016 Elsevier Inc. All rights reserved.
dontics where some overlap in the abilities to
1073-8746/16/1801-$30.00/0 perform specific procedures may exist. The
http://dx.doi.org/10.1053/j.sodo.2016.05.007 guidelines of the American Academy of Pediatric

Seminars in Orthodontics, Vol 22, No 3, 2016: pp 205–210 205

206 Chinn

Dentistry advocate for the establishment of a In some oral trauma cases, the child or ado-
Dental Home that can provide comprehensive, lescent may present to the orthodontist as a
continually accessible, family centered care.9 In referral after the emergent issues have been
many cases this involves having the pediatric addressed at the emergency room or the
dentist serve as the primary dental care provider pediatric dental office. Regardless of the timing
who then makes “referrals to dental specialists of initial involvement or who serves as the lead
when care cannot be directly provided within the primary care coordinator, the orthodontist
dental home”. Regardless of which specialist should feel comfortable contacting the pediatric
assumes this responsibility, interdisciplinary dentist or emergency physician for any missing or
care requires deliberate organization and additional patient information. If the ortho-
coordination of patient care activities as well as dontist is taking on the responsibility of coordi-
sharing of relevant information among all nating patient care, arrangements should be
participants concerned. In cases involving made to ensure that all partners involved in
pediatric dental trauma where timing and patient care are provided with information that
follow up is crucial to a successful clinical includes (1) results of the trauma evaluation, (2)
outcome, this requires that patient’s needs and medical and social history, (3) trauma history,
preferences are known and communicated to the and (4) results of the clinical examination.
right people at the right time. The initial evaluation of any pediatric patient
post-oral trauma should address or confirm
findings from the clinician’s observations and the
Case example patient’s or consenting guardian’s historical
report. Reported loss of consciousness, dizziness,
A 12-year-old male presents to your private nausea, or disorientation, non-equal or reactive
practice approximately 4 h post-trauma pupils or another cranial nerve deficiency when
(Fig. 1). His last visit to the office was for assessed should be transferred for emergency
initial evaluation last week for Phase II care right away. Circumstances of the trauma
orthodontics. The injury occurred in the should be documented including time and date
morning while playing basketball. It was of the injury, detailed description and location of
noted that teeth were chipped with one the injury, how the injury occurred, and time
tooth “pushed in.” The family has come to lapsed since injury, and any treatment that was
you because the physician at the emergency received. This information can advise on the
room thought he might need the tooth to be need for antibiotic coverage/tetanus and aid in
“pulled back into the right spot.” The child has the clinical prognosis10 and expected outcome as
a pediatric dentist with his last routine visit well as capture information for any reporting that
being over a year ago. may be required in advocacy of the child/
adolescent patient. Injuries to the head and
neck occur in 65–75% of the cases involving
physically abused children.11–13 Clinical pre-
sentations of an injury that are found to be
inconsistent with reporting or evidence of inju-
ries found to be in various stages of healing may
necessitate additional investigation and/or pos-
sible reporting to authorities on behalf of the
child.14 Gathering and reviewing a complete
medical and social history is essential in order
to ensure patient safety, confirm against any
contraindications to care, and avoid potential
complications during treatment.
A detailed history can also provide the clini-
Figure 1. Initial presentation of a 12-year-old patient cian with a clearer sense of potential behavioral
presenting as a walk-in emergency approximately 4 h challenges due to a health condition, how well
post-trauma. (Adapted from Dr. Amr Moursi.) a child may tolerate procedures, and what
 The pediatric dental trauma patient 207

