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Dental Neglect, one type of child abuse - Narrative review

NEGLIGÊNCIA DENTÁRIA, UMA MODALIDADE DE ABUSO INFANTIL – REVISÃO NARRATIVA

Abstracts

Dental neglect is defined as an intentional failure of the caretaker in the pursuit and continuity of necessary treatment to achieve an oral health that allows adequate function, free from pain and infection. We intend to clarify, according to the current scientific literature, the clinical indications for the identification of dental neglect in children. After the search in databases and search engines with the keywords "child", "dental" and "neglect", between 1996 and 2016, the results revealed that identifying this condition requires not only a detailed clinical history and clinical data that clearly show the lack of oral health care but also investigating the social and parental determinants in which the child is involved. Thus, inserting the dentist in teams of analysis in case of suspicion proves to be indispensable for the detection of this and other situations of abuse.

KEYWORDS:
Child Abuse; Oral Health; Negligence


A negligência dentária é definida como a falta intencional do responsável pela criança na procura e manutenção do tratamento necessário para garantir um nível de saúde oral essencial para a função adequada, livre de dor e infeção. Neste sentido, pretendemos esclarecer, de acordo com a literatura científica atual, os indícios clínicos para a identificação de negligência dentária em crianças. Após pesquisa em bases de dados e motores de busca, com as palavras-chave "child", "dental", "neglect", entre 1996 e 2016, os resultados revelaram que a identificação desta condição requer, não só a obtenção de uma história clínica detalhada e de dados clínicos que evidenciem claramente a falta de cuidados na saúde oral como também a investigação dos determinantes sociais e parentais em que a criança se insere. Assim, inserir o médico dentista nas equipas de análise nos casos de suspeita revelou-se indispensável para o despiste desta e outras situações de abuso.

PALAVRAS-CHAVE:
abuso infantil; saúde oral; negligência


INTRODUCTION

Child neglect is generally defined as a persistent inability to meet the basic physical and/or psychological needs of the child and is likely to cause serious damage to the child’s development or health.11 Welbury R. Dental neglect, child maltreatment, and the role of the dental profession. Contemp Clin Dent. 2016;7(3):285-6. DOI: 10.4103/0976-237X.188535
https://doi.org/10.4103/0976-237X.188535...

2 American Acadamy of Pediatric Dentistry. Clinical guideline on oral and dental aspects of child abuse and neglect. Vol. 26, Pediatric dentistry. 2004.
-33 Crespo M, Andrade D, Alves AL-S, Magalhães T. Abuso Infantil - O papel do médico dentista no seu diagnóstico e atuação legal. Acta Med Port. 2011;24(S4):939-48. More precisely, dental neglect consists in the voluntary failure of the child’s educator or legal guardian to prevent situations of orofacial disease and/or failure to continue the necessary treatment to ensure adequate oral health, to establish adequate function, free from pain and infection. Thus, when the educator allows the child to constantly miss dental appointments that are necessary for his or her well-being, this fulfils the definition and must be considered an act of neglect.11 Welbury R. Dental neglect, child maltreatment, and the role of the dental profession. Contemp Clin Dent. 2016;7(3):285-6. DOI: 10.4103/0976-237X.188535
https://doi.org/10.4103/0976-237X.188535...
,22 American Acadamy of Pediatric Dentistry. Clinical guideline on oral and dental aspects of child abuse and neglect. Vol. 26, Pediatric dentistry. 2004.,44 American Academy of Pediatric Dentistry. Definition of Dental Neglect. Reference Manual. 2010.

Good oral health in children and adolescents increases their competence in physical and psychological development and in social activities. However, the existence of orofacial disease increases their chances of experiencing pain/discomfort, embarrassment, difficulty in cognitive development, reduction of self-esteem or limitation in daily activities. These symptoms are common, even in developed populations that historically have experienced lower rates of caries.55 McGrath C, Broder H, Wilson-Genderson M. Assessing the impact of oral health on the life quality of children: implications for research and practice. Community Dent Oral Epidemiol. 2004;32(2):81-5. DOI: 10.1111/j.1600-0528.2004.00149.x
https://doi.org/10.1111/j.1600-0528.2004...
In Portugal, recent developments, linked to the presence of caries, reveal that in the six-year-old group, 88% of the temporary teeth had caries, and that half of the 12-year-old sample had already experienced caries. However, it is questionable whether the presence of untreated caries in the child, as an isolated act, may represent negligence.66 Direção Geral da Saúde. Estudo Nacional de Prevalência das Doenças Orais. 2008.

Considering the influence that dental neglect represents in children’s life, our objective was to identify and describe the clinical evidence that allows us to suspect dental negligence, as described by current scientific literature.

MATERIAL AND METHODS

A search was performed in Pubmed, SCOPUS and Web of Science, using the keywords "child", "dental", "neglect", between 1996 and 2016. We used the Boolean operator "AND". We selected observational or case-control descriptive articles written in English or Portuguese, that specifically addressed the topic of dental neglect in children.

RESULTS

Table 1 summarizes the selection procedure: among the 25 articles analyzed,11 Welbury R. Dental neglect, child maltreatment, and the role of the dental profession. Contemp Clin Dent. 2016;7(3):285-6. DOI: 10.4103/0976-237X.188535
https://doi.org/10.4103/0976-237X.188535...
,55 McGrath C, Broder H, Wilson-Genderson M. Assessing the impact of oral health on the life quality of children: implications for research and practice. Community Dent Oral Epidemiol. 2004;32(2):81-5. DOI: 10.1111/j.1600-0528.2004.00149.x
https://doi.org/10.1111/j.1600-0528.2004...
,77 Guarnizo-Herreño CC, Wehby GL. Children’s Dental Health, School Performance, and Psychosocial Well-Being. J Pediatr. 2012;161(6):1153-9. DOI: 10.1016/j.jpeds.2012.05.025
https://doi.org/10.1016/j.jpeds.2012.05....

