Dental Neglect and Its Connection to Recognize Child Abuse
Hanan Aljohani, Ahmed Alsharif, Alaa AlGhamdi, Ghaida Alfarsi, Haifa Binthabit, Miral Almanasif, Noha Aldahian, Noor Alnasser, Amjad Aljumaydi, Abdullah Hanafi, Mayaseem Bokhedher
Keywords: child, abuse, dental, neglect, health
Child abuse refers to all forms of emotional and physical abuse, sexual abuse, negligence, and exploitation that cause or threaten harm to child's health, development, or dignity while dental neglect is defined as failure of parents or guardians to access or follow the oral treatment required for adequate functioning and relief from pain. Dentists are very critical in recognition of child abuse due to presence of most of the abusive injuries in the oral and craniofacial region also the compromised oral health of children is a sign of neglect. However, the reporting rate of dentists for child abuse and neglect is quite low due to their various concerns in practice. The aim of this research is to review the available information about dental neglect and its connection to child abuse. The dental profession has widely accepted its role in diagnosing and resolving aspects of child abuse in the last two decades. However, there is a written but underdeveloped link between poor dental health and child abuse also there is a gap between dentist perceptions of child abuse and self-esteem and their ability to detect and disclose concerns about child protection. In order to protect children and their families from the vicious cycle of violence in today's time, dentists must evaluate, record, and report the suspected cases also awareness campaigns and seminars for general public regarding child abuse and dental neglect are needed. Specialized training programs for reporting child abuse and dental neglect for dentists should be held regularly to promote better protection for children.
The World Health Organization defines child abuse or maltreatment as the participation or non-participation of parents or children in any conduct that breaches the right of children and jeopardizes their decent existence and dignity. Physical abuse is when the child experiences or suffer a visible injury as a result of parental or guardian abuse. Sexual child abuse is described as an adult abusing a child for the purpose of sexual gratification. Emotional child abuse happens when a parent or guardian refuses or threatens a child on a regular basis and neglect occurs when parents or caregivers fail to meet a child's fundamental requirements, such as food, clothing, housing, and medical treatment, to the point where the child's mental and physical development are impaired considerably. Because the indications of child abuse and neglect are frequently present in the oral and facial area, the dentist can help identify children who have been abused. Furthermore, child neglect is frequently accompanied by poor dental health (1). Various nations have reported the incidence of child abuse, and variety of social and cultural factors are responsible for it. It is more pervasive than any other health problem in the world; in the United States, approximately 47 of every 1,000 children are suspected of maltreatment, with over 1,000 child fatalities linked to abuse reported in a single year, whereas in Europe and Latin America, the prevalence ranges from 5 to 30 cases per 1,000 children per year, depending on social background. According to some authors, dentists report just 1% of cases of child abuse and neglect (2).
According to the American Academy of Paediatric Dentistry, dental neglect is defined as the purposeful inability of a parent or guardian to acquire or continue through with treatment necessary to achieve a degree of oral health sufficient for optimal function and freedom from pain and illness. When abused and physically mistreated children are compared to the general population, they have higher incidence of tooth decay. Dentists and other health professionals are often unwilling to notify cases of suspected of dental neglect due to a lack of assurance regarding the diagnosis or fear of repercussions, such as a negative influence on their practice or potential litigation. Concerns about jeopardizing the patient and family-physician relationship, as well as reservations about the advantages of reporting suspected cases of maltreatment, are other reasons influencing physicians' decisions not to disclose suspected cases of maltreatment. However, dental neglect should be recognized and reported since it can be an early symptom of overall physical neglect, as well as a source of substantial discomfort and loss of oral function (3).
Child abuse is rarely unintentional and can be caused by a variety of situations. Some of the risk factors for child abuse are children with special healthcare needs like learning difficulties, developmental problems, chronic illnesses, and mental retardation, unwanted children, insufficient knowledge about parenting and child care, family violence due to depressed parents, living in a risky neighbourhood or not having any or poor recreational activities and poverty and its ramifications. However, children from all socioeconomic backgrounds, not only those from low-income families, are at risk of maltreatment (4). At least 50% of physically abused children exhibit evidence of orofacial abuse, such as abrasions or bruising of the mouth, lips, and tongue, oral mucosa, hard and soft palate, gingiva, alveolar mucosa, frenum; dentoalveolar injuries, avulsions, jaw fractures, burns, and tattoo injuries, as per various studies. As a result of nutritional deficit, neglected children may exhibit manifestations of compromised oral hygiene such as halitosis, untreated dental caries with advancement, odontogenic infections, plaque and calculus deposits, and aphthous ulcers. These negative consequences may have an impact on these children's learning, communication, natural growth, and development. Dentists therefore can provide valuable information and aid about the oral and dental aspects of child abuse and neglect (5). The purpose of this research is to review the available information about dental neglect and its connection to child abuse.
