Multi-specialty practices are a growing trend in the orthodontic field, with orthodontics partnered with pediatric dentistry the favored combination to bring under one roof. The combination of these two specialties under one doctor’s belt, however, is still rather rare. But these doctors offer a unique insight into the opportunities and challenges to be had by bringing orthodontic and pediatric dentistry training together.

Christina Carter, DMD, is one such doctor to learn from.

Carter is the daughter of Staten Island, NY, orthodontist Robert W. Carter, DDS, and spent much of her childhood in his office. But when she attended dental school at what is now Rutgers School of Dentistry, she was initially drawn to pediatric dentistry. “I loved the little children. It’s really my first love,” she shares. But midway through her pediatric dentistry residency at New York University (NYU), while working with children with cleft lip and cleft palate at the Institute of Reconstructive Plastic Surgery—NYU Langone Medical Center, she felt the tug toward orthodontics.

Carter loved working with the children at the Institute, and reached out to orthodontist Barry Grayson, DDS, a member of the cleft palate team at the Institute to talk about how she could incorporate this work into her pediatric dental practice. His response: You need to be an orthodontist to do this work.

Carter went home that weekend to talk it over with her parents. Her father, she recalls, asked her if she was happy as a pediatric dentist. Her reply, “I absolutely love what I do.” He then pointed out that nothing would be lost by applying for an orthodontics residency program. So, Carter rushed to meet the application deadline that was only a month away. She matched and did an additional residency in orthodontics and dentofacial orthopedics at NYU. There, she completed a year-long fellowship in cleft, craniofacial, and surgical orthodontics at the Institute of Reconstructive Plastic Surgery.

“That’s how it happened,” Carter says of her dual specialties. “It just evolved. It was never my master plan by any means. In fact, if you told me I would spend 5 years after dental school in training, I would tell you you were crazy.”

Once her residencies were behind her, Carter started to figure out how she would meld her two specialties. She initially worked as an associate in two separate practices—one the pediatric dentistry practice of Mitchell Bayroff, DDS, in Summit, NJ, where she worked solely as a pediatric dentist, and the other her father’s orthodontic practice, where she focused on orthodontics. In addition, she was a member of the Institute’s cleft and cranial facial team. This work allowed her to see some of those patients in her private practice, allowing her to marry her two specialties at times. But after 10 years in this setup, Carter decided it was time to open up her own practice and finally combine her specialties to better serve patients.

“When I was working [as a pediatric dentist] in the pediatric office, I knew that my patients were being referred to the orthodontist at the right time,” Carter says. “The orthodontist in the area and I worked beautifully together because we were all on the same page. And the patients were educated and knew what was coming down the line. They had a lot of what we call anticipatory guidance. I would tell them what was coming down the pike, what we’re looking for, what the timing is, and when to go see the orthodontist. So that worked well.”

But when she was working in the orthodontic office, wearing her orthodontist hat, Carter often found herself frustrated on her patients’ behalf.

“I was frustrated because the pediatric dentist or the general dentist was referring patients too late,” she shares. “It made the treatment harder on the patients. It could have been done much more easily if I had seen them earlier. So, I was really frustrated by things that were missed, especially impacted canines, or when it was too late to do some early treatment.”

ChristinaCarter_2Since opening Carter Smile, her Morristown, NJ-based practice, though, Carter knows that she can better serve her patients with her combined skill set.

“I really think it benefits both the patients and the parents because they are well educated. They understand what is going on,” she says.

When her practice first opened, pediatric dentistry patients made up the bulk of her patient population with a 70/30 split. But just 2½ years later, her orthodontic patient population has exploded, and the split is now 50/50.

Much of this growth is organic—her younger pediatric patients are now ready for orthodontics. In addition, parents of her pediatric dentistry patients who find out she does orthodontics often come to her saying, “I didn’t realize you did orthodontics. I’d love to get this done.” Today, adults make up about 10% of her orthodontic practice.

Carter fundamentally believes there are more than enough children to go around, and thus refrains from any type of turf war with other local orthodontists. If a family has an older child treated by a different orthodontist, she has no problem telling a family to maintain that relationship with the younger child who she is seeing as a pediatric dentistry patient. She will even refer patients to another orthodontist if there is one that is closer to the patient.

“I always say to parents, ‘Let me refer you to somebody because I know what to look for.’ That’s something that the orthodontists in the area are actually really surprised about, because I will absolutely make a referral,” Carter says. “The orthodontists always feel like they were endorsed by another orthodontist, and it just makes life easier. And it’s true: I know who the really good ones are. For the most part, everyone in my area is really good. Some parents will even ask, ‘Who do you think will be best for my child’s personality or my child’s quirks?’”

ChristinaCarter_1Setting Up the Dual Specialty Practice

When it came to setting up her practice, Carter knew she wanted a child-friendly environment, but that didn’t have to mean a child-like decor. “A lot of times you go into pediatric offices and it’s all cartoon characters or movie themes, and I didn’t want that. I have to appeal to the teens and young adults as well,” she says. Carter opted for clean aesthetics and bright colors—what she calls the “Lily Pulitzer palette.”

From a clinical perspective, scheduling and software were the big challenges for her dual specialty practice. As she says, “There’s really not a great pedo/ortho combined software program. There are beautiful orthodontic programs and there are some great pedo programs, but there are no combined programs. So that’s been difficult.”

