When should I take my child to see an orthodontist?

Between the ages of eight and ten, for an assessment. That is the recommendation of the Australian Association of Orthodontists, and it holds even if your child's teeth look straight. See Specialist Orthodontists and Children's Braces & Invisalign.

The Australian Dental Association gives the window slightly wider, stating that “The Australian Society of Orthodontists' recommend children have an orthodontic assessment between the ages of 7 – 10.” The two overlap on the years that matter, and nothing is lost by asking at seven rather than eight. The ADA adds a point that saves a lot of unnecessary waiting: “All the adult teeth do not have to be present in the mouth for an assessment to be done.”

An assessment at that age is not the same as starting treatment. In most cases treatment will not begin for several years — the point of the appointment is to find out whether, and when, anything is needed.

It is also much later than the first dental visit, which happens in the toddler years: when should a child first visit the dentist? and First Visit to the Dentist

Why eight to ten

By about eight, a child has enough permanent teeth for an orthodontist to evaluate the relationship and development of the teeth and jaws. Which teeth should have arrived by then is set out in order and appearance of baby teeth.

The deeper reason is growth. Young jaws are much easier to influence, and specialist orthodontists are trained to direct or manage tooth eruption and jaw growth where required. The same discrepancy that can be guided at ten may require surgery to correct at twenty, because braces move teeth but they do not move jaws — growth does. See what is orthognathic surgery?

So the window is not arbitrary. It is the period in which options exist that later close. How long does my child need to wear braces? sets out the two treatment phases and what skipping the first one costs.

What orthodontics is actually for

It is worth being clear that this is not a cosmetic appointment with a cosmetic question. The ADA describes orthodontics as “a specialty field in dentistry that involves the diagnosis, prevention, and correction of crooked teeth, jaws, and unfavourable bite patterns”, and lists what it treats as:

• Crooked or crowded teeth
• Incorrect biting patterns
• Severe misalignment of teeth and/or jaws
• Past habits such as thumb sucking that have affected the position of the tooth and development of the jaw bones

And it puts the purpose plainly: “Orthodontic treatment is not just about straight teeth. It can correct a bad biting pattern, help with sleep apnoea, and prevent uneven wear of the teeth.” Those last two are the reasons an assessment is worth having even when a parent is not troubled by how the teeth look.

What early treatment can and cannot do

A first stage of treatment — Phase I — can be beneficial in some cases. It is worth being precise about what it achieves:

• It does not necessarily eliminate the need for further treatment later. Most children who have Phase I treatment go on to have a second phase in the teenage years — usually braces or Invisalign
• It can reduce the severity of a problem that would otherwise be more difficult to deal with later, and in some cases avoid extractions or surgery

Equally, most children assessed at eight need no treatment at that point — just monitoring until the right moment. An orthodontist who says “come back in two years” is giving you a useful answer, not a non-answer.

In the meantime the ordinary things still matter most: regular check-ups and cleaning. See Children's Dentistry, Kids' Teeth Cleaning Tips, Paediatric Dentists and should your child see a specialist paediatric dentist? Keeping the adult molars decay-free while you wait is the single most useful thing: protecting your child from dental disease, the role of fissure sealants in children's teeth and, when brushing is a nightly argument, how to encourage your child to brush their teeth

What to look for

Straight-looking teeth do not rule out a developmental issue. Signs worth having assessed:

• Crowded or misplaced teeth
• Early loss of baby teeth — neighbouring teeth drift into the space; see should I pull out my child's loose tooth?
• Finger or thumb sucking beyond age five or six
• Open bite — the front teeth do not overlap
• Deep bite — too much overlap of the front teeth
• Underbite — lower front teeth sitting in front of the uppers
• Crossbite — upper back teeth sitting inside the lowers
• Mouth breathing
• Protrusive teeth
• Functional problems affecting chewing or speech
• Snoring

Collectively these are what is meant by a malocclusion: what is malocclusion of the teeth? and treatment of malocclusion

Two of those deserve particular attention, because they are easy to dismiss as habits rather than signs.