This study is based on a comprehensive literature search conducted on May 9, 2022, in the Medline and Cochrane databases, utilizing the medical topic headings (MeSH) and a combination of all available related terms, according to the database. To prevent missing any possible research, a manual search for publications was conducted through Google Scholar, using the reference lists of the previously listed papers as a starting point. We looked for valuable information in papers that discussed the information about dental neglect and its connection to child abuse. There were no restrictions on date, language, participant age, or type of publication.
Physical abuse of young children can range from mild to severe, even leading to fatal injuries. Because the orofacial region is involved in so many of these traumas, dentists are often the first to spot indications of physical abuse, sexual abuse, health-care neglect, dental neglect, and safety neglect. Nonetheless, global statistics suggest that suspicious instances are not being reported, which could be owing to a lack of information on diagnosis and knowledge of the requirement to report cases suspected among different healthcare professionals (6, 7). The dental profession has widely accepted its role in diagnosing and resolving oral health components of child maltreatment over the last two decades. This shift in focus is global in scope, and it is supported by a growing body of information about the link between child abuse and neglect also known as child maltreatment and child oral health. New legal and professional obligations to safeguard children from maltreatment and serious harm have shaped dentistry's greater engagement with child welfare and child protection in many national contexts (8, 9). Abusive injuries typically involve the face and oral cavity, and dental professionals may be the first to see them. In compliance with local or state legal regulations, dental clinicians must report injuries that appear to be the result of abuse or neglect to child protective services. Such observations, their relevance, and importance, and how to thoroughly examine and document them should all be known to healthcare personnel. A paediatric dentist or a dentist with professional expertise in forensic odontology can assure thorough testing, diagnosis, and treatment when questions are raised and consultation is required (10).
Oral and dental aspects of child abuse and neglect
Dental neglect can be part of a child's overall neglect, resulting in short-term issues like caries as well as long-term effects including poor growth and reduced quality of life. Early detection of dental neglect is critical in preventing negative consequences for children. Early detection of dental neglect and referral to child protective services may protect the kid and avoid additional harm. Although dental neglect might be difficult to detect. As a result, dentists should be knowledgeable about dental negligence and how to handle these situations. To enhance understanding and awareness of all facets of child neglect, effective education is required (11).
A case note review from Iran in 2012 assessing child abuse and orofacial lesions revealed that the average age of the children was 8 years at the time of abuse with about equal numbers of boys and girls. The children had a lot of physical activity 66.1%. At least 60% of these children suffered facial and oral trauma, 77.1% were emotionally abused, while 64.1% reported neglect, and 4.1% reported sexual abuse. Author further concluded that according to preliminary research, there is considerable evidence of child maltreatment related to orofacial lesions, and dentists should be alert of this (12). Findings of a cross-sectional study conducted in 2021 among 250 victims of child abuse showed that 30% had lacerations of various places, including the lip (n=13), frenum (n = 8), buccal mucosa (n = 26), palate (n = 16), and mouth floor (n = 9). Avulsion symptoms were seen 11.6%. Eighteen children had dento-alveolar fractures while 104 had dental caries and 7.6% reported with missing teeth. Deposits were observed in all of the respondents. Since the oral cavity is a prominent focus for physical abuse, a thorough intraoral and perioral examination of the participants who have been victims of abuse and neglect is required (13).
Results of a Nigerian cross-sectional survey in 2018 depicted that the respondents displayed a good understanding of the various types of child abuse with a score of 95.2%, 85.5% correctly identified the risk factors for child abuse and neglect as children with physical and mental problems, 84.4% as products of unplanned pregnancies, 71.5% as children from polygamous homes, and 68.2% as children from low socioeconomic backgrounds. The most common signs of physical, sexual, and mental abuse and neglect were bruises behind the ears (90.5%), oral warts (63.7%), low self-esteem (88.3%), and untreated rampant caries (76.5%). Children with child abuse and neglect were not seen by 46.5% of the dentists while only 14.1% of those who saw suspected child abuse and neglect cases reported it to the social service. The main hurdles to reporting child abuse and neglect cases were a lack of knowledge of referral procedures and issues about confidentiality (14). Findings of another Indian survey in 2017 showed that even while responding dentists were familiar of the diagnosis of child abuse, they were reluctant to disclose it because they didn't know who to report it. The lack of information regarding the role of dentists in reporting child abuse accounted for 55% of the reasons for not reporting. Therefore, increased training in the areas of child abuse and neglect recognition and reporting should be prioritized (15). Dentists have unique reporting responsibilities. Despite the fact that a large number of dentists claim to have observed or suspected such occurrences, the reporting rate is low. Paediatric dentists should be given a training program that includes a child abuse curriculum, as well as seminars and conferences on the subject. Dentists' educational curriculum should include training seminars on child abuse and neglect (16).