8 Hooley M, Skouteris H, Boganin C, Satur J, Kilpatrick N. Parental influence and the development of dental caries in children aged 0-6 years: A systematic review of the literature. J Dent. 2012;40(11):873-85. DOI: 10.1016/j.jdent.2012.07.013.
https://doi.org/10.1016/j.jdent.2012.07....

9 Bhatia SK, Maguire SA, Chadwick BL, Hunter ML, Harris JC, Tempest V, et al. Characteristics of child dental neglect: a systematic review. J Dent. 2014;42(3):229-39. DOI: 10.1016/j.jdent.2013.10.010.
https://doi.org/10.1016/j.jdent.2013.10....

10 Hornor G. Child neglect: Assessment and intervention. J Pediatr Health Care. 2014;28(2):186-92. DOI: 10.1016/j.pedhc.2013.10.002.
https://doi.org/10.1016/j.pedhc.2013.10....

11 Harris J. Dental neglect in children. Paediatr Child Health. 2012;22(11):476-82. DOI: 10.1016/j.paed.2012.06.005
https://doi.org/10.1016/j.paed.2012.06.0...

12 Kellogg N. Oral and dental aspects of child abuse and neglect. Pediatrics. 2005;116(6):1565-8. DOI: 10.1542/peds.2005-2315.
https://doi.org/10.1542/peds.2005-2315...

13 Montecchi PP, Di Trani M, Sarzi Amade D, Bufacchi C, Montecchi F, Polimeni A. The dentist’s role in recognizing childhood abuses: study on the dental health of children victims of abuse and witnesses to violence. Eur J Paediatr Dent. 2009;10(4):185-7.

14 Castellanos K, Gómez D, Florido R, Díaz N, Simancas Y. Hallazgos clínicos odontologicos en maltrato infantojuvenil en el departamento de odontologia forense del CICPC Merida-Venezuela. Acta Bioclinica. 2016;6(12):22-36.

15 Massoni AC de LT, Ferreira ÂMB, Aragão AKR, Menezes VA, Colares V. Aspectos orofaciais dos maus-tratos infantis e da negligência odontológica Orofacial aspects of childhood abuse and dental negligence. Cien Saude Colet. 2010;15(2):403-10. DOI: 10.1590/S1413-81232010000200016.
https://doi.org/10.1590/S1413-8123201000...

16 Acharya S, Pentapati KC, Bhat P V. Dental neglect and adverse birth outcomes: A validation and observational study. Int J Dent Hyg. 2013;11(2):91-8. DOI: 10.1111/idh.12001.
https://doi.org/10.1111/idh.12001...

17 Bradbury-Jones C, Innes N, Evans D, Ballantyne F, Taylor J. Dental neglect as a marker of broader neglect: a qualitative investigation of public health nurses’ assessments of oral health in preschool children. BMC Public Health. 2013;13:370. DOI: 10.1186/1471-2458-13-370
https://doi.org/10.1186/1471-2458-13-370...

18 Benedetti G, Stauf N, Strohmenger L, Campus G, Benzian H. Political priority of oral health in Italy: An analysis of reasons for national neglect. Int Dent J. 2015;65(2):89-95. DOI: 10.1111/idj.12144
https://doi.org/10.1111/idj.12144...

19 Tilvawala D, Murray C, Farah R, Broadbent JM. New Zealand dental therapists’ beliefs regarding child maltreatment. Aust N Z J Public Health. 2014;38(5):480-4. DOI: 10.1111/1753-6405.12238.
https://doi.org/10.1111/1753-6405.12238...

20 Cukovic-Bagic I, Dumancic J, Kujundzic Tiljak M, Drvaric I, Boric B, Kopic V, et al. Croatian dentists’ knowledge, experience, and attitudes in regard to child abuse and neglect. Int J Paediatr Dent. 2015;25(6):444-50. DOI: 10.1111/ipd.12151.
https://doi.org/10.1111/ipd.12151...

21 Scorca A, Santoro V, De Donno A, Grattagliano I, Tafuri S, Introna F. Early childhood caries (ECC) and neglect in child care: analysis of an Italian sample. Clin Ter. 2013;164(5):e365-71. DOI: 10.7417/CT.2013.1614.
https://doi.org/10.7417/CT.2013.1614...

22 Pandey V, Chandra S, Dilip Kumar HP, Gupta A, Bhandari PP, Rathod P. Impact of dental neglect score on oral health among patients receiving fixed orthodontic treatment: A cross-sectional study. J Int Soc Prev Community Dent. 2016;6(2):120-4. DOI: 10.4103/2231-0762.178752.
https://doi.org/10.4103/2231-0762.178752...

23 Ramazani N. Child Dental Neglect: A Short Review. Int J High Risk Behav Addict. 2014;3(4):e21861. DOI: 10.5812/ijhrba.21861.
https://doi.org/10.5812/ijhrba.21861...

24 Jacobi G, Dettmeyer R, Banaschak S, Brosig B, Herrmann B. Child abuse and neglect: diagnosis and management. Dtsch Arztebl Int. 2010;107(13):231-9; quiz 240. DOI: 10.3238/arztebl.2010.0231.
https://doi.org/10.3238/arztebl.2010.023...