Crossbite often causes the lower jaw to shift sideways to find a comfortable bite. Left through the growth years, that shift can become built into the developing jaw — which is one of the clearest cases for treating early. It can also load the joint unevenly: see TMD and Teeth Grinding and what are the most common symptoms of TMD? Grinding in children is common and usually not a cause for alarm on its own — night time tooth grinding and clenching

Mouth breathing and snoring may point to an airway problem. Persistently obstructed nasal breathing affects facial growth, and disturbed sleep in children can present as inattention, irritability and difficulty at school. That is worth investigating with your GP or paediatrician alongside the orthodontic assessment — it is not solely a dental matter. See Snoring & Sleep Apnoea, Orofacial Myofunctional Therapy and mouth breathing: the silent habit that's changing your face and your health

Protrusive front teeth are also worth acting on for a practical reason: they are markedly more likely to be broken in a fall or a knock. See Sport Mouthguards, should my child wear a mouthguard? and Children's Dental Emergencies.

A warning about mail-order aligners

This belongs on a page aimed at parents, because the marketing is aimed at parents and teenagers and the price is the selling point.

Some companies sell tooth-straightening treatment direct to the public without the patient seeing a dentist or orthodontist at all — usually described as do-it-yourself or direct-to-consumer orthodontics. The Australian Dental Association does not recommend it. Its stated reason is blunt: the risks are many, and “They can lead to permanent damage to your teeth, gums, and jaw joints.” What the ADA recommends instead is in-person treatment with a dentist or orthodontist, “which includes a thorough assessment before starting treatment and ongoing supervision”.

The assessment and the supervision are the parts being removed to make the price work. A growing child is exactly the patient for whom that is least advisable, because the thing being assessed is not only where the teeth are now but where the jaws are going.

Keeping teeth clean if treatment does start

This is the part that determines whether a child finishes treatment with straight teeth or with straight teeth and decay. The ADA's guidance is specific:

• With braces, brushing after every meal is recommended, because food gets caught around the brackets. Both manual and electric toothbrushes can be used.
• Angle the brush at 45 degrees to the gums, bristles split evenly over the teeth and gums, moving in small circular or back-and-forward motions — then turn the brush to clean the top of the brackets, and again to clean along the bottom of them.
• Spit out the excess toothpaste but do not rinse with water. The ADA's reason is that this “allows the fluoride paste to sit on the teeth for longer, increasing protection”. See the benefits of fluoride
• String floss is difficult around brackets. Floss threaders made for braces, or interdental brushes, do the job — interdental brushes clean between the teeth and between the brackets. See is flossing really that important? and dental cleans and hygienists

For clear aligners, the ADA says the trays “should be worn at all times other than when eating and drinking liquids other than water”, and warns that drinking fruit juice or soft drink while wearing them traps the liquid against the teeth, which can damage them if it happens often. The trays themselves can be cleaned with an antibacterial liquid soap and a spare toothbrush, rinsed well with warm water, while the teeth are brushed and flossed as normal. See what are the hygiene benefits of Invisalign?

Making the appointment

A referral letter is not required to see a specialist orthodontist. You can make an appointment directly — see Complimentary Orthodontic Consultation. Confirm the current terms when you book — what the appointment includes, whether records such as scans or radiographs are part of it or charged separately, and whether any deposit applies. Contact Us.

If your child is anxious about dental appointments, say so when booking rather than on the day: combating dental anxiety in children and Dental Anxiety.

Worth asking at the consultation:

• Is treatment needed now, or is monitoring appropriate?
• What happens if we wait?
• What would Phase I achieve, and would a second phase still be likely?
• What are the costs of each stage? See What is the cost of braces?, the Price Guide and understanding your treatment
• How often should we come back for review if we are monitoring?

