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Article:

Harris, J.C. orcid.org/0000-0002-5597-3737 (2018) The mouth and maltreatment: safeguarding issues in child dental health. Archives of Disease in Childhood. ISSN 0003-9888

https://doi.org/10.1136/archdischild-2017-313173

[email protected]://eprints.whiterose.ac.uk/

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CopyrightArchivesofDiseaseinChildhood.PublishedOnlineFirst,22February2018

http://adc.bmj.com/content/early/2018/02/22/archdischild-2017-313173

LEADINGARTICLE

Themouthandmaltreatment:safeguardingissuesinchilddentalhealth

JennyCHarris1,2

1CharlesCliffordDentalServices,SheffieldTeachingHospitalsNHSFoundationTrust

2SchoolofClinicalDentistry,UniversityofSheffield

[email protected]

Keywords: childabuse,childneglect,oralinjury,dentistry,dentalcaries

2

ABSTRACT

Awiderangeofissuesinchilddentalhealtharerelevanttosafeguardingchildren.

Themouthplaysakeyroleinhealthanddevelopmentbutsometimesbecomesthe

focusofabuseorneglect.Oralsignsincludedentalcaries,asapotentialindicatorof

dentalneglect,andoralinjury.Dentalprofessionalscancontributetosafeguarding

byrecognisingsignsofmaltreatmentinchildrenandyoungpeoplereceivingdental

care,canassistwithassessingchildren’sneedswhenchildprotectionconcernshave

beenraisedandcanprovidedentalrehabilitationofdentalneglectororalinjury.

Thereispotentialforgreaterinterdisciplinaryworkingtobetterusethecombined

skillsofpaediatriciansandpaediatricdentists.

Fromthefirstcryofanewbornbaby,thefirstsmile,firsttooth,firstword,

themouthplaysakeyroleinchildren’shealthanddevelopment.Itbenefitsfroma

wholeteamofdentalhealthprofessionalsdedicatedtomaintenanceofitsessential

andlifelongfunctionsincommunicationandfeeding.Sometimesthemouthbecomes

thefocusofabuseorneglect.Inthecontextofsafeguardingandpromotingwelfare,

bothdentalhealthanddentalcarearerecognisedasnotableaspectsofchildren’s

needs.[1,2]Neverthelessitisuncommonforpaediatriciansanddentalprofessionals

toworksufficientlycloselytogethertoensurethatoralhealthisfullyincludedin

multi-agencyassessmentandplanningforchildrenexperiencingmaltreatment.

Theaimofthisarticleistooutlinethescopeofsafeguardingissuesinchild

dentalhealth.Itwillconsidertheinterpretationoforalfindingsasindicatorsof

maltreatment,discussthearguablyunderusedcontributionthatdentalprofessionals

3

canmaketochildprotectionandwillexplorethepotentialforenhancingworking

togetherwithpaediatricians.Theintentionistostimulatediscussionanddebate.

ORALSIGNSOFCHILDMALTREATMENT

Examinationofthemouth‘shouldbepartofeverychildprotectionassessmentthatthe

paediatricianundertakes.’[3]Anythinglessshouldberecognisedasanincomplete

examinationofthechild.Howeveritisacknowledgedthatdoctorsmaynotrecognise

oralsignsofmaltreatmentasreadilyasthoseaffectingotherpartsofthebody.[4,5]

Ifthereisobviousdentaldecayorotherpathologythechildshouldbereferredfora

dentalopinion.[3]Whilstdentaldecay(caries)asapotentialindicatorofneglectis

themostobvioussign,signsofphysicalabuse,sexualabuseandconditions

associatedwithemotionalharmmayallbeobservedintheoralcavity.