25 Park C, Welbury R. Current and historical involvement of dentistry in child protection and a glimpse of the future. Oral Dis. 2016;22(7):605-8. DOI: 10.1111/odi.12485.
https://doi.org/10.1111/odi.12485...

26 Stevens CL. Is dental caries neglect? Br Dent J. 2014;217(9):499-500. DOI: 10.1038/sj.bdj.2014.950.
https://doi.org/10.1038/sj.bdj.2014.950...

27 Thomson WM, Spencer AJ, Gaughwin A. Testing a child dental neglect scale in South Australia. Community Dent Oral Epidemiol. 1996;24(5):351-6. DOI: 10.1111/j.1600-0528.1996.tb00875.x
https://doi.org/10.1111/j.1600-0528.1996...

28 Nuzzolese E, Lepore M, Montagna F, Marcario V, De Rosa S, Solarino B, et al. Child abuse and dental neglect: the dental team’s role in identification and prevention. Int J Dent Hyg. 2009;7(2):96-101. DOI: 10.1111/j.1601-5037.2008.00324.x
https://doi.org/10.1111/j.1601-5037.2008...
-2929 Cairns AM, Mok JYQ, Welbury RR. Injuries to the head, face, mouth and neck in physically abused children in a community setting. Int J Paediatr Dent. 2005;15(5):310-8. DOI: 10.1111/j.1365-263X.2005.00661.x
https://doi.org/10.1111/j.1365-263X.2005...
five were selected, four of which had a descriptive observational design1717 Bradbury-Jones C, Innes N, Evans D, Ballantyne F, Taylor J. Dental neglect as a marker of broader neglect: a qualitative investigation of public health nurses’ assessments of oral health in preschool children. BMC Public Health. 2013;13:370. DOI: 10.1186/1471-2458-13-370
https://doi.org/10.1186/1471-2458-13-370...
,1919 Tilvawala D, Murray C, Farah R, Broadbent JM. New Zealand dental therapists’ beliefs regarding child maltreatment. Aust N Z J Public Health. 2014;38(5):480-4. DOI: 10.1111/1753-6405.12238.
https://doi.org/10.1111/1753-6405.12238...
,2121 Scorca A, Santoro V, De Donno A, Grattagliano I, Tafuri S, Introna F. Early childhood caries (ECC) and neglect in child care: analysis of an Italian sample. Clin Ter. 2013;164(5):e365-71. DOI: 10.7417/CT.2013.1614.
https://doi.org/10.7417/CT.2013.1614...
,2727 Thomson WM, Spencer AJ, Gaughwin A. Testing a child dental neglect scale in South Australia. Community Dent Oral Epidemiol. 1996;24(5):351-6. DOI: 10.1111/j.1600-0528.1996.tb00875.x
https://doi.org/10.1111/j.1600-0528.1996...
and one had a case-control design;1313 Montecchi PP, Di Trani M, Sarzi Amade D, Bufacchi C, Montecchi F, Polimeni A. The dentist’s role in recognizing childhood abuses: study on the dental health of children victims of abuse and witnesses to violence. Eur J Paediatr Dent. 2009;10(4):185-7. all were focused on the theme of dental neglect in children. Three articles included children and their educators,2727 Thomson WM, Spencer AJ, Gaughwin A. Testing a child dental neglect scale in South Australia. Community Dent Oral Epidemiol. 1996;24(5):351-6. DOI: 10.1111/j.1600-0528.1996.tb00875.x
https://doi.org/10.1111/j.1600-0528.1996...
,2121 Scorca A, Santoro V, De Donno A, Grattagliano I, Tafuri S, Introna F. Early childhood caries (ECC) and neglect in child care: analysis of an Italian sample. Clin Ter. 2013;164(5):e365-71. DOI: 10.7417/CT.2013.1614.
https://doi.org/10.7417/CT.2013.1614...
,1313 Montecchi PP, Di Trani M, Sarzi Amade D, Bufacchi C, Montecchi F, Polimeni A. The dentist’s role in recognizing childhood abuses: study on the dental health of children victims of abuse and witnesses to violence. Eur J Paediatr Dent. 2009;10(4):185-7. one included dentists1919 Tilvawala D, Murray C, Farah R, Broadbent JM. New Zealand dental therapists’ beliefs regarding child maltreatment. Aust N Z J Public Health. 2014;38(5):480-4. DOI: 10.1111/1753-6405.12238.
https://doi.org/10.1111/1753-6405.12238...
and one included public health nurses.1717 Bradbury-Jones C, Innes N, Evans D, Ballantyne F, Taylor J. Dental neglect as a marker of broader neglect: a qualitative investigation of public health nurses’ assessments of oral health in preschool children. BMC Public Health. 2013;13:370. DOI: 10.1186/1471-2458-13-370
https://doi.org/10.1186/1471-2458-13-370...
In three articles, a questionnaire was used as a method of collecting data;1717 Bradbury-Jones C, Innes N, Evans D, Ballantyne F, Taylor J. Dental neglect as a marker of broader neglect: a qualitative investigation of public health nurses’ assessments of oral health in preschool children. BMC Public Health. 2013;13:370. DOI: 10.1186/1471-2458-13-370
https://doi.org/10.1186/1471-2458-13-370...
,1919 Tilvawala D, Murray C, Farah R, Broadbent JM. New Zealand dental therapists’ beliefs regarding child maltreatment. Aust N Z J Public Health. 2014;38(5):480-4. DOI: 10.1111/1753-6405.12238.
https://doi.org/10.1111/1753-6405.12238...
one used a clinical evaluation of children’s the oral cavity1313 Montecchi PP, Di Trani M, Sarzi Amade D, Bufacchi C, Montecchi F, Polimeni A. The dentist’s role in recognizing childhood abuses: study on the dental health of children victims of abuse and witnesses to violence. Eur J Paediatr Dent. 2009;10(4):185-7. and two combined these two methods of data collection.2121 Scorca A, Santoro V, De Donno A, Grattagliano I, Tafuri S, Introna F. Early childhood caries (ECC) and neglect in child care: analysis of an Italian sample. Clin Ter. 2013;164(5):e365-71. DOI: 10.7417/CT.2013.1614.
https://doi.org/10.7417/CT.2013.1614...
,2727 Thomson WM, Spencer AJ, Gaughwin A. Testing a child dental neglect scale in South Australia. Community Dent Oral Epidemiol. 1996;24(5):351-6. DOI: 10.1111/j.1600-0528.1996.tb00875.x
https://doi.org/10.1111/j.1600-0528.1996...

