Healthy Teeth & Early Orthodontic Treatment

Media item: article

Date published: 12 March 2015

Subject: children's oral health and interceptive orthodontics

This page records the media item. The original article is the property of its publisher and is not reproduced here.

When a child should first be assessed

The widely used professional guidance is an orthodontic assessment at around age 7 or 8. Smile Solutions recommends around age 9 to 10, when the adult front teeth and first molars are through and developmental problems in the teeth or jaws first become clearly visible — see Children's Dentistry. Both are assessment ages, not treatment ages, and the difference matters less than actually having the assessment. When to take a child to an orthodontist is covered separately.

That is not the age to start treatment. It is the age at which enough permanent teeth have arrived — usually the first molars and the lower incisors — for a practitioner to see how the bite is developing and whether anything needs intervening in while the jaws are still growing.

Most children assessed at this stage need nothing done then. The value of the assessment is in identifying the minority who do, because a small number of problems are genuinely easier, cheaper and less invasive to correct early, and considerably harder later.

Separately, every child should have had a dental examination well before that. Smile Solutions recommends a first visit from age three, and sooner if there is any sign of decay; widely used professional guidance recommends a first check by around the first birthday or within six months of the first tooth appearing. That earlier visit is about decay and habits, not orthodontics.

What early treatment genuinely helps

These are the situations where interceptive orthodontics has real support:

Posterior crossbite. Where upper teeth bite inside the lower ones, often because the upper jaw is narrow. It frequently causes the child to shift the jaw sideways to bite, and a persistent shift can affect how the jaw develops. Widening the upper jaw is far easier before the mid-palatal suture fuses, which is a genuine biological window, not a marketing one. What malocclusion actually is is set out separately.

Anterior crossbite. A single upper front tooth biting behind a lower one can cause gum recession on the lower tooth and enamel wear. Correcting it is usually simple and quick.

Severe protrusion of upper front teeth. This is the one clear evidence-based reason for treating early: prominent upper incisors have a substantially increased risk of traumatic injury, and reducing the protrusion reduces that risk during the years children are most likely to fall or be struck — which is also the argument for a mouthguard in contact sport.

Habits. Persistent thumb or finger sucking, and tongue thrust, can move teeth and alter jaw development. Most children stop naturally; where the habit persists past the arrival of permanent front teeth, intervention is reasonable — sometimes with orofacial myofunctional therapy.

Early or late loss of baby teeth. A baby molar lost early lets the permanent molar drift forward and close space the permanent tooth needed. A space maintainer is a small, cheap appliance that prevents a large, expensive problem.

Impacted or ectopic teeth. Canines in particular can erupt into the wrong path and damage the roots of adjacent incisors. This is detectable on a radiograph years before it becomes visible, and early intervention — sometimes just removing the baby canine — can redirect it.

Severe crowding, and airway or breathing concerns, which need a proper assessment rather than an assumption.

What early treatment does NOT do — and this is where the evidence is clear

Two-phase treatment for prominent upper front teeth does not produce a better final result than waiting.

This has been tested properly. Large randomised controlled trials in the UK and the US compared early treatment in the mixed dentition followed by a second phase in adolescence against a single course of treatment in adolescence. The findings have been consistent:

The final alignment, the final bite, and the final jaw relationship are no better after two phases.
Two-phase treatment takes longer overall and costs more, because it is two courses of treatment rather than one.
The one real advantage of early treatment is a reduced risk of incisal trauma during the intervening years — which for a child with very prominent teeth, particularly one playing contact sport, can be a good enough reason on its own.

So the honest position is: early treatment for protrusion is a decision about trauma risk, not about the final result. A practice that presents it as producing a better outcome is overstating the evidence.

Similarly:

Early treatment does not reliably avoid extractions later, though it sometimes does.
Orthodontics does not change the growth of the lower jaw in any lasting way. Skeletal discrepancies large enough to matter are ultimately treated with growth modification of limited effect, camouflage, or in adulthood with orthognathic surgery.
"Early treatment prevents the need for braces" is not a claim that survives contact with the evidence. Most children who have interceptive treatment still need comprehensive orthodontics in adolescence.

Who provides orthodontic treatment in Australia

Orthodontics is one of the recognised dental specialties. An orthodontist is a dentist who has completed an approved postgraduate qualification — typically a three-year full-time program — and holds specialist registration in orthodontics with the Dental Board of Australia.

The title is protected by law. A general dentist may lawfully provide orthodontic treatment, and many do it well, but may not call themselves an orthodontist without specialist registration. Terms like "orthodontic provider", "specialising in orthodontics" or "orthodontic dentist" used by a non-specialist are the sort of wording the regulator has taken issue with — and the difference it makes is worth understanding before you choose.

Aligners and children

Clear aligners are used in adolescents, and appropriately so in selected cases. Two cautions:

Compliance is the whole treatment. Aligners work only while worn, typically 20–22 hours a day. In a teenager, that is a real variable.
Direct-to-consumer aligners — ordered online without an in-person examination or radiographs — are not appropriate for a growing child, and dental boards and professional bodies in Australia have raised specific concerns about this model. Orthodontic tooth movement without a diagnosis can move teeth through bone that will not tolerate it, and can miss undiagnosed decay, gum disease, or an impacted tooth.