modifications may be beneficial. The medical appropriate care is important. Such guidelines
history can be helpful in providing anticipatory must be credible, readily understandable, and
guidance for future incidents such as informing easily accessible. While this has been a challenge
on appropriate guarding and fall prevention with in the past, several dental trauma resources today
patients with epilepsy or seizure disorders. With are available to the clinician including online
regard to social history, it must be remembered resources and mobile applications available by
that the clinician is not only addressing an issue phone or tablet.10,15,16
with a tooth but also a child who resides within a
system of support (or lack thereof). Child pop- Extra-oral examination reveals the patient to
ulations include unique sub-groups such as foster have a contusion to the upper lip but no other
care, the juvenile justice system, and emanci- significant findings. Intra-oral exam reveals
pated minors, each requiring special attention in lacerated attached gingiva adjacent to the
issues of consent in cases of trauma or other maxillary right permanent central incisor #8.
instances where irreversible care is to be pro- Tooth #8 has also been intruded approxi-
vided. Understanding the level of parental/ mately 8 mm and uncomplicated Ellis Class II
caregiver support as well as any family life change crown fractures was noted on teeth #8 and #9.
or transition can also suggest the expected level Class I mobility is noted on teeth #7, 8, and 10.
of compliance for any needed home care No mobility of tooth #8 is noted. Teeth #7, 8, 9,
instructions and ability to provide continuity of and 10 are slightly positive to percussion and
care. palpation with tooth #8 producing a high
metallic sound. A failed lingual wire that was
The orthodontist confirms that the patient was previously bonded to the lingual of the
taken immediately to the emergency room maxillary anterior teeth from past limited
and evaluated for a closed head injury after orthodontic treatment is also noted. Radio-
the incident by his mother because he graphs confirm mature root development and
reported some disorientation and dizziness. closed apices. No facture to either the root or
Injury presentation is consistent with report- alveolus was noted.
ing. Examination was within normal limits
with no loss of consciousness and normal Dental trauma has been classified into the
review of cranial nerves. The patient was following categories16:
dismissed with his mother with no treatment
recommendations other than to immediately  Infractions
follow up at a dentist for noted dental issues.  Fractures of the enamel, enamel–dentin, and
Review of medical history reveals that the enamel–dentin–pulp
patient has ADHD and currently taking  Fractures of the root, crown and root, and/
methylphenidate (Concerta) in addition to or pulp
over the counter ibuprofen for dental pain.  Alveolar fracture
Social history reveals that patient’s parents are  Concussion
divorced with the mother having full custody.  Subluxation
A discussion with the pediatric dentist reveals  Extrusion
that shorter morning appointments have  Luxation
worked best in the past and that patient can  Intrusion
tolerate procedures well and is motivated due  Avulsion
to his desire to correct the appearance of
his teeth.
Intrusion injuries are a displacement of the
A complete and systematic clinical oral eval- tooth into the alveolar bone and associated with
uation should be performed, which includes comminution or fracture of the alveolar socket.
extra-oral and intra-oral soft tissues, skeletal hard The associated injury to the periodontium and the
tissues, and dentition. For the clinician in a pulp has been found to be associated with root
practice setting where dental trauma is infre- resorption and marginal bone breakdown as well as
quent, access to guidelines that can assist the pulpal necrosis and incomplete root formation.17
clinician in decision-making and delivering While a more common finding in patients with
208 Chinn

primary dentition, intrusion injuries are Surgical repositioning is to be considered in

comparatively rare in the permanent teeth cases of extreme intrusion of 7 mm or more and
accounting for only 0.5–2% of all dental trauma in situations where a less time demanding
affecting adult dentition.17 With little published approach is preferred. One advantage of surgical
literature, recommendations for the management repositioning is the removal of the bacteria
of intrusion injuries are considered very empirical contaminated crown from its position in the
and there remains some conflicting evidence on socket and the immediate release of peri-
selecting one of the three currently accepted radicular compression. Surgical repositioning,
treatment approaches17: regular observation to however, involves an additional traumatic event
monitor passive re-eruption and active reposition- that may increase healing complications com-
ing using either orthodontics or surgery (Fig. 2). parative to passive eruption or gradual reposi-
The amount of root development and the tioning with orthodontics.17,18 In cases of
severity of the intrusion have been associated extreme intrusion, clinicians should inform
with pulpal necrosis, root resorption, and poor families of high probability of issues with future
tooth survival.17–19 In cases involving teeth with gingival contour and esthetics as well as an
immature root development and o7 mm of increased likelihood of root resorption, failure
intrusion or teeth with mature root development and future need for extraction.19
and o3 mm of intrusion, observation of passive In cases of intrusion injury to immature per-
eruption has been suggested as the desired manent dentition pulpal revascularization may
treatment approach as it avoids further dis- occur, but due to the high incidence of pulpal
turbance to the periodontal tissues.18 necrosis for fully developed permanent teeth,
In cases involving permanent teeth with complete pulpectomy using calcium hydroxide
mature apices and an intrusion injury 43 mm, as an interim dressing to be completed within 3
active surgical or orthodontic repositioning weeks of the initial injury in order to minimize
should be considered18 as it is thought to relieve the possibility of inflammatory resorption.18
compression zones in the periodontal and pulpal
area and protect against ankylosis by creating Tooth #8 was diagnosed with an intrusion
distance between the root surface and the luxation of approximately 8 mm with no noted
contused bone socket.17,18 The use of light mobility. Tooth #9 was diagnosed with a
orthodontic forces is recommended in cases of subluxation. Teeth #8 and #9 were also found
intrusion up to 6 mm. Orthodontic repositioning to have uncomplicated mesioincisal fractures
has been found to be more protective against limited to the dentin. Due to the severity of the
root resorption than surgical repositioning and intrusion, the orthodontist, in consultation
to enable the repair of marginal bone in the with the pediatric dentist, agreed that passive
socket along with the slow repositioning of the re-eruption was unlikely and that surgical
tooth.16 Orthodontic repositioning can also be a repositioning was preferable to orthodontic
successful treatment alternative when no passive movement due to the extent of the injury. It
re-eruption has been noted or for patients who was decided that the pediatric dentist would
have experienced a significant delay in receiving take the lead in coordinating the trauma
treatment.18 management and follow up. The patient was