Table 1
Articles general information and selection procedure

It is difficult to enumerate the exact indicators of dental neglect, however, the articles that were selected1313 Montecchi PP, Di Trani M, Sarzi Amade D, Bufacchi C, Montecchi F, Polimeni A. The dentist’s role in recognizing childhood abuses: study on the dental health of children victims of abuse and witnesses to violence. Eur J Paediatr Dent. 2009;10(4):185-7.,1717 Bradbury-Jones C, Innes N, Evans D, Ballantyne F, Taylor J. Dental neglect as a marker of broader neglect: a qualitative investigation of public health nurses’ assessments of oral health in preschool children. BMC Public Health. 2013;13:370. DOI: 10.1186/1471-2458-13-370
https://doi.org/10.1186/1471-2458-13-370...
,1919 Tilvawala D, Murray C, Farah R, Broadbent JM. New Zealand dental therapists’ beliefs regarding child maltreatment. Aust N Z J Public Health. 2014;38(5):480-4. DOI: 10.1111/1753-6405.12238.
https://doi.org/10.1111/1753-6405.12238...
,2121 Scorca A, Santoro V, De Donno A, Grattagliano I, Tafuri S, Introna F. Early childhood caries (ECC) and neglect in child care: analysis of an Italian sample. Clin Ter. 2013;164(5):e365-71. DOI: 10.7417/CT.2013.1614.
https://doi.org/10.7417/CT.2013.1614...
,2727 Thomson WM, Spencer AJ, Gaughwin A. Testing a child dental neglect scale in South Australia. Community Dent Oral Epidemiol. 1996;24(5):351-6. DOI: 10.1111/j.1600-0528.1996.tb00875.x
https://doi.org/10.1111/j.1600-0528.1996...
reveal signs that raise a suspicion of this condition. These signs were included in three groups: oral manifestations and clinical history of the child, social determinants of the child; parental characteristics.1717 Bradbury-Jones C, Innes N, Evans D, Ballantyne F, Taylor J. Dental neglect as a marker of broader neglect: a qualitative investigation of public health nurses’ assessments of oral health in preschool children. BMC Public Health. 2013;13:370. DOI: 10.1186/1471-2458-13-370
https://doi.org/10.1186/1471-2458-13-370...
,1919 Tilvawala D, Murray C, Farah R, Broadbent JM. New Zealand dental therapists’ beliefs regarding child maltreatment. Aust N Z J Public Health. 2014;38(5):480-4. DOI: 10.1111/1753-6405.12238.
https://doi.org/10.1111/1753-6405.12238...
The clinical history and oral manifestations of the included children were: the youngster (a) successively fails dental appointments;1919 Tilvawala D, Murray C, Farah R, Broadbent JM. New Zealand dental therapists’ beliefs regarding child maltreatment. Aust N Z J Public Health. 2014;38(5):480-4. DOI: 10.1111/1753-6405.12238.
https://doi.org/10.1111/1753-6405.12238...
(b) caries lesions; (c) manifests significant untreated orofacial pain after the educator has been informed by the health professional;1717 Bradbury-Jones C, Innes N, Evans D, Ballantyne F, Taylor J. Dental neglect as a marker of broader neglect: a qualitative investigation of public health nurses’ assessments of oral health in preschool children. BMC Public Health. 2013;13:370. DOI: 10.1186/1471-2458-13-370
https://doi.org/10.1186/1471-2458-13-370...
,1919 Tilvawala D, Murray C, Farah R, Broadbent JM. New Zealand dental therapists’ beliefs regarding child maltreatment. Aust N Z J Public Health. 2014;38(5):480-4. DOI: 10.1111/1753-6405.12238.
https://doi.org/10.1111/1753-6405.12238...
(d) presents with early childhood caries,2121 Scorca A, Santoro V, De Donno A, Grattagliano I, Tafuri S, Introna F. Early childhood caries (ECC) and neglect in child care: analysis of an Italian sample. Clin Ter. 2013;164(5):e365-71. DOI: 10.7417/CT.2013.1614.
https://doi.org/10.7417/CT.2013.1614...
bacterial plaque involving more than two thirds of the dental crown;1313 Montecchi PP, Di Trani M, Sarzi Amade D, Bufacchi C, Montecchi F, Polimeni A. The dentist’s role in recognizing childhood abuses: study on the dental health of children victims of abuse and witnesses to violence. Eur J Paediatr Dent. 2009;10(4):185-7. (e) has spontaneous gingival bleeding.1313 Montecchi PP, Di Trani M, Sarzi Amade D, Bufacchi C, Montecchi F, Polimeni A. The dentist’s role in recognizing childhood abuses: study on the dental health of children victims of abuse and witnesses to violence. Eur J Paediatr Dent. 2009;10(4):185-7. The social determinants of the child that may be suffering from dental neglect include (i) single parent families; (ii) families living in the street or in precarious home; (iii) situations of domestic abuse;1717 Bradbury-Jones C, Innes N, Evans D, Ballantyne F, Taylor J. Dental neglect as a marker of broader neglect: a qualitative investigation of public health nurses’ assessments of oral health in preschool children. BMC Public Health. 2013;13:370. DOI: 10.1186/1471-2458-13-370
https://doi.org/10.1186/1471-2458-13-370...
(iv) low-income families.2121 Scorca A, Santoro V, De Donno A, Grattagliano I, Tafuri S, Introna F. Early childhood caries (ECC) and neglect in child care: analysis of an Italian sample. Clin Ter. 2013;164(5):e365-71. DOI: 10.7417/CT.2013.1614.
https://doi.org/10.7417/CT.2013.1614...
,2727 Thomson WM, Spencer AJ, Gaughwin A. Testing a child dental neglect scale in South Australia. Community Dent Oral Epidemiol. 1996;24(5):351-6. DOI: 10.1111/j.1600-0528.1996.tb00875.x
https://doi.org/10.1111/j.1600-0528.1996...
Parental characteristics include: (A) parental history of substance misuse,1717 Bradbury-Jones C, Innes N, Evans D, Ballantyne F, Taylor J. Dental neglect as a marker of broader neglect: a qualitative investigation of public health nurses’ assessments of oral health in preschool children. BMC Public Health. 2013;13:370. DOI: 10.1186/1471-2458-13-370
https://doi.org/10.1186/1471-2458-13-370...
(B) oral health quality among child’s educators, (C) parents who do not routinely visit the dentist or do not attend regular dental visits1717 Bradbury-Jones C, Innes N, Evans D, Ballantyne F, Taylor J. Dental neglect as a marker of broader neglect: a qualitative investigation of public health nurses’ assessments of oral health in preschool children. BMC Public Health. 2013;13:370. DOI: 10.1186/1471-2458-13-370
https://doi.org/10.1186/1471-2458-13-370...
,2727 Thomson WM, Spencer AJ, Gaughwin A. Testing a child dental neglect scale in South Australia. Community Dent Oral Epidemiol. 1996;24(5):351-6. DOI: 10.1111/j.1600-0528.1996.tb00875.x
https://doi.org/10.1111/j.1600-0528.1996...
and (D) low level of parental schooling.2727 Thomson WM, Spencer AJ, Gaughwin A. Testing a child dental neglect scale in South Australia. Community Dent Oral Epidemiol. 1996;24(5):351-6. DOI: 10.1111/j.1600-0528.1996.tb00875.x
https://doi.org/10.1111/j.1600-0528.1996...