Dentalcariesanddentalneglect

DentalcariesisoneofthecommonestdiseasesofchildhoodbothintheUKand

worldwide.IntheChildDentalHealthSurvey2013,31%of5-year-oldsinEngland,

WalesandNorthernIrelandhadobviousdecayexperienceintheirprimaryteethand

46%of15-year-oldsintheirpermanentteeth.DespiteaccesstofreeNHStreatment,

diseasein28%of5-year-oldsand21%of15-year-oldsremaineduntreated,andwas

classedassevereorextensivein13%and15%respectively.[6]UKtrendssincethe

1970sindicateafallingprevalenceoverallbutthispreventablediseaseisnow

concentratedinaminorityofchildren,[7]beingstronglyassociatedwithsocial

deprivation.Higherthanaveragelevelsofdecayarealsoreportedinternationallyin

variousvulnerablegroups,includingchildrenmaltreated,lookedafter,withahistory

ofadversechildhoodexperiencesandthoseofsubstance-usingparents.[8-13]

4

Amongstthesesomesufferdentalneglect,definedintheUKas‘thepersistentfailure

tomeetachild’sbasicoralhealthneeds,likelytoresultintheseriousimpairmentofa

child’soralorgeneralhealthordevelopment’.[14]

Thesequelaeofuntreateddentalcariesincludeacuteorchronicpulpitisor

periapicalperiodontitis(allofwhichcancausetoothacheofvaryingseverity),dental

abscess,facialswelling,dischargingsinus(whetherintra-oralorontheface)or

spreading,andoccasionallylife-threatening,oro-facialinfection.[15]Children

complainofstoppingplaying,difficultyeatingandsleepingandofnotgoingto

school[16]orbeingtiredatschool.[17]Furtheradverseimpactsincludeunsightly

dentalappearance,and,particularlyinpre-schoolchildren,failuretothriveand

reducedqualityoflife.[18]Ifawaitingtreatment,forexamplegeneralanaesthesiafor

toothextractionorrestoration,repeatedantibioticsmaybeneededasaninterim

measure.Anowsignificantbodyofevidenceshowsthatreceivingappropriatedental

treatmentresultsincatchupgrowthandimprovedqualityoflife.[18]

Dentalcarieshasacomplexaetiology.Cariesriskstatusisdeterminedbyalarge

numberofphysical,biological,environmental,behaviouralandlifestyle-related

factors.Theseincludehighnumbersofcariogenicbacteria,inadequatesalivaryflow,

insufficientfluorideexposure,poororalhygiene,frequentdietarysugar

consumption,methodofinfantfeedingandpoverty.[19]Parentalinfluencesare

knowntobeimportant,particularlyinyoungerchildren.[20,21]Night-timebottle-

feedingandbetween-mealsnackingareassociatedwithincreaseddecayrates.In

contrast,lowerratesofdecayareobservedinfamilieswithsupervisedtooth

brushinghabitsandregulardentalattendance,butsomefactorslieoutsideparental

control.Thereforedifferentiatingdentalcariesfromdentalneglectisdifficult,not

leastbecauseitlackspreciseclinicalfindingsorthresholdstoaidthedistinction.[22]

5

Dentalneglectmayoccuraloneandact,whenrecognised,asapotentially

valuableindicatorpromptingreferralofafamilytoreceiveearlyhelp[23]oritmay

beoneindicatorofbroaderormoreseriousneglectrequiringassessmentand

intervention.[24]Dentists,whetherworkinginhospital,communityorgeneral

practicesettings,recognisedentalneglectasacommonproblem[25,26]which

affectschildrenofallages.[27,28]

Sohowcanwedistinguishbetweendentalcaries-thedisease-anddental

neglect-thesignofmaltreatment?Failuretoseek,ordelayseeking,dentalcare

(whetherforcariesorothersignificantoralpathology)withadversedental

consequencesarehighlightedascauseforconcern,[4,14,29]guidancenow

evidencedbythefirstsystematicreview.[22]IntheUK,whereNHSdentalcareis

availablefree-of-chargeforchildren,complaintofdifficultyfindingadentistshould

neverbeacceptedasanexcusewithoutcarefulenquiry.Somesimplediagnostic

pointerstobeusedasa‘ruleofthumb’areshowninTable1.Forfurtherdiscussion,

differentialdiagnosesandaglossaryofdentalterminologythereaderisreferredto

anillustratedarticlewrittenspecificallyforamedicalaudience.[30]