Soumya states in her study findings that even while dentists believe they are capable of detecting child maltreatment, just 16% of them could identify a suspected case in their practice, over 90% of respondents did not receive any instructions or training on child abuse and neglect, and the majority believe that further training is required on this topic. Given the high likelihood of oral and dental injuries occurring as a result of child abuse, the majority of them stated that there are several barriers to reporting these cases, including a lack of knowledge about the referral procedure (45%), the consequences to the child (15.7%), concerns about confidentiality (9.8%), and the impact on work and fear of litigation. The findings further reveal that more knowledge and training in the identification and reporting of child abuse and neglect are needed at all levels of the dentistry profession (17).
Oral health needs of children who have endured, or are suspected of having experienced, abuse or neglect have been a source of concern around the world. The mapping of the current nature of the research landscape in this burgeoning topic is thus valuable and pertinent. There is a well-documented but conceptually undeveloped link between poor dental health and child maltreatment. There are gaps between dental team members' understanding of child maltreatment and their confidence and ability to recognize and disclose child protection concerns. However, there is considerable evidence that the oral health needs of this population of vulnerable children are not regularly satisfied (18). Although dental neglect in children is one of the situations in which a health professional is required to report, many professionals do not because they have questions about the diagnosis. The affirmation of dental neglect allows us to anticipate the incidence of neglect in a generalized form, in addition to the undeniable decline in quality of life and the immediate risks to the child's overall health. Dental neglect can manifest itself in a variety of ways, including chronic orofacial pain, orofacial trauma, untreated caries, unfinished tooth care despite caregivers' knowledge of the need, orofacial infections, and edema owing to dental abscesses or cellulitis (19).
Child abuse is a heinous crime that affects people from all walks of life. In their daily practice, dentists are more likely to come across such occurrences. When it comes to detecting child abuse, dentists have an advantage. Because the majority of the distinctive indications may be seen in the craniofacial and oral regions, recognizing and reporting abuse becomes not only a moral but also a legal responsibility. However, due to a lack of understanding, such occurrences frequently go unreported. Not only that but it has been noted that, in order to conceal suspicion, perpetrators frequently switch hospitals and clinicians; yet they return to the same dentist. It is critical to report child abuse in order to protect these children from further abuse (20).
To safeguard patients and their families from the cycle of violence that is all too common in today's society, dental professionals must recognize, record, report, and refer. When a child suffers oral injuries or dental neglect is believed, the physician should consult with a paediatric dentist or a dentist who has completed forensic odontology training. Paediatric dentists and oral and maxillofacial surgeons, whose advanced degree programs contain a required child abuse curriculum, can provide physicians with essential knowledge and help on the oral and dental components of child abuse and neglect. Physicians on multidisciplinary child abuse and neglect teams should seek out local dentists who can act as advisors for these teams. These initiatives will improve the ability to prevent and identify child maltreatment and neglect, as well as the ability to care for and safeguard children (21). Dental neglect and child abuse are established phenomena and with the passage of time is getting more highlighted however, more awareness campaigns are needed to educate the general public regarding the child abuse and dental neglect as there is lack of awareness in the general community and also in future more clinical research should focus on dental neglect and its connection to child abuse as the availability of clinical studies in literature is quite sparse which will not only aid in signifying its importance but will also contribute in protection and well-being of children.
Child abuse is a grave crime that should be punished severely. Dentists are well-versed in this and must act quickly to assist the victims. Signs of child abuse should be recognized by dentists. It is critical to carefully document suspicious injuries and provide supporting evidence. There is a need for more information and training in the evaluation and reporting of child abuse and neglect at all levels of the dentistry profession. Child abuse and dental neglect could be reduced through public awareness campaigns and programs that aim to educate not only physicians and dentists but also parents and the entire community.
The authors declare no conflict of interest.
Data that support the findings of this study are embedded within the manuscript.
All authors contributed equally to the drafting, writing, sourcing, article screening and final proofreading of the manuscript.