DISCUSSION

Oral manifestations and Clinical history of the child

In general, more than half of child’s abuse signs occur in head and neck areas.1515 Massoni AC de LT, Ferreira ÂMB, Aragão AKR, Menezes VA, Colares V. Aspectos orofaciais dos maus-tratos infantis e da negligência odontológica Orofacial aspects of childhood abuse and dental negligence. Cien Saude Colet. 2010;15(2):403-10. DOI: 10.1590/S1413-81232010000200016.
https://doi.org/10.1590/S1413-8123201000...
Thus, it is important to carefully evaluate perioral and intraoral regions in such cases where abuse or neglect is suspected. Statistically, there are groups with a higher risk of maltreatment and neglect, such as pre-school children.1212 Kellogg N. Oral and dental aspects of child abuse and neglect. Pediatrics. 2005;116(6):1565-8. DOI: 10.1542/peds.2005-2315.
https://doi.org/10.1542/peds.2005-2315...
,1515 Massoni AC de LT, Ferreira ÂMB, Aragão AKR, Menezes VA, Colares V. Aspectos orofaciais dos maus-tratos infantis e da negligência odontológica Orofacial aspects of childhood abuse and dental negligence. Cien Saude Colet. 2010;15(2):403-10. DOI: 10.1590/S1413-81232010000200016.
https://doi.org/10.1590/S1413-8123201000...
,2727 Thomson WM, Spencer AJ, Gaughwin A. Testing a child dental neglect scale in South Australia. Community Dent Oral Epidemiol. 1996;24(5):351-6. DOI: 10.1111/j.1600-0528.1996.tb00875.x
https://doi.org/10.1111/j.1600-0528.1996...
,2828 Nuzzolese E, Lepore M, Montagna F, Marcario V, De Rosa S, Solarino B, et al. Child abuse and dental neglect: the dental team’s role in identification and prevention. Int J Dent Hyg. 2009;7(2):96-101. DOI: 10.1111/j.1601-5037.2008.00324.x
https://doi.org/10.1111/j.1601-5037.2008...