Intra-oralinjuries

Accidentalinjuriestothemouthareverycommon,particularlyinthefirst10years

oflife.[31]Whenconsideringinjuriestotheteethalone,worldwidepopulation-based

surveysshowthatthatonethirdofallpreschoolchildrensufferatraumaticdental

injuryinvolvingtheprimarydentition.Aquarterofallschoolchildrensuffertrauma

tothepermanentdentition,risingtoalmostonethirdofadults,withvariationboth

withinandbetweencountries.[31]

6

Repeatedaccidentsinchildhoodmaygivecauseforconcernaboutneglectto

provideadequatesupervisionbutthetypeofmaltreatmentusuallyassociatedwith

intraoralinjuriesisphysicalabuse.Theheadandneckregionisfrequentlythetarget

ofabuse,withinjuriesoccurringin59-76%ofphysicallyabusedchildren.[32-37]

Intraoralinjuriesarefarlesscommonlyobserved,makingup2-7%ofallrecorded

injuriesinchildrenassessedforphysicalabuse(seeTable2),[32-38]leadingmanyto

suggestitislikelythatabusiveintra-oralinjuriesoftengoundetected.[32,34,35,39]

Severalfactorsareprobablyinvolved:bleedingstopsquicklyafterminororalsoft

tissuetrauma,injurytotheinsideofthemouthremainshiddenfromviewofthe

casualobserverandtheoralmucosahealsquickly,oftenwithoutactivetreatment

andusuallywithoutobviousscarring.Furthermore,theoralcavityispossiblynot

alwaysfullyexploredortheexaminingdoctormaylacktraininginhowtoconductan

optimalexamination.[5,40]Standarddentaltechniquesuseadditionalbright

lighting,amouthmirrorandsofttissueretraction,recordfindingsonanexpanded

mouthmap[41]anddentalchart,andusecalibratedexaminersinresearch.Ina

studyinBrazil,whereforensicdentistscontributedtoexpertmedicalreports,a

muchhigherprevalenceofintraoralinjurywasrecordedat12.4%ofconfirmedcases

ofphysicalabuse(Table1).[37]

Typesofabusiveinjurytothesofttissuesofthemouthincludebruising,

petechiae,lacerations,swellingandburns.[39]Thecommonestsiteisthelips,inone

studyaccountingfor80.4%of133confirmedabusiveintra-oralinjuries,[37]but

injurycanoccuranywhereinthemouthandnositeisspecifictoabuse.Fractures

andluxationinjuriesofthedentalhardtissues(brokenorlooseteeth)accountedfor

5.2%ofintra-oralinjuriesinthesamestudy:mainlyfracturedmaxillaryincisors,[37]

alsothecommonestteethtobeinjuredaccidentally.[31]Bizarrecasesofintra-oral

7

injuryhavealsobeenreported:examplesbeinganadultbitetoaninfant’stongue

andthreesiblingswithmissingteethwhereforcibletoothextractionhadbeenused

asapunishment.[39]

Detectionof‘sentinelinjuries’,definedasminorabusiveinjuryoccurring

sometimepriortoseriousabuse,importantlyrepresentanopportunitytoprotecta

childbeforeabuseescalates.Acase-controlstudyfoundthat27.5%of200abused

infantsunder12-months-oldhadaprevioussentinelinjury,ofwhichintraoralwas

thetypeofinjuryin11%,secondonlytobruisingin80%.[42]Incontrastoralinjury

innon-abusedcontrolinfantswasrare,leadingtotherecommendationthatahistory

ofanyoralinjuryina‘pre-cruising’childofthisageevaluatedforabuseshould

heightenthelevelofsuspicion.Thelatestevidencefromalargemulti-centrestudy

foundhighratesofoccultinjuriesinchildrenunder10withoralinjuryevaluatedfor

abusewithriskpersistingbeyondinfancy.[38]

