Communication & Referral Timing: Getting It Right

You have identified a problem, maybe a severe Class III malocclusion in a 9-year-old, or it is an impacted canine. But what to do next?

When do you refer him to the specialist? How do you communicate it to the parent?

Here is what every practising general dentist needs to know about orthodontic referral timing and effective communication.

The AAO Guideline: Age 7 Screening

The American Association of Pediatric Dentistry (AAPD) recommends that all children should be screened by an orthodontist around the age of  7¹. 

By this age, your child usually has enough permanent teeth for an orthodontist to evaluate the developing teeth and jaws. It can reveal a lot about the developing occlusion and facial symmetry.

Now, this guideline is usually an excellent idea, but it may not suit everyone. The optimal timing depends on the type and severity of malocclusion.

Also, another important point is age 7 doesn't mean treatment at age 7. At an early consultation, the orthodontist may only determine if the patient's growth and development are on track². Mostly it is, and nothing needs to be done. Great news for the parents! 

The evaluation creates a baseline and allows early detection of problems that benefit from interceptive treatment.

Benefits of Early Intervention

Scientific evidence suggests interceptive therapy can be beneficial for posterior crossbites, mild to moderate Class III, Class II malocclusions, open bites and some arch length discrepancies³. 

Specific conditions that require early referral:

• Posterior crossbite with functional shift at age 7-9
• Skeletal Class III with maxillary retrusion at age 8-10, before the growth spurt happens
• Ectopic canine eruption at age 10-11, before apex formation
• Severe crowding may require serial extractions
• Anterior crossbite as early correction prevents TMJ issues and tooth wear

Correcting an anterior crossbite early can also help prevent swallowing and speech problems, and allows the teeth and jaws to continue growing correctly to avoid additional complications⁴.

What Can Wait Until Adolescence?

It is important to understand when to hold back, as not every malocclusion requires immediate treatment. The orthodontist can detect minor growth or tooth discrepancies and may opt to treat with just simple observation and monitoring.

Cases that can wait:

• Mild crowding without skeletal discrepancy
• Class I malocclusion with simple alignment needs
• Class II Division 1 without severe overjet 
• Most cases of spacing

The risk of waiting too long: Most of the structural formation of the face is complete by 6-7 years, which is why identification and treatment of conditions affecting skeletal growth is critical in early years⁵.

How to Communicate the Referral?

Discuss the proposed referral for treatment with patients so they actually reach out to the expert⁶.

1. Explain WHY the referral is needed - Tell the parents in clear words that their child is developing a malocclusion, and addressing it while they are growing can help guide the jaw with simpler appliances.

2. Reassure about continuity of care - Reassure them that this transfer is temporary, and you are still in charge of their care, and will be looking out for them. It is important for them to hear this, as they possibly have a bond with the dentist.

3. Discuss the specialist's credentials - Soothe their doubts by discussing the education and credentials of the dentist to whom you are referring, and let them know that you have complete confidence in the provider's training and expertise.

4. Set clear expectations - Let parents know:

• Whether your staff will schedule the appointment or they should call
• That most orthodontists offer complimentary consultations
• The evaluation doesn't automatically mean treatment starts immediately

What Happens After Referral? 

General dentists can develop long-term relationships with their patients. But communication often breaks down after the referral.

Build strong specialist relationships by:

• Referring to orthodontists who provide timely treatment reports
• Following up with parents and asking them directly if they went and what they recommended.
• Requesting post-treatment reports so you know what was done/

It can help sustain collaborative treatment.

Common Referral Mistakes to Avoid

• Waiting until permanent dentition to refer severe skeletal problems
• Referring without explanation and simply telling your patient they need an orthodontist evaluation.
• Referring to multiple orthodontists creates confusion
• Not following up after referral to see if the patient actually went and what was recommended

Final Takeaway

Referral timing isn't just about clinical judgment, it is also bout communication, trust, and collaboration.

Screen all children by age 7. Know which conditions benefit from early intervention and which can wait. Communicate clearly with parents and tell them why you are referring and what they can expect.

And build relationships with orthodontists who will communicate back to you. Because collaborative care benefits everyone, especially the patient.

References

1. American Academy of Pediatric Dentistry. Management of the developing dentition and occlusion in pediatric dentistry. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2024:414-25.
2. American Association of Orthodontists. Early orthodontic care at age 7: A path to cost-effective treatment [Internet]. St. Louis (MO): AAO; 2024 Dec 12
3. Schneider-Moser UEM, Moser L. Very early orthodontic treatment: when, why and how? Dental Press J Orthod. 2022;27(2):e22spe2.
4. Paglia L. Interceptive orthodontics: awareness and prevention is the first cure. Eur J Paediatr Dent. 2023 Feb;24(1):5. 
5. Knigge RP, Hardin AM, Middleton KM, McNulty KP, Oh H, Valiathan M, Duren DL, Sherwood RJ. Craniofacial growth and morphology among intersecting clinical categories. Anat Rec (Hoboken). 2022 Feb 11;305(9):2175–2206.
6. American Dental Association. Speciality referrals [Internet]. Chicago (IL): ADA [cited 2025 Nov].