Payment plan options are available. Where a plan is advertised as interest free, that describes the plan term only — a deposit may be required, an establishment fee and ongoing account fees may apply, and charges can apply if the balance is not cleared within the agreed period. The applicable terms depend on the provider and the amount financed, and are set out in writing before you commit — ask what the deposit and the establishment fee are, in dollars, and what the total will be by the end. Payment Plans. Orthodontics is not covered by the Child Dental Benefit Schedule, though general dental care for eligible children is — how does the Child Dental Benefits Schedule operate?

On who does the work: the ADA notes that as well as specialist orthodontists, “Many general dentists also perform orthodontic treatment.” Both are lawful and both can be appropriate; what differs is the length and type of training behind the treatment plan. See Orthodontic treatment: general dentist vs specialist orthodontist? and why would I need to see a dental specialist?

An orthodontist who is comfortable recommending no treatment yet is giving you an honest assessment. Not every child benefits from starting early, and the aim is to start at the right time rather than the earliest possible one.

And afterwards

Whatever treatment is eventually done, retention is lifelong. Teeth drift throughout life, and without a retainer they move back. Ask what the retention plan is, what it costs, and how long it continues — the answer should be “indefinitely”. See Will my teeth need retainers after I've had braces? and why do teeth shift?

Common questions

Seven, eight, ten — why does everyone give a different age?

Because two professional bodies publish two slightly different windows, and it is better to see both than to be handed one. This page leads with the Australian Association of Orthodontists' recommendation of eight to ten. The Australian Dental Association's consumer material reports the Australian Society of Orthodontists as recommending an assessment between seven and ten.

They overlap on the years that matter and they disagree only at the early edge. Nothing is lost by asking at seven; the risk sits entirely at the other end, in the years after ten when growth-based options begin to close.

The ADA adds the line that resolves the usual objection: ‘all the adult teeth do not have to be present in the mouth for an assessment to be done.' Waiting until the mouth looks finished is waiting past the point of the exercise.

My child snores and breathes through their mouth. Will orthodontic treatment fix that?

This is the question on this page where the evidence and the marketing diverge most, so it is worth setting out carefully.

First, who decides what the problem is. The ADA's policy on sleep-disordered breathing is explicit that ‘initial diagnosis of Sleep Apnoea must be made by an appropriate medical practitioner'. A dental practice does not diagnose or test for sleep apnoea. Snoring in a child is a reason to see your GP or paediatrician, and an orthodontic assessment runs alongside that rather than instead of it.

Second, what appliances have actually been shown to do in children — which is less than the language around them suggests. The Cochrane review of oral appliances and functional orthopaedic appliances for obstructive sleep apnoea in children (CD005520) searched 686 trials and found one suitable for inclusion, in which 32 children were randomised and 23 finished. It rated the evidence ‘very low quality' and concluded: ‘there is insufficient evidence to support or refute the effectiveness of oral appliances and functional orthopaedic appliances for the treatment of obstructive sleep apnoea in children.' The narrow statement it does permit is that such appliances ‘may be considered in specified cases as an auxiliary in the treatment of children who have craniofacial anomalies which are risk factors for apnoea'.

Third, what the usual treatment actually is. The same review notes that ‘the most common treatment for obstructive sleep apnoea syndrome (OSAS) in childhood is adeno-tonsillectomy' — a surgical decision made by medical practitioners, not a dental one — and lists the childhood risk factors as adenotonsillar hypertrophy, obesity, neuromuscular disorders and craniofacial anomalies.

So how does that sit with the ADA's own sentence, quoted above, that orthodontic treatment ‘can... help with sleep apnoea'? Both statements are on the record and we are not going to reconcile them for you. The ADA's is a general consumer statement; Cochrane's is a formal assessment of the trial evidence in children specifically, and it found almost none. If anyone proposes an appliance for your child's snoring, ask what the diagnosis is, who made it, and what the appliance is expected to change.