Atornupperlabialfrenumhasattractedparticularattentionintheliterature

because,althoughatrivialinjuryinitself,ithasbeenobservedinassociationwith

highlevelofconcernorsevereorfatalabuse,usuallyinchildrenagedunder5.[38,

43,44]Otherthanadirectblowtothemouth,proposedmechanismsofabusive

injury,suchasforcedfeeding,areunsubstantiatedbyevidence.Frenaltearsalso

resultfromarangeofaccidentalcausesbutthesupportingliteratureissparse.[39]

Neitheristhereanyevidenceregardingchildrenpresentingoutsideofhospital

settings:agapintheliterature.Ofnote,interpretationofupperlabialfrenuminjury

musttakeaccountofmorphologicalvariationbothbetweenindividualsandasthe

dentitionmatures;itsalveolarinsertioncontinuestomigrateawayfromthegingival

marginintoadolescence.[45]

8

Aswithanyinjury,anoralinjurymustneverbeinterpretedinisolationbut

mustalwaysbeassessedinthecontextofmedicalandsocialhistory,developmental

stage,explanationgiven,fullclinicalexaminationandrelevantinvestigations.[39]If

thenstillunexplaineditmustpromptafullinvestigationtoexcludethepresenceof

otheroccultinjuries.Healthcareprovidersshouldbecautiousofblanketacceptance

ofnormalaccidentaleventsinambulatorychildrenasexplanationandmustreferif

concerned.[38]

Oralsignsofsexualabuse

Oralsignsofsexualabuse,whetherastraumaorsexuallytransmittedinfection,are

saidtoberarelyobviousonexamination.[4]Specificinformationaboutexamining

fororalmanifestationsofsexualabuseandinterpretinganyfindingsis

conspicuouslyabsentfromauthoritativeguidancedocuments,[3,29]theprimary

focusbeingonano-genitalsignsandinfections.[46]

Publishedevidenceismainlyintheformofindividualcasereports.

Unexplainedinjuryorpetechiaeatthejunctionofthehardandsoftpalatemaybe

evidenceofforcedoralsex.[4]Reportedinlessthan1%ofsexuallyabused

children,[46]thecharacteristicorallesionsofsyphilisarechancreinprimary

syphilis,mucouspatchesorsnail-trackulcersinsecondarysyphilisandleukoplakia

orgummaintertiarysyphilis.[47]Oralgonorrhoeamaymanifestaspharyngitisor

gingivitisbutisusuallyasymptomatic.[47]Oralfindingsarecommonmanifestations

ofHIVinfectioninchildren,particularlyoralcandidosis,herpessimplexvirus

infection,lineargingivalerythema,parotidenlargementandrecurrentaphthous

ulcers.[48]Inpre-pubertalchildrenwherethereisnoclearevidenceofvertical

transmissiontheseinfectionswouldbealertingfeaturestosuspectsexualabuse.[29]

9

Thesignificanceoforalwartsinrelationtosexualabuseisunclear.[4]Adultwomen

survivorsofchildhoodsexualabuseself-reporthigherprevalenceofarangeofdental

conditions,includingbruxism(toothclenchingandgrinding)and

temperomandibulardysfunction.[49]

Whensexualabuseissuspected,childrenshouldalwaysbepromptlyreferred

tospecialistcentreswiththeexpertisetoconductforensicexaminationaccordingto

acceptedevidence-basedstandardsincluding,whenappropriate,mouthswabsfor

semenandDNA.[3,46]

Otheroralanddentalsignsofmaltreatment

Certainoralconditionsarerecognisedaspotentialalertingfeaturesofemotional

distressinchildrenandyoungpeople,anddeservebriefmentionbecause

maltreatmentshouldbeincludedinthedifferentialdiagnosisofunderlyingcauses.