Early childhood caries has been shown to be one of the parameters that allow us to suspect dental neglect. Figure 1 illustrates this point. However, the existence of caries lesions alone cannot be defined as an act of neglect, although this is an important finding in such cases.66 Direção Geral da Saúde. Estudo Nacional de Prevalência das Doenças Orais. 2008.,1515 Massoni AC de LT, Ferreira ÂMB, Aragão AKR, Menezes VA, Colares V. Aspectos orofaciais dos maus-tratos infantis e da negligência odontológica Orofacial aspects of childhood abuse and dental negligence. Cien Saude Colet. 2010;15(2):403-10. DOI: 10.1590/S1413-81232010000200016.
https://doi.org/10.1590/S1413-8123201000...
,1717 Bradbury-Jones C, Innes N, Evans D, Ballantyne F, Taylor J. Dental neglect as a marker of broader neglect: a qualitative investigation of public health nurses’ assessments of oral health in preschool children. BMC Public Health. 2013;13:370. DOI: 10.1186/1471-2458-13-370
https://doi.org/10.1186/1471-2458-13-370...
,2121 Scorca A, Santoro V, De Donno A, Grattagliano I, Tafuri S, Introna F. Early childhood caries (ECC) and neglect in child care: analysis of an Italian sample. Clin Ter. 2013;164(5):e365-71. DOI: 10.7417/CT.2013.1614.
https://doi.org/10.7417/CT.2013.1614...
,2727 Thomson WM, Spencer AJ, Gaughwin A. Testing a child dental neglect scale in South Australia. Community Dent Oral Epidemiol. 1996;24(5):351-6. DOI: 10.1111/j.1600-0528.1996.tb00875.x
https://doi.org/10.1111/j.1600-0528.1996...
Through the clinical evaluation of the child, the health professional is expected to be aware of multiple factors, and to keep an updated record, not only of caries lesions and untreated orofacial pain in the child, but also of the existence and extension of dental plaque and gingival bleeding.66 Direção Geral da Saúde. Estudo Nacional de Prevalência das Doenças Orais. 2008.,1717 Bradbury-Jones C, Innes N, Evans D, Ballantyne F, Taylor J. Dental neglect as a marker of broader neglect: a qualitative investigation of public health nurses’ assessments of oral health in preschool children. BMC Public Health. 2013;13:370. DOI: 10.1186/1471-2458-13-370
https://doi.org/10.1186/1471-2458-13-370...
,1919 Tilvawala D, Murray C, Farah R, Broadbent JM. New Zealand dental therapists’ beliefs regarding child maltreatment. Aust N Z J Public Health. 2014;38(5):480-4. DOI: 10.1111/1753-6405.12238.
https://doi.org/10.1111/1753-6405.12238...
These factors, associated with privation or delay in seeking dental treatment for significant trauma, failure to complete recommended treatment, and allowing the child’s oral health to deteriorate, are highlighted in a systematic review as defining recognizable characteristics of dental neglect.99 Bhatia SK, Maguire SA, Chadwick BL, Hunter ML, Harris JC, Tempest V, et al. Characteristics of child dental neglect: a systematic review. J Dent. 2014;42(3):229-39. DOI: 10.1016/j.jdent.2013.10.010.
https://doi.org/10.1016/j.jdent.2013.10....

Figure 1
Two 5-year-old children with early childhood caries, with a history of missing scheduled appointments.

Social Determinants of the Child

Dental neglect is strongly associated with family conditions; however, its social determinants such as low socioeconomic level, poor living conditions, single-parent family or history of domestic abuse have proved to be important data to be registered, in the case of suspicion.

Low family income is an important health indicator, associated with weaker oral health and less favorable attitudes regarding oral care, contributing to the development of caries since an early age.99 Bhatia SK, Maguire SA, Chadwick BL, Hunter ML, Harris JC, Tempest V, et al. Characteristics of child dental neglect: a systematic review. J Dent. 2014;42(3):229-39. DOI: 10.1016/j.jdent.2013.10.010.
https://doi.org/10.1016/j.jdent.2013.10....
,3030 Prabhu A, Rao AP, Reddy V, Ahamed SS, Muhammad S, Thayumanavan S. Parental knowledge of pre-school child oral health. J Community Health. 2013;38(5):880-4. DOI: 10.1007/s10900-013-9693-x
https://doi.org/10.1007/s10900-013-9693-...
Figure 2 illustrates the point. This is confirmed by analysis of some studies, showing a negative association with the socioeconomic level and the severity of early childhood caries, meaning that children with lower socioeconomic level have greater predisposition to develop severest lesions of early childhood caries.1717 Bradbury-Jones C, Innes N, Evans D, Ballantyne F, Taylor J. Dental neglect as a marker of broader neglect: a qualitative investigation of public health nurses’ assessments of oral health in preschool children. BMC Public Health. 2013;13:370. DOI: 10.1186/1471-2458-13-370
https://doi.org/10.1186/1471-2458-13-370...
,2121 Scorca A, Santoro V, De Donno A, Grattagliano I, Tafuri S, Introna F. Early childhood caries (ECC) and neglect in child care: analysis of an Italian sample. Clin Ter. 2013;164(5):e365-71. DOI: 10.7417/CT.2013.1614.
https://doi.org/10.7417/CT.2013.1614...

Figure 2
Spontaneous gingival bleeding, gingival pain and multiple caries lesions in a young patient with low family income.

Also, the number of educators within the family seems to influence the probability of dental neglect. Children that belong to single-parent families appear to be at greater risk of being neglected than two-parent families, since the single educator will probably have less resources (time and money) to devote to their child’s healthcare.2727 Thomson WM, Spencer AJ, Gaughwin A. Testing a child dental neglect scale in South Australia. Community Dent Oral Epidemiol. 1996;24(5):351-6. DOI: 10.1111/j.1600-0528.1996.tb00875.x
https://doi.org/10.1111/j.1600-0528.1996...
,3131 Berger LM. Income, family structure, and child maltreatment risk. Child Youth Serv Rev. 2004;26(8):725-48. DOI: 10.1016/j.childyouth.2004.02.017
https://doi.org/10.1016/j.childyouth.200...

