A young child comes to your office for an emergency visit. He has dental trauma and bruised lips as well as decayed teeth. Could these findings be related to child abuse or neglect?
At least one in seven children in the United States experiences child abuse and neglect each year, according to national data. Maltreatment may have been even higher during and after the COVID-19 pandemic due to factors such as increased family stressors, isolation from community support systems and underreporting.
A revised AAP clinical report reviews the oral aspects of abuse and dental neglect in children and provides guidance on how pediatricians, dental professionals and other physicians can evaluate such conditions. It includes sections on physical abuse, sexual abuse, medical child abuse, bite marks on the skin, bullying, human sex trafficking and dental neglect.
The report Oral and Dental Aspects of Child Abuse and Neglect, from the Section on Oral Health and Committee on Child Abuse and Neglect, is available at http://doi.org/10.1542/peds.2024-068024 and will be published in the September issue of Pediatrics.
Bite marks
The report provides an update on evaluating whether acute or healed bite marks on skin signal abuse and their use in identifying potential perpetrators.
Bite marks are challenging to interpret because of distortion on skin and the time between the injury and the evaluation. Guidelines no longer endorse positive identification of a suspect’s dentition to a bitemark.
Pediatricians, dental professionals and other physicians should consult with a forensic odontologist, pediatric dentist experienced in forensic issues or child abuse pediatrician for help in evaluating bite marks.
Physical, sexual, medical child abuse
Oral injuries due to physical abuse can include burns or cuts on the tongue and lips, avulsed teeth and jaw fracture. Abuse may be suspected when a child has multiple injuries or injuries that are in different stages of healing.
Sexual abuse often causes injuries or infections in the oral cavity. The report reviews when to consider testing for sexually transmitted infections within the oral cavity.
Medical child abuse, also known as Munchausen syndrome by proxy, can have an impact on oral health conditions. For example, one case of medical child abuse involved recurrent mucosal bleeding and ulcerations due to forced ingestion of toxic cleaning products.
Dental neglect
The American Academy of Pediatric Dentistry defines dental neglect as the “willful failure of parent or guardian, despite adequate access to care, 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.”
Populations that are vulnerable to dental neglect include children with disabilities, LGBTQ+ youth, children and adolescents with overweight and children from racially minoritized groups. Therefore, special attention should be paid to these children and youth.
Collaborating with experts
The report recommends collaboration among health care and dental professionals to help prevent, detect and treat cases of child abuse and neglect. Physician members of multidisciplinary child abuse and neglect teams are encouraged to identify dental providers in their communities to serve as consultants for these teams. In addition, physicians with expertise in child abuse and neglect can make themselves available to dentists and dental organizations as consultants and educators.
Recommendations
The following are among the recommendations in the clinical report.
- Pediatricians, dental professionals and other physicians must report injuries concerning for abuse or neglect to child protective services in accordance with local or state legal requirements.
- Children with dental abnormalities are at increased risk for bullying. Therefore, providers should ask their patients about bullying and advocate for antibullying prevention programs in schools and other community settings.
- Children who have experienced human trafficking may visit a variety of health care settings. Health care providers and dental professionals are encouraged to be aware of human trafficking screening tools and the risk factors for human trafficking to identify children at risk and to safely report and connect patients to resources.
- If parents do not obtain necessary treatment for a child’s oral or dental disease after barriers to care have been addressed, the case should be reported to the appropriate child protective services agency as concerning for dental neglect.
Dr. Tate is an AAP associate member and a former member of the Section on Oral Health Executive Committee.