Examplesare:oralulcerationor‘gingivitisartefacta’duetoself-harm;extremely

poororalhygieneinself-neglect;symptomsoftemperomandibulardysfunction,

toothgrindingorclenching;andperhapsorthodontic(toothposition)abnormalities

exacerbatedbypersistentdigitsucking(ahabitofconcernonlyifpersistingwell

beyondtheageconsidereddevelopmentallyappropriate).

DENTISTSASCONTRIBUTORSTOSAFEGUARDINGCHILDREN

Theroleofdentalprofessionalsascontributorstosafeguardingchildrenfallsinto

threeareas:

• recognitionandresponsetosignsofmaltreatmentinchildrenandyoung

peoplereceivingdentalcare

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• contributiontodiagnosis,assessmentofchildren’sneedsandplanningwhen

childprotectionconcernshavebeenraised

• dentalrehabilitationofneglectororalinjury.

Recognisingandrespondingtosignsofmaltreatment

Dentalprofessionalsaregenerallyconsideredtobeinagoodpositiontorecognise

signsofmaltreatmentandtosafeguardandpromotechildren’swelfare.Dental

treatmentiscarriedoutinclosepersonalcontactandtakestime.Injuriestothehead

andneck,andtootherpartsofthebodyvisibleinaclothedchild,arereadily

observed.AsencouragedinthecurrentBritishSocietyofPaediatricDentistry(BSPD)

‘DentalCheckbyOne’(DCby1)campaign,regulardentalpreventionvisitsare

advised,startingbyachild’sfirstbirthday.[50-52]Thismeansthatotherwisehealthy

childrenwhohavenoneedforappointmentswithotherhealthcareprovidersmay

nonethelessbewell-knowntotheirdentist.Generaldentalpractitioners(GDPs)

oftentreatseveralmembersofafamily,somaybeawareofinformationrelevantto

parentingcapacity,suchasparentalchronicillnessormentalhealthcondition.

Furthermore,thevisitprovidesanopportunitytoobserveinteractionbetween

childrenandparents:usuallyacaringparentcomfortingananxiouschildbut

occasionally,whenchildrenareunabletocooperatewithtreatmentduetoanxietyor

otherreason,afrustratedparentprovokedsuchthatemotionalorphysicalabuseis

witnessedinthedentalsurgery.Occasionallyachilddisclosesmaltreatmenttoa

trusteddentalprofessional.

Childrenwithcomplexdentalproblemsandthosewithmedical,

developmentalorbehaviouralneedsmaybeunderthecareofspecialistor

consultantpaediatricdentists,whointheUKaremainlybasedinhospitalsorthe

11

communitydentalservice.Childrenwithdisabilitiesaremorelikelythantheirnon-

disabledpeerstoexperiencemaltreatment,especiallyneglect,[53]andare

recommendedtohavemorefrequentdentalcare,[50]givingparticularopportunity

torecognisearangeofsafeguardingconcernsasdemonstratedinTable3.

In2005,67%ofUKpaediatricdentistsself-reportedpreviouslysuspecting

maltreatmentofachildintheircare,[54]almostdoublethatreportedbyGDPs[55]

andthehighestrecordedinasummaryofsimilarsurveysinternationallybetween

1998and2010.[56]Thosewithpreviouschildprotectiontrainingweremorelikely

tohavesuspectedmaltreatment(71%v47%)andmadeareferraltosocialservices

(33%v8%).[54]Inrelationtodentalneglect,which81%reportedseeingatleast

weekly,multiagencycommunicationwasmorecommonlyundertakenbythosewith

training.[25]InSwedenastudyofreasonsfor147dentalreferralstosocialcare

showedthatneglectandmissedappointmentsweretheunderlyingconcernsin145

cases.[28]Missedhealthcareappointmentsareconsistentlyacommonfindingin

SeriousCaseReviews(SCRs)[57]butindentistry,asinotherfieldsofhealthcare,

onlyrecentlyaretheybeingfullyconsideredfromtheperspectiveofsafeguarding

thechild.[58,59]