Predictably, reports indicate that when a child lives in poorer conditions, especially when he or she lives in a precarious home or on the street, they tend to have irregular practices in their oral health.3232 Castilho AR, Mialhe FL, Barbosa TDS, Puppin-Rontani RM. Influence of family environment on children’s oral health: a systematic review. J Pediatr (Rio J). 2013;89(2):116-23. DOI: 10.1016/j.jped.2013.03.014.
https://doi.org/10.1016/j.jped.2013.03.0...

33 Peterson-Sweeney K, Stevens J. Optimizing the health of infants and children: their oral health counts! J Pediatr Nurs. 2010;25(4):244-9. DOI: 10.1016/j.pedn.2009.03.003.
https://doi.org/10.1016/j.pedn.2009.03.0...
-3434 Kaur H, Chaudhary S, Choudhary N, Manuja N, Chaitra TR, Amit SA. Child abuse: Cross-sectional survey of general dentists. J Oral Biol Craniofacial Res. 2016;6(2):118-23. DOI: 10.1016/j.jobcr.2015.08.002.
https://doi.org/10.1016/j.jobcr.2015.08....
Thus, their medical record should contain this information, not only for tighter control of the child’s oral health, but also (if the case is not already under surveillance) for signaling the case to social services.1717 Bradbury-Jones C, Innes N, Evans D, Ballantyne F, Taylor J. Dental neglect as a marker of broader neglect: a qualitative investigation of public health nurses’ assessments of oral health in preschool children. BMC Public Health. 2013;13:370. DOI: 10.1186/1471-2458-13-370
https://doi.org/10.1186/1471-2458-13-370...
,3232 Castilho AR, Mialhe FL, Barbosa TDS, Puppin-Rontani RM. Influence of family environment on children’s oral health: a systematic review. J Pediatr (Rio J). 2013;89(2):116-23. DOI: 10.1016/j.jped.2013.03.014.
https://doi.org/10.1016/j.jped.2013.03.0...

Family violence, or a previous history of violence, is a contributory factor to child neglect in general.2828 Nuzzolese E, Lepore M, Montagna F, Marcario V, De Rosa S, Solarino B, et al. Child abuse and dental neglect: the dental team’s role in identification and prevention. Int J Dent Hyg. 2009;7(2):96-101. DOI: 10.1111/j.1601-5037.2008.00324.x
https://doi.org/10.1111/j.1601-5037.2008...
A qualitative study performed by public health nurses revealed that a history of domestic abuse was one of the most telling warning signs in cases where dental negligence was suspected.1717 Bradbury-Jones C, Innes N, Evans D, Ballantyne F, Taylor J. Dental neglect as a marker of broader neglect: a qualitative investigation of public health nurses’ assessments of oral health in preschool children. BMC Public Health. 2013;13:370. DOI: 10.1186/1471-2458-13-370
https://doi.org/10.1186/1471-2458-13-370...
However, most children that attend dental offices do not appear referenced with a history of violence/family abuse, so it is up to the dentist to have the appropriate sensitivity and training to identify, record and report these cases.2828 Nuzzolese E, Lepore M, Montagna F, Marcario V, De Rosa S, Solarino B, et al. Child abuse and dental neglect: the dental team’s role in identification and prevention. Int J Dent Hyg. 2009;7(2):96-101. DOI: 10.1111/j.1601-5037.2008.00324.x
https://doi.org/10.1111/j.1601-5037.2008...

