Knowledge of child protection is essential in everyday practice for the whole dental team as they are well placed to take part in the shared responsibility of protecting children. Physical abuse, neglect, sexual abuse and emotional abuse may all present to the dental team in various ways. This article aims to provide some top tips for general dental practitioners who have concerns regarding possible child abuse/neglect and remind them of what observations to make and what questions to ask themselves when they are concerned about a child's welfare.
Clinical Relevance: Abuse and neglect are areas in child protection that the dental team can provide important information about to the local child protection team. All members of the dental team need to be aware of the signs and symptoms of child abuse/neglect and where to go for help.
Article
The aim of this article is to provide some ‘top tips’ for GDPs when it comes to dealing with child protection. This is an issue which naturally causes anxiety among GDPs, yet is essential in everyday general dental practice, whether children are seen directly or adult patients, who may have contact with children at home or elsewhere, have issues associated with a child's welfare. The whole dental team needs to know how to respond in the case of a child protection concern.
The dental team is well placed to take part in the shared responsibility of protecting children. The reasons for this include:1
Dentists are skilled at examining the head and neck and recording their findings;
The head and neck is frequently a site of injury in physical abuse;
Untreated dental disease may itself be a sign of neglect;
Children often attend the dentist regularly, even when they may have little or no contact with other health services;
Dentists often treat more than one family member, so may get to know about wider issues that impact on a child's wellbeing.
Dental professionals may observe the signs of abuse or neglect, or hear something that causes them concern about a child. Studies in the UK have consistently shown disparity between the numbers of dental professionals who suspect the need for child protection services versus those who actually refer these cases.2,3,4 However, dealing with child protection concerns is never a task that the dental team faces alone. Advice and support is always available from experienced child protection professionals.
Tips on identifying suspected cases
Abuse or neglect may present to the dental team in a number of different ways:1
Through a direct allegation (sometimes termed a ‘disclosure’ made by the child, a parent or some other person);
Through signs and symptoms which are suggestive of maltreatment;
Through observations of child behaviour or parent-child interaction.
However it presents, any concerns should be taken seriously and appropriate action taken. It is assumed that the dentist will be examining a child who is fully dressed.
There are many sources of help available to GDPs when it comes to identifying suspected cases of child abuse or neglect. One of the main ‘go to’ guides for the dental profession is the manual Child Protection and the Dental Team,5 which is also available online. In addition, in many Health Boards in Scotland there are Child Protection Advisors available with whom dental teams can discuss their concerns. Alternatively, this advice may be sought from other members of local Child Protection Teams or Safeguarding Teams.
Physical abuse
Previously there has been much written about the dentist's role in the identification of physical abuse of children. Studies of the prevalence of injuries to the head, face and neck of physically abused children have been repeated all over the world and it has been consistently shown that 50–75% of physically abused children have orofacial signs of abuse which would be obvious to a dental practitioner.6–10 Orofacial signs of physical child abuse include bruising of soft tissues (especially those that do not overlie a bony contour), abrasions, multiple injuries, bruising of different vintages, scarring of the lips, dento-alveolar injuries, fractures, burns and ‘tattoo’ injuries which reflect the shape of the offending object. Facial fractures are not frequent. A child with one injury may have further injuries that are not visible so, where possible, arrangements for the child to have a comprehensive medical examination by medical colleagues should be made. It is important to state that no injuries are pathognomonic of child abuse. Any text that suggests so is incorrect, however, some injuries or patterns of injury will be highly suggestive of it.
The assessment of any physical injury involves three stages:1
Evaluating the injury itself, its extent, site and any particular patterns;
Taking a history with a focus on understanding how and why the injury occurred and whether the findings match the story;
Exploring the broader picture, including aspects of the child's behaviour, the parent-child interaction, underlying risk factors or markers of emotional abuse or neglect.