Alldentalprofessionalshavearesponsibilitytoreferchildrentosocialcarewhen

theyhaveconcernsaboutmaltreatment[60]yetlackofknowledgeorconfidence,

barrierstoactionandshortcomingsinpracticeareregrettablycommon.[5,22,55,

56,61]Evenamongstpaediatricdentistsagapisevidentbetween67%everhaving

recognisedand29%everhavingreferredconcerns.[54]Thesegapsreflectdentists’

dilemmasabouttheircontradictoryrolesofsupportingorreportingfamilies,

differentiatingcompromisedwellbeingfromsignificantmaltreatmentandperceived

shortcomingsofthechildprotectionsystem.[62]Lessonslearnedinanumberof

12

SCRsindicatethatharmmighthavebeenavoidedhaddentalprofessionalsraised

concernsearlier.

AninsightfulqualitativestudyintheNorthEastofEnglandexplored

inhibitorsandfacilitatorstodentists’involvementinchildprotection.[61]Isolation

ofdentistryinrelationtootherhealthcareproviderswasidentifiedasamajor

barrierwhich,despitearevolutionincommunicationandinformationtechnology,

remainstothisday.Inotherrespectssignificantadvanceshavebeenmade,notably

withraisingdentists’awareness.WhereastheUKandmuchofEuropepreviously

laggedbehindtheUSA,trainingandguidanceisnowreadilyavailable.ADepartment

ofHealthfundededucationalresource,Childprotectionandthedentalteam,[63]was

distributedtoeveryNHSdentalpracticeinEnglandandScotlandin2006and

updatedonlinein2013.Evidenceregardingtheprofession’slearningneeds[25,54,

61]wasusedindevelopingitskeymessages.Tacklingthegreatestbarriersto

referral,itreassureddentiststhat,firstly,theyshouldreferconcernsratherthanwait

tobecertainmaltreatmenthadoccurredand,secondly,theywouldneverbesolely

responsibleformakingthediagnosisbutcouldrelyontheadviceandsupportof

experiencedchildprotectionprofessionals.Writteneducationalmaterialstypically

onlyhaveasmallbeneficialeffectyetreportedusageandchangeinprofessional

practicewasunusuallyhigh,[55,64]perhapsreflectingdentists’hungerforadvice;

93%ofthosewhorememberedreceivingthedocumenthadusedit,withmany

attributingimprovedknowledge,confidenceandactionstoadirectresultof

followingitsguidance.[64]

Whilstprofessionalandstatutoryguidance[63,65]makesitclearthat

frontlinehealthprofessionalswithconcernsshouldthemselvesmakedirectreferrals

tosocialcare,childprotectionpaediatriciansmayyetreceiverequestsfromdentists

13

foradvice:forassistancewithinterpretingthesignificanceofobservedinjuries,the

dentalfindingsinrelationtoachild’sgeneralwelfareorjudgingthelevelofharm.

CaseexamplesandopportunitiestopoolexpertisearedetailedinTable4.

Witheffectivelocalleadershipandstakeholderinvolvement,improvementsin

informationsharingcanbeachieved.Inarecentpublishedexampleofgoodpractice,

aNamedDoctorforSafeguardingChildrenleddevelopmentsrelatedtoageneral

anaestheticdentalextractionservice.[66]Betterintegrationofdentistryintopatient

administrationandrecordkeepingsystemswouldbeafurtherstepforward.Simple

changessuchasaddingafieldtohospitalelectronicrecordsfortheGDP’saddress

wouldenablesuchbasicsasexchangingcopiesofrelevantclinicalcorrespondence.