Parental Characteristics

Scientifically, the strong influence that parents have in their children’s oral health is well evidenced.88 Hooley M, Skouteris H, Boganin C, Satur J, Kilpatrick N. Parental influence and the development of dental caries in children aged 0-6 years: A systematic review of the literature. J Dent. 2012;40(11):873-85. DOI: 10.1016/j.jdent.2012.07.013.
https://doi.org/10.1016/j.jdent.2012.07....
They are responsible, not only for making the child attend dentist appointments, but also for teaching and maintaining everyday habit routines that ensure good oral health.88 Hooley M, Skouteris H, Boganin C, Satur J, Kilpatrick N. Parental influence and the development of dental caries in children aged 0-6 years: A systematic review of the literature. J Dent. 2012;40(11):873-85. DOI: 10.1016/j.jdent.2012.07.013.
https://doi.org/10.1016/j.jdent.2012.07....
,1111 Harris J. Dental neglect in children. Paediatr Child Health. 2012;22(11):476-82. DOI: 10.1016/j.paed.2012.06.005
https://doi.org/10.1016/j.paed.2012.06.0...
,2828 Nuzzolese E, Lepore M, Montagna F, Marcario V, De Rosa S, Solarino B, et al. Child abuse and dental neglect: the dental team’s role in identification and prevention. Int J Dent Hyg. 2009;7(2):96-101. DOI: 10.1111/j.1601-5037.2008.00324.x
https://doi.org/10.1111/j.1601-5037.2008...
Thus, in the face of the suspicion of dental neglect, it is mandatory that the oral health professional should also consider the attitudes and the oral health of the educator. The analyzed studies reveal that the quality of parents’ oral health, and the failure to attend their regular dental appointments, are also associated with dental neglect of their children.1717 Bradbury-Jones C, Innes N, Evans D, Ballantyne F, Taylor J. Dental neglect as a marker of broader neglect: a qualitative investigation of public health nurses’ assessments of oral health in preschool children. BMC Public Health. 2013;13:370. DOI: 10.1186/1471-2458-13-370
https://doi.org/10.1186/1471-2458-13-370...
,2727 Thomson WM, Spencer AJ, Gaughwin A. Testing a child dental neglect scale in South Australia. Community Dent Oral Epidemiol. 1996;24(5):351-6. DOI: 10.1111/j.1600-0528.1996.tb00875.x
https://doi.org/10.1111/j.1600-0528.1996...
When the oral health is neglected by the parent, such neglect is likely to be a predictor of caries for their children, since it is within the family that the child adopts habits that will define his/her behavior towards oral health; this is especially true with respect to mothers’ attitudes.3535 Mezzich AC, Bretz WA, Day B-S, Corby PM, Kirisci L, Swaney M, et al. Child neglect and oral health problems in offspring of substance-abusing fathers. Am J Addict. 2007;16(5):397-402. DOI: 10.1080/10550490701525509
https://doi.org/10.1080/1055049070152550...
Additionally, the importance of oral health among parents, and their education level are factors to consider when suspecting dental neglect. The health professional should consider the educator’s degree of perception regarding his child’s oral health, and if required, attempt to increase his knowledge.99 Bhatia SK, Maguire SA, Chadwick BL, Hunter ML, Harris JC, Tempest V, et al. Characteristics of child dental neglect: a systematic review. J Dent. 2014;42(3):229-39. DOI: 10.1016/j.jdent.2013.10.010.
https://doi.org/10.1016/j.jdent.2013.10....
,2323 Ramazani N. Child Dental Neglect: A Short Review. Int J High Risk Behav Addict. 2014;3(4):e21861. DOI: 10.5812/ijhrba.21861.
https://doi.org/10.5812/ijhrba.21861...
However, through the analysis of a systematic review, we verified that mothers of children from ethnic minorities present greater difficulties in communication and lower levels of schooling, which may result in worse oral health conditions. This should be considered by the health professional when collecting information.3232 Castilho AR, Mialhe FL, Barbosa TDS, Puppin-Rontani RM. Influence of family environment on children’s oral health: a systematic review. J Pediatr (Rio J). 2013;89(2):116-23. DOI: 10.1016/j.jped.2013.03.014.
https://doi.org/10.1016/j.jped.2013.03.0...
Parental education level can determine the ease of increasing oral health knowledge and is considered a determinant factor in dental neglect, in which, once again, it is the maternal figure who has the greatest influence.2727 Thomson WM, Spencer AJ, Gaughwin A. Testing a child dental neglect scale in South Australia. Community Dent Oral Epidemiol. 1996;24(5):351-6. DOI: 10.1111/j.1600-0528.1996.tb00875.x
https://doi.org/10.1111/j.1600-0528.1996...
Education level is associated with employability, social status, income and resource accessibility, being the main predictor of a series of risk factors for oral health.88 Hooley M, Skouteris H, Boganin C, Satur J, Kilpatrick N. Parental influence and the development of dental caries in children aged 0-6 years: A systematic review of the literature. J Dent. 2012;40(11):873-85. DOI: 10.1016/j.jdent.2012.07.013.
https://doi.org/10.1016/j.jdent.2012.07....
Likewise, the studies analyzed indicate that children belonging to families with low level of education, are more likely to have their oral health neglected.2727 Thomson WM, Spencer AJ, Gaughwin A. Testing a child dental neglect scale in South Australia. Community Dent Oral Epidemiol. 1996;24(5):351-6. DOI: 10.1111/j.1600-0528.1996.tb00875.x
https://doi.org/10.1111/j.1600-0528.1996...
This condition also occurs when educators have a history of substance misuse. Children with this parental history are more likely to be neglected, and tend to present high rates of dental trauma, gingival bleeding, caries lesions and orofacial infections, as exemplified in Figure 3. Therefore, this should be an evidence to consider when suspecting dental neglect.1717 Bradbury-Jones C, Innes N, Evans D, Ballantyne F, Taylor J. Dental neglect as a marker of broader neglect: a qualitative investigation of public health nurses’ assessments of oral health in preschool children. BMC Public Health. 2013;13:370. DOI: 10.1186/1471-2458-13-370
https://doi.org/10.1186/1471-2458-13-370...
,3535 Mezzich AC, Bretz WA, Day B-S, Corby PM, Kirisci L, Swaney M, et al. Child neglect and oral health problems in offspring of substance-abusing fathers. Am J Addict. 2007;16(5):397-402. DOI: 10.1080/10550490701525509
https://doi.org/10.1080/1055049070152550...

Figure 3
Multiple and extensive caries lesions with orofacial pain, and abundant bioflm in a 10-year-old child whose educators have a history of substance abuse.

SUMMARY

Although dental neglect in children is included in the cases in which the health professional has an obligation to report, many do not do so, because of their doubts regarding the diagnosis. In addition to the undeniable reduction in quality of life and the imminent risks to the child’s overall health, the confirmation of dental neglect allows us to suspect the occurrence of neglect in a generalized way.

Dental neglect may appear associated with a wide range of signs such as: chronic orofacial pain, trauma of the orofacial region, untreated caries, unfinished dental care despite caregivers being informed of the need, repeated orofacial infections and orofacial edema due to dental abscesses or cellulitis. Consequently, there is an enormous potential for the creation of health professional teams in which dentists are essential.

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    Mezzich AC, Bretz WA, Day B-S, Corby PM, Kirisci L, Swaney M, et al. Child neglect and oral health problems in offspring of substance-abusing fathers. Am J Addict. 2007;16(5):397-402. DOI: 10.1080/10550490701525509
    » https://doi.org/10.1080/10550490701525509

Publication Dates

  • Publication in this collection
    May-Jun 2017

History

  • Received
    19 May 2017
  • Accepted
    04 June 2017
  • Accepted
    16 June 2017
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