The part everyone skips

Orthodontics does not work in an unhealthy mouth, and brackets make oral hygiene harder, not easier.

Before and during any orthodontic treatment:

Decay and gum disease must be controlled. Fixed appliances create plaque traps, and white-spot demineralisation around brackets is common, permanent, and entirely preventable.
Fluoride matters more, not less, during treatment. Many orthodontic patients are candidates for high-fluoride toothpaste.
Diet matters more. Sugary drinks plus brackets is the reliable recipe for the white marks people notice the day the braces come off.
Retainers are not optional and not temporary. Teeth move for life. Without retention, relapse is expected, not exceptional — and this is the single most common cause of disappointment years after treatment. Ask what the retention plan is, how long it runs, and what replacement retainers cost, before starting.

Common questions

Age 7 or 8, or 9 to 10? Which assessment age should I actually use?

The apparent disagreement mostly dissolves when you read the source behind it. The Australian Society of Orthodontists recommends an orthodontic assessment between the ages of 7 and 10 — a range, not a point. Both figures on this page sit inside it.

One detail from the same guidance removes the commonest reason parents delay: “All the adult teeth do not have to be present in the mouth for an assessment to be done.” An examination at this age “can allow for early intervention treatment should it be needed” — which is the purpose, rather than starting anything.

So: any time between 7 and 10, and earlier within that window if you can already see something you are worried about. Waiting for the rest of the adult teeth is the one approach the guidance rules out.

What is the trauma argument actually based on? The wording matters.

It is worth seeing the profession's own phrasing, because it is more cautious than the way this is usually sold. The Australian Dental Association's policy on oral injuries states that “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.”

“May be” and “may benefit”, twice — this is a reasonable inference from an anatomical fact, not a quantified risk reduction. Anyone presenting you with a percentage on this is going beyond what the ADA has published.

The same policy points at the cheaper intervention first. “The most effective protection against oral damage is a custom fitted mouthguard”; over-the-counter guards “provide better protection than no mouthguard”, though their protection “varies depending on the design, comfort, adaptation and thickness”, and “quality control of at-home custom adaptation is not achievable”. It also notes that the sports where a guard is “impractical or not warranted due to low risk of injury” are a short list — “swimming, athletics, aerobics, and rowing”.

A mouthguard addresses the trauma risk this year, for a fraction of the cost, and without committing a nine-year-old to two phases of treatment. That is the comparison to put on the table. Sports mouthguards covers fitting.

My teenager wants aligners they saw online. What is the position on that?

Unambiguous. “The Australian Dental Association (ADA) do not recommend Australians have DIY orthodontic treatment. There are many risks to this treatment. They can lead to permanent damage to your teeth, gums, and jaw joints.” Its recommendation is “in-person treatment with a dentist or orthodontist which includes a thorough assessment before starting treatment and ongoing supervision.”

Even with properly supervised aligners there is a mechanism most teenagers are never told about. Aligner trays “should be worn at all times other than when eating and drinking liquids other than water”, because “drinking liquids such as fruit juice or soft drink while wearing clear aligners can trap the liquids against the teeth, which can cause damage to the teeth if it happens frequently.”

That is not a theoretical risk in this age group. The ADA's consumer survey found 27% of children have fruit juice every day and 38% between two and five times a week, despite 87% of parents saying they are aware these drinks lead to tooth decay. A tray holding juice against enamel for hours is the same problem as a bracket, concentrated.

The practical rule is one sentence: trays out for everything except water, and rinse before they go back in.

If the Child Dental Benefits Schedule will not pay for braces, what will it pay for?

The basic care that has to happen first, which is not a consolation prize. Services Australia covers “up to $1,158 for each eligible child over 2 calendar years for basic dental services”, with the cap “indexed yearly on 1 January”. Orthodontic dental work, cosmetic dental work and any dental services in a hospital are excluded — so no braces, and nothing done in theatre.

But examinations, radiographs, cleans, fluoride, fillings and extractions sit inside it, and those are precisely the things that must be under control before any appliance goes on. Spending the CDBS entitlement on getting a mouth orthodontically ready is the most efficient possible use of it.

Two mechanics worth knowing. The period is two consecutive calendar years — “if you don't use the full amount within the 2 calendar years, you can't use the remaining funds” — and spending it all in year one “will leave no funds for the second year”. Ask to have work sequenced across both years before the first appointment, particularly if a course of treatment is anticipated. The Child Dental Benefit Schedule has the eligibility detail.

Practical details

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

Children may be eligible for Medicare-funded basic dental treatment under the Child Dental Benefits Schedule; eligibility can be checked through Services Australia or myGov. The CDBS does not cover orthodontic treatment.

Every practitioner's registration and any specialist entry can be verified free on the AHPRA public register at ahpra.gov.au.

This page records a published article and its date, with general information. It is not a diagnosis, a treatment plan or a promise of any particular outcome. Orthodontic treatment carries risks including root resorption, decalcification and relapse, and individual results vary. Third-party published content is not reproduced.

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