Contributingtodiagnosisandassessmentofchildren’sneeds

Wheninvitedtodoso,achild’susualGDPorpaediatricdentistcancontributea

reportforcaseconferenceorcareproceedings,includingthedentalhistory,any

previousconcerns,anyobservedstrengthsandanoutlineofthechild’sdentalneeds.

Inexperienceddentistsmayrequireassistancetocontribute.Suchinputisusually

valuedbyotherprofessionals(seebriefcaseexamplesinTable4,Role2)butatthe

presenttimeintheUKisrarelyrequested.

SeveralauthorscitedinTable1concludedthatspecialistpaediatricdentists

shouldroutinelyexamineallchildrenbeingassessedforsuspectedphysicalabuse.It

isanticipatedthatthiswouldbothincreasedetectionofabusiveoralinjuriesand

alsoalertpaediatricianstooraldiseasesanddevelopmentalconditionsthatmightbe

mistakenformaltreatment.InGlasgowsince2009oralassessmentsbyadentist

havebeensuccessfullyintegratedintocomprehensivemedicalassessmentpathways

forchildrenwithvariedsafeguardingconcerns,mainlyneglect.[67]Thisgeneratesa

14

standardiseddentalappendixtothepaediatrician’smedicalreportforachild

protectioncaseconference,includinganoralcareplanandtargetsagreedwith

parents.Caseexamplesillustratethepotentialbenefitsofthisinnovation.[67]Long

termevaluation,particularlyifreportingadditionaldiagnosticyieldandimproved

outcomesforchildren,couldprovidecompellingevidenceforwideradoptionofthis

practice.

Onecircumstancewhenpaediatriciansmustalwaysseekadviceisinrelation

tobitemarks.Anabusivehumanbiteisuniqueamongphysicalinjuriessinceits

patterncanpotentiallyidentifyorexcludeaspecificperpetrator.[68]Occasionally

certaintyisenhancedbyDNAretrieval.Earlyreferralofsuspiciousinjuriesto

forensicdentists(forensicodontologists)isessential.[69]

Rehabilitationoforalinjuryorneglect

Maltreatedchildrenandyoungpeoplehavearighttoenjoy‘thehighestattainable

standardofhealthandtofacilitiesforthetreatmentofillnessandrehabilitationof

health’[70]yetaretwiceaslikelytohavepoorself-perceivedoralhealththantheir

non-abusedpeers,increasedto23-foldforthosewithmultipleformsofabuse.[11]

Theyshouldbesupportedtoreceivenecessarydentalcare.

Treatmentofdentalcariesimprovesqualityoflife.[18,71]Evidence-based

preventivetreatmentssuchasfluoridevarnishandfissuresealants[50]arefree-of-

chargeontheNHS,simpletoprovideandeasilyacceptedbychildren,withthe

benefitsofdiseasereductionlastingtooldage.Adviceonsmoking,alcoholand

healthyeatingisgivenalongsidedentalrecommendations,usingacommonrisk

factorapproach,withpotentialforwiderhealthgainsandforempoweringthe

recoveringchild.

15

Restorationoftraumaticdentalinjuries(fracturedandloosenedteeth)is

essentialbecauseoftheimportanceoffrontteethinfacialappearance.Poordental

appearanceaffectsqualityoflife,[72]exposeschildrentoadversesocialjudgements

bytheirpeers[73]andaffectslifeopportunities.Successfultreatmentoftenrequires

bothcarefulemergencymanagementandlong-termspecialisttreatment,with

prognosisstronglyinfluencedbypromptnessandqualityofcare.Forthosewith

malocclusion,orthodontictreatment(straighteningteethwithbraces)in

adolescenceleadstoimprovementinemotionalandsocialwellbeing.[74]As

treatmenttakesmanymonths,youngpeoplerequiresupporttomaintainscrupulous

oralhygiene,motivationandattendancewhichareessentialtotreatmentsuccess,a

particularchallengeforthosewithoutparentalsupportorastablehomelife,for

exampleifmovingbetweenresidentialplacements.