Differential diagnosis
Although dental practitioners should be suspicious of all injuries to children, they should be aware that the diagnosis of child physical abuse is never made on the basis of one sign, as various other conditions can be mistaken for child physical abuse.1 The lesions of impetigo may look similar to cigarette burns, birthmarks can be mistaken for bruising and conjunctivitis can be mistaken for trauma. If children are reported to bruise easily and extensively they should be screened for bleeding disorders. Unexplained, multiple or frequent fractures may rarely be due to osteogenesis imperfecta; a family history, blue sclerae and the dental changes of dentinogenesis imperfecta may all help in establishing this diagnosis.
Neglect
Dentists should be involved in the recognition of neglect.4,5,11 Neglect is defined as ‘the persistent failure to meet a child's basic physical and/or psychological needs, likely to result in the serious impairment of the child's health or development.’12 Historically, the reporting of dental neglect as part of physical neglect was nearly non-existent. However, Badger suggested that the diagnosis of severe dental neglect does not require any additional training of dentists.13 Recent guidance commissioned by the National Institute for Clinical Excellence describes situations which may lead a professional to suspect or consider child abuse or neglect, such as if parents have access to, but persistently fail to obtain, treatment for their child's tooth decay.14
When it comes to dental neglect, in particular, the American Academy of Pediatric Dentistry (AAPD) defines it as the ‘wilful failure of parent or guardian to seek and follow through with treatment necessary to ensure a level of oral health essential for adequate function and freedom from pain and infection’.15 The British Society of Paediatric Dentistry (BSPD) published guidelines on dental neglect in 2009. Their definition is ‘the persistent failure to meet a child's basic oral health needs, likely to result in the serious impairment of a child's oral or general health or development.’4
Sexual abuse
Dentists may also come into contact with children who have been sexually abused. The general features that the literature suggests dentists should be made aware of are the oral manifestations of sexually transmitted infections in children whose behaviour is withdrawn.16 Casamassimo17 devoted a whole article to child sexual abuse and the paediatric dentist. He listed the signs and symptoms of child sexual abuse that may alert a dentist as:
A history of sexual assault;
Physical findings of venereal disease;
Pregnancy in a child younger than 12 years of age;
Direct reports from children.
Dentists should, however, have knowledge of the oral appearances of sexually transmitted infections and what tests are required to confirm or refute their differential diagnoses.
Emotional abuse
Emotional abuse impacts on a child's mental health, behaviour and self-esteem and is now recognized as a component in all categories of abuse.12 Signs and symptoms of emotional abuse may be noticed by dentists and include babies who are demanding/clingy or irritable, and who may also have feeding difficulties and cry a lot. In school-aged children there may be developmental delay, soiling or wetting problems, poor behaviour, and non-attendance at school or rejection by their peers. Teenagers who have suffered emotional abuse may exhibit problems with drugs/alcohol, behavioural problems, self harming, eating disorders or depression.12
Questions to ask yourself when you suspect child physical abuse
Could the injury have been caused accidentally and if so how?;
Does the explanation for the injury fit the age and the clinical findings?;
If the explanation is consistent with the injury, is this itself within normally acceptable limits of behaviour?;
Has there been delay in seeking advice and are there reasons for this?
Observations to make if you suspect neglect/child physical abuse
The general demeanour of the child;
The nature of the relationship between guardian and child;
The child's reactions to other people;
The reaction of the child to any medical or dental examination;
Comments by the child and/or guardian that give concern about the child's upbringing or lifestyle.
Conclusion
The dental team have an important role in child protection. It is essential that all members of the dental team are appropriately trained in child protection, whether they have direct contact with children and young people or not. This article has sought to give a brief overview of this topic and suggests some ‘Top tips’ for dealing with these issues.
Tips on where to go for further information
In Scotland: your local NHS Trust Child Protection website, eg Greater Glasgow and Clyde: www.nhsggc.org.uk/childprotectionunit
In England, Wales and Northern Ireland: your local child safeguarding board website, eg Cumbria: www.cumbrialscb.com Caerphilly: www.caerphilly.gov.uk/cscb/english/home
Child Protection and the Dental Team: www.cpdt.org.uk
