Module 3: Oral Health Supervision
Special Care- Oral Health Supervision

3.4 Child Abuse and Neglect

CSHCN are more likely to be victims of physical abuse, neglect, and sexual abuse compared to children without special health care needs. 1 CSHCN may be at higher risk because parents may become overwhelmed by their responsibilities associated with caring for their child with special health care needs and also because CSHCN are more vulnerable than children in general. 2

Child Abuse

A careful and thorough intraoral and perioral examination is necessary in all cases of suspected child abuse and neglect. Oral injuries may be inflicted with instruments such as eating utensils or bottles during forced feedings, hands, fingers, scalding liquids, or caustic substances. The abuse may result in contusions, burns, or lacerations of the tongue, lips, buccal mucosa, palate (soft and hard), gingivae, alveolar mucosa, or frenum; fractured, displaced, or avulsed teeth; or facial bone and jaw fractures. 3

Slap Marks to the Face

Slap Marks to the Face.*

Bite Marks of Human Origin

Bite Marks of Human Origin.*

 An Oral Condyloma, a Venereal Wart, Indicative of Sexual Abuse

An Oral Condyloma, a Venereal Wart, Indicative of Sexual Abuse.*

A Tooth Knocked Loose, Lacerations to the Lip, and Bruising of the Gums, Resulting from an Open-Handed Slap to the Face

A Tooth Knocked Loose, Lacerations to the Lip, and Bruising of the Gums, Resulting from an Open-Handed Slap to the Face.*

*Adapted, with permission, from Arkansas PANDA Coalition. N.d. PANDA Prevent Abuse and Neglect Though Dental Awareness [PowerPoint presentation]. Little Rock, AR: Arkansas PANDA Coalition.

Although children are frequently injured while playing, there are some clues that can help to differentiate between injuries resulting from play and those resulting from abuse. Injuries resulting from abuse are more likely to be located on the buttocks and lower back, genitals and inner thighs, cheeks, ears, lips and labial frenum, and neck. In addition, injuries from play tend to heal all at the same time, whereas injuries from abuse are often in various stages of healing.

Trauma in children is often caused by an adult violently striking the child’s lips and teeth with the back of the hand or with an implement. Because children communicate through the mouth, child abuse is often directed at the mouth. Dental trauma may be an important marker for child abuse because craniofacial, head, face, and neck injuries occur in more than half of the cases of child abuse. 4

Dento-facial trauma may be manifested as avulsed teeth, non-vital teeth, lip laceration, tongue injuries, frenum injuries, or jaw fractures. Injuries to the face can be in various forms, including contusions and echymoses, abrasions and lacerations, burns, bites, and fractures.

Sexual abuse can be manifested as oral lesions from a sexually transmitted disease or as bruising and petechia of the palate from oral sex.

Fact

Prevent Abuse and Neglect through Dental Awareness (PANDA) coalitions were started in some states to address a lack of child abuse and neglect reporting by oral health professionals. PANDA offers online and in-person educational programs that address topics such as family violence, clinical examples of abuse and neglect, and legal and liability issues involved in family violence interventions.

While child abuse may be identified by the nature and frequency of injuries, dental neglect is more elusive.

Neglect

Untreated Rampant Caries, Indicative of Dental Neglect.*
 Untreated Rampant Caries,
 Indicative of Dental Neglect.*

Dental neglect, which is one type of general neglect, can lead to pain, poor growth, and impaired quality of life. Identifying dental neglect is challenging, which results in a reluctance to report suspected cases. Features of dental neglect include failure or delay in seeking care for significant dental caries or trauma, failure to complete a recommended course of treatment, and permitting the child’s oral health to deteriorate when these things could be avoided.

Recognizing dental neglect is important because, in many cases, it is associated with general neglect. One reason for dental neglect is that many parents are under the false impression that the primary teeth are unimportant and that their care may be ignored. The ability to pay for treatment may influence the decision to seek care. Nevertheless, it is a mistake to confuse intentional neglect with poverty or ignorance.

*Adapted, with permission, from Arkansas PANDA Coalition. N.d. PANDA Prevent Abuse and Neglect Though Dental Awareness [PowerPoint presentation]. Little Rock, AR: Arkansas PANDA Coalition.

Documenting and Reporting Suspected Abuse or Neglect

Oral health professionals should document oral health history, clinical findings, and recommended follow-up in the child’s health record. In most states, the District of Columbia, and U.S. jurisdictions, oral health professionals are required to report suspected child abuse and/or neglect.

If child abuse and/or neglect are suspected, the first step an oral health professional should take is to call the state child protective services agency. This is required by law. (Search Google for “state child abuse reporting numbers” to find the appropriate phone number.) The agency will investigate whether abuse is occurring.6 In some cases, the oral health professional may choose to hold a confidential consultation with the child’s primary care health professional to determine whether a report needs to be made. Case managers or social services workers can be particularly helpful in recognizing and managing suspected dental abuse or neglect.

Each state is responsible for providing its own definitions of child abuse and neglect that meet federal minimum standards found in the Child Abuse Prevention and Treatment Act. The Child Welfare Information Gateway offers training on the identification of child abuse and neglect and an array of information related to state statues on child abuse and neglect. Assistance is also available from the Childhelp USA National Child Abuse Hotline at (800)-A-CHILD ((800) 422-4453).

Fact

Physical abuse, sexual abuse, and dental neglect can be manifested on the face or in the mouth. 5