Pastmaltreatmentmayaffectachild’sabilitytocopewithdentaltreatment,

necessitatingadditionalanxietymanagementwithbehaviouraltechniquesor

sedation.Inparticular,sexualabusecancauselong-lastingdentalfearextendinginto

adulthood[75]butthiscanbesuccessfullymanagedbyaccesstoappropriately

adjustedorspecialcaredentalservices.[76]

Regrettablyinclusionofarequirementtoaddressdentalneedsiscommonly

overlookedinchildprotectionplanssotheopportunitytointervenewhilethefamily

isreceivingsocialservicessupportandmonitoringismissed.Allfamiliesshouldbe

askediftheyhaveadentistand,ifnot,paediatriciansmustnothesitatetoreferthem.

Itispossibletoachievehighlevelsofsubsequentattendance,81%inonestudy.[9,

77]Developmentoflocalinteragencynetworksfacilitatesreferralandensuresthat

childrenreceivecarefromappropriatelyskilledstaff,whetherGDPsorspecialists,at

aconvenientlocation.Lookedafterchildren,forexample,havehighertreatment

16

needsandpooreraccesstodentalhealthservicesthanthegeneralpopulation[78]

andmaybenefitfromdesignatedcarepathways.[79]

POOLINGOUREXPERTISE

Thisreviewshowsthatsafeguardinginchilddentalhealthhasamuchwiderscope

thanisoftenrealised-recognising,respondingandrehabilitating.Tomakegood

decisionsformaltreatedchildrenandyoungpeople,weallneedthebestpossible

researchevidence,trainingandleadership.Thereisgreatpotentialtodevelopnew

waysofinterdisciplinaryworkingthatmakebetteruseofthecombinedskillsof

paediatriciansandpaediatricdentists.

Someimportantresearchquestionsremaintobeaddressed,fallingthrough

thegapbetweenmedicineanddentistry.Clinicalimplicationsforpractising

cliniciansaresometimesunclearornotgeneralizablebetweensettings.Strategic

directionisneededtobuildstronginterdisciplinarycollaborationsthatpoolour

expertise.

TheUKdentalprofessionhasmovedalongwayinthepastdecadeandits

specialistandprofessionalsocietieshaveactivelyencouragededucational

developments.[14,63]Medicineanddentistrymustlearnfromeachotherby

reciprocalinputtotrainingatundergraduatetospecialistlevel,fosteringan

understandingofeachother’srolesandmakingopportunitiesforpaediatricdentists

anddoctorstotrainside-by-side.[80]

UnfortunatelydentistryintheUKhasnostatutoryrequirementfor

safeguardingclinicalleadership,fallingunderthealreadystretchedremitof

DesignatedandNamedDoctors.Thismeansthatcurrentprogressislargelyreliant

onthegoodwillofenthusiasts.Itisnowtimetomovebeyondtheseadhoc

17

arrangementstocommissioneddentalleadershipworkingtoensurethatourtwo

disciplinescollaboratetobettermeettheneedsofvulnerablechildrenandyoung

people.

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Neglect.RecognizingandRespondingtoMedicalNeglect.Pediatrics

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3. RoyalCollegeofPaediatricsandChildHealth.Childprotectioncompanion.2nd

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Table 1. Diagnosing dental neglect: a ‘rule of thumb’

Features of particular concern

1. Obvious dental disease: untreated dental disease, particularly that which is

obvious to a layperson or non-dental health professional.

2. Significant impact on the child: evidence that dental disease has resulted in a

significant impact on the child.

3. Failure to obtain dental care: parents or carers have access to but persistently fail

to obtain treatment for the child.

Excerpt from table first published in Harris (2012)[30] used with permission of Elsevier

29

Table 2. Intra-oral injury in child maltreatment

30

Table 3. Ten selected examples of safeguarding concerns observed in specialist

paediatric dental practice

31

Table 4. Paediatric dentists and paediatricians pooling expertise to safeguard

children: case examples and opportunities