My child's front teeth stick out. Is that a reason to act early rather than wait?

There is a specific ADA statement on this, and it is one of the clearer early-treatment arguments available. Its policy on oral injury and mouthguards states at clause 1.7: ‘Children with prominent front teeth may be a higher risk of injury and may benefit from orthodontic assessment and early treatment to reduce this risk.' Note the hedging the ADA itself uses — ‘may be' and ‘may benefit' — which is the honest strength of the claim.

The reasoning is mechanical rather than cosmetic. Teeth that sit forward of the lip take the impact in a fall, a collision or a knock, and a broken or knocked-out permanent front tooth at nine commits a person to restorative work for the rest of their life.

In the meantime, the protection is a custom-fitted mouthguard, worn at training as well as at matches. The ADA's position is that the most effective protection against oral damage is a custom-fitted guard, that over-the-counter guards provide better protection than none but vary with design, comfort, adaptation and thickness, and that quality control of at-home adaptation is not achievable. Children in growth need theirs remade regularly. See Sport Mouthguards and should my child wear a mouthguard?

Orthodontist or general dentist — what actually differs, and how do I check?

Both are lawful routes, and the ADA says so directly: as well as specialist orthodontists, ‘many general dentists also perform orthodontic treatment'. What differs is the training behind the plan, not whether the treatment is permitted.

Orthodontics is one of the thirteen dental specialties recognised in Australia. The Dental Board of Australia states that ‘there are 13 dental specialties in Australia which are approved by the Australian Health Workforce Ministerial Council', and a practitioner registered in one of them must also have completed a minimum of two years of general dental practice on top of their specialist training.

You can check this for yourself in a minute, and it is worth doing. AHPRA's public register shows whether a practitioner is registered, in what division, whether they hold specialist registration and in which specialty, and whether there are conditions on their registration. What it does not tell you is anything about how a particular case would be handled, how many of them the practitioner has done, or what the plan would be — those are questions for the consultation. Orthodontic treatment: general dentist vs specialist orthodontist? goes further.

What will it cost, and why will nobody give me a figure on the phone?

Because the figure depends on things nobody knows before the assessment, and a number given over the phone would be an invention. What drives the total is how long treatment runs, whether it is one phase or two, the appliance chosen, how many review appointments it needs, and what the retention plan is afterwards.

We could not locate an independent Australian source that publishes fee ranges for orthodontic treatment, so this page does not quote one. Published practice fees are in the price guide, and what is the cost of braces? covers the structure.

What you are entitled to is a written, itemised plan before anything starts — staged, so you can see what each phase costs, what the review appointments cost, and what retention costs after treatment finishes. Retention is the line most often left out of the conversation and it continues indefinitely. Understanding your treatment covers how to read a plan, and it is entirely reasonable to take it away and think about it.

Related reading

• How long does my child need to wear braces?
• How do I know which orthodontic treatment is best for me?
• How long does it take to have orthodontic treatment?
• What are the most common complaints associated with conventional braces?
• What are the hygiene benefits of Invisalign?
• Orthodontics

Practical details

Orthodontics is a recognised dental specialty. Specialist registration can be verified on the AHPRA register, or by calling 1300 419 495; the clinicians are listed on Our Team, with registered specialists identified as such.

Smile Solutions, Level 1, 220 Collins Street, Manchester Unity Building, Melbourne VIC 3000 — getting here. Phone 13 13 96, or theteam@smilesolutions.com.au. Monday–Friday 8.00am–6.00pm, Saturday 8.30am–1.30pm, Sunday by appointment.

Published 3 December 2018. General information only; it does not replace advice from your treating practitioner. Outcomes vary between individuals, and all treatment carries risks. Statements attributed to the Australian Dental Association, the Dental Board of Australia and Cochrane are those publishers' own. Payment plan terms are set by the credit provider and change; confirm current terms directly before you commit.

Smile Solutions trades under ABN 28 193 514 103.