Carter ran into a similar problem when it came to scheduling: Schedulers with both pediatric dentistry and orthodontic scheduling experience are, at best, hard to come by. She had an orthodontic scheduler who knew what that patient population required and a pediatric scheduler who knew what that patient population required—but she needed them to integrate their knowledge. More than anything, it required a change of mindset. In the end, her schedulers got up to speed. Today, Carter relies on block scheduling, setting aside increments for bonding, adjustments, etc. But often, when her orthodontic patients come in for hygiene appointments, she and her staff will take out wires, do the cleaning, and the adjustment all at the same time. The justification for these bundled appointments is to make the patient’s life easier. “These patients are busy. They lead busy lives with sports and academic activities. [During these appointments,] we can kind of kill two birds with one stone,” she says.

When it came to hygienists, Carter again faced the fact that most are trained in either pediatric dentistry or orthodontics, not both. She took the time to get her staff trained, and as a result ended up with hygienists with a renewed love of their work. “They really loved [the training in a new specialty]. They actually felt like it renewed their love of dentistry because they got a new interest and a new passion right when things were starting to get routine,” she says.

Carter knows, that like her dual-trained staff, she is a rarity: A dual trained pediatric dentist/orthodontist. This combination makes up a small percentage of the dental professionals currently practicing. Having a pediatric dentist and an orthodontist in the same office, however, is becoming more common. The argument for these combo practices is the steady referral stream. Carter, who is a past president of the Northeastern Society of Orthodontists, agrees this is a definite selling point for dental professionals considering such a venture. But what’s more, the patients see it as a selling point as well. “The patients know this as a familiar name, a familiar face, a familiar office,” she says. “There’s less anxiety for the child too when it’s the same building. With me, they say, ‘Oh, we know you.’

“And the other thing for patients is they’ve known the hygienist forever, and it’s like, ‘Oh, they’re just going to do something else on me.’ There’s less fear, less anxiety.” That trust and that established relationship, Carter adds, goes a long way to an smoother experience for everyone.

Treating Special Needs

Carter’s practice sees a large number of special needs patients. She sees children with sensory processing disorder, learning disabilities, or speech issues; children on the autism spectrum; children who are wheelchair bound from cerebral palsy; children with epilepsy; and children with cleft lip, cleft palate, and other cranial facial syndromes. She provides both pediatric dentistry and orthodontic care to these patients.

“Not every special needs child needs orthodontics, but some of them really do, and we’re able to do it,” Carter says. “We’re able to do it without pharmacology, and without adding any OR treatment—just routine orthodontic visits.”

So, what is it that allows Carter to treat these children without pharmacology or any OR intervention? First, experience and training. Much of Carter’s insight into treating special needs patients comes from her pediatric training, which not only included her time at the Institute of Reconstructive Plastic Surgery, but also a rotation at the Rose F. Kennedy Children’s Evaluation & Rehabilitation Center which provides dental care to children and adults with intellectual and developmental disabilities as part of its integrated care approach. All these experiences allowed her to develop the behavioral management techniques that come in handy when treating this population. In addition, Carter has the advantage that patients transitioning from her pediatric to orthodontic care are used to her and her team.

When setting up her practice, Carter made a point of creating a space that accommodates the needs of these children. Carter puts a lot of forethought into the products she chooses, thinking through every possible sensory issue or logistical consideration that could arise during their treatment. Carter’s practice has everything from patient chairs without arms or a cuspidor for patients with physical limitations to lights that dim and handpieces and suction that make the least amount of noise. She has an iTero® intraoral scanner (Align Technology Inc) for patients with gag issues, as well as a NOMAD handheld portable x-ray (Aribex). There are sensory balls, weighted blankets, and unflavored versions of every product.

Carter pays close attention to her patients’ triggers as well. For patients who are sensitive to their lips drying out during treatment, Carter has ChapStick available. Flavored versions of this ChapStick also come in handy when a patient has a smell sensitivity. She will put the ChapStick under their nose to mask the offensive smell. For those patients who can’t lie back, or who are physically limited, Carter treats them standing up.

Carter’s experience with treating special needs patients has taken her on the lecture circuit, where she frequently talks about managing parents’ expectations. “Sometimes the parents are the patient’s best advocate, and sometimes the parents lose sight of what the most achievable optimum is,” Carter says. Another popular topic is her use of a therapy dog in her practice.

ChristinaCarter_4A Canine Companion

Callie, Carter’s 5-year-old, 10-pound, hypoallergenic toy poodle, is a certified therapy dog and AKC Canine Good Citizen, who has been a fixture in the practice since the beginning. Callie can be found greeting a patient at the door or playing with them in the waiting room. She’ll come back into the bay and check on patients, often responding to patients who sound distressed. In those instances, she comes in and sits chair side to make sure everybody is okay. For those patients who want her, Callie will jump up on the treatment chair and either lie next to the patient’s leg or on their belly; or she will sit on the floor within reach of the patient’s hand so they can pet her during treatment. The interaction is based on the patient’s needs and Callie’s willingness.

While Callie can officially be found roaming the office two days a week, Carter will happily bring her in if a patient requests her.

“It really is amazing to watch the interaction between the patient and Callie,” Carter says. “The patient will be lying there and just petting Callie throughout the whole treatment. It’s just a distraction. Or Callie will be licking their hand, and you actually watch the tension dissipate from their body. It’s really sweet.”

Carter is especially moved by Callie’s effect on nonverbal, or less than verbal, patients. “When Callie’s there, they actually start talking to her, and it’s amazing. Sometimes in their own little language, and sometimes they actually use words. And parents will say, ‘Wow, that’s more than my son has spoken in a long time,’ and they’re talking to Callie.”

Carter’s dual specialty training allows her to provide a level of care to her patients that is impactful and lasting. “People always ask me, ‘Which [specialty] do you like better?’ and I always say, I can’t choose. For me it’s just the commitment to the child and watching them grow; seeing their needs change from when they’re little to when they’re in adolescence and then when they’re older and out of braces.” OP