Figure 2. Intrusion Treatment Guidelines for Permanent Teeth. International Association of Dental Traumatol-
ogy. Available at: 〈http://www.iadt-dentaltrauma.org/〉.
 The pediatric dental trauma patient 209

able to schedule with the pediatric dentist that pediatric dentist and orthodontist should remain
same afternoon as an emergency walk-in. The in regular contact and be notified of any
patient tolerated the procedure well with abnormal findings on routine recall examination
tooth #8 receiving complete surgical reposi- or intended changes in treatment plans.
tioning utilizing local anesthesia and inhaled
Due to the extent of the injury to tooth #8, the
nitrous oxide/oxygen. A semi-rigid splint was
orthodontist and pediatric dentist were in
then placed on teeth #6–11 using 40 pound
agreement to delay previously planned ortho-
monofilament fishing line and interim glass
dontic treatment for 1 year during which the
ionomer restorations were placed on teeth
root canal therapy was completed on tooth #8.
#8 and #9. Patient was placed on soft food diet
While no complications were found at sub-
for 1 week and provided with a chlorhexidine
sequent recall, the family was informed of
rinse. The patient returned 2 weeks later for
future esthetic issues and a guarded long-term
radiographic and clinical follow up, removal
prognosis for tooth #8 with heightened risk for
of the splint, and pulpectomy of tooth #8 and
future root resorption and ankylosis.
composite resins on teeth #8 and #9. The
patient returned again at 4 weeks post-trauma As there are specific guidelines for the man-
for follow up and additional radiographs. No agement of a fully developed permanent incisor
clinical or radiographic pathology were noted. suffering an extreme intrusion injury, the clinical
decision to perform surgical repositioning in this
Current evidence supports short-term, non- particular case example is rather clear as was the
rigid splints for stabilizing luxated, avulsed and rationale to have the pediatric dentist take the
root-fractured teeth, however, the specific type of lead in coordinating care. In cases of less severe
splint or the duration of splinting have not sig- intrusion injuries, passive re-eruption or ortho-
nificantly related to healing outcomes.17 For dontic repositioning may present as more viable
intrusion injuries, it has been recommended options. In all instances, the interdisciplinary
that splint removal occur at the 2 week follow-up team must be able to communicate to achieve a
appointment and that clinical and radiographic mutually agreed upon a course of action that
re-examination occur at 2, 4, and 6 weeks, maximizes each individual member’s skillsets and
6 months, and then yearly for 5 years.16 the best opportunities for success. In cases when
Unfavorable outcomes include clinical orthodontics are favored, the orthodontist may
evidence of ankylosis, radiographic signs of be the most skilled to apply directional forces to
apical periodontitis, and external inflammatory resolve displaced teeth as well as the best indi-
root or replacement resorption. vidual to take the lead in coordinating care.5 The
As recommended by the American Academy team may decide to have the patient complete
of Pediatric Dentistry, any tooth that has suffered follow-up appointments at one specialist’s dental
trauma must be evaluated carefully prior to practice location rather than another due to
beginning or continuing any tooth movement.10 practicality. The main challenge of inter-
This includes minor trauma involving crown and disciplinary care between dental specialties is that
root fractures without pulpal involvement as well members will often possess areas of overlapping
as minor trauma to the tooth or periodontium competence. Further, dentists may enjoy a high
such as a subluxation or concussion. In these level of autonomy in their traditional private
cases, a 3-month waiting period is recommended. practice settings that may make shared decision-
In cases of moderate and severe trauma a min- making challenging. In order to be successful
imum of 6 months is recommended. For cases interdisciplinary care requires all involved parties
that involve root fracture, any tooth movement to have clear communication of roles and
should be delayed for at least 1 year. Teeth that expectations and to be able to identify and
have completed endodontic treatment may resolve potential conflicts due to differences in
begin or continue orthodontic movement as treatment goals or values.20 Role assignments
soon as healing is evident but with careful may need to be flexible in order to avoid
monitoring for the possible complication of root underutilizing others’ potential contribution
resorption during any orthodontic treatment. and expertise. When properly executed,
Following any significant oral trauma, the interdisciplinary care between dental specialists
210 Chinn

holds great potential to improve patient 10. Clinical guideline on management of acute dental
satisfaction and health outcomes. trauma. American Academy of Pediatric Dentistry. Pediatr
Dent. 2004;26(suppl 7):S120–S127.
11. Becker DB, Needleman HL, Kotelchuck M. Child abuse
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