___________________________________ DCA06DT Dental Treatment of Pediatric and Adolescent Patients
This is a moral and ethical obligation, as all states require den- tists to report suspected cases of child abuse to the appropriate social service or law enforcement agencies. Many cases of child abuse go unreported, so it is difficult to determine the exact number of children affected by physical, emotional, and psychologic abuse. According to the U.S. Department of Health and Human Services, the rate of child abuse and neglect was 7.4 per 1,000 children in 2023 [29]. Neglect represented the most frequent type of abuse, occur- ring in 76.1% of victims; physical abuse occurred in 16.5% of victims. Dental professionals are often the practitioners who have the most frequent interactions with children and therefore must be attentive to any signs of physical abuse, as abusive injuries to children often involve the face, jaw, mouth, teeth, and tongue [13]. Studies indicate that more than half of abused children have visible injuries to the head, face, neck, and intraoral regions [49]. Child abuse should be considered as a potential source for injuries that are inconsistent with an explanation as to their origin, when several injuries in various stages of healing are present, when children or adolescents appear reluctant or fearful to discuss their injuries, and if parents or guardians appear evasive or defensive when they are questioned about the origin of the child’s injuries. While there is no single injury to the head, neck, oral, or peri- oral region that is absolutely indicative of child abuse, some injuries and patterns should be viewed with more suspicion than others. Injuries or bruises in the shape of a distinguish- able object, such as a belt buckle, strap, rope, electrical cord, clothes iron, or hand, are cause for concern [49]. The cheeks and lips are the most common site of intentionally inflicted injuries in the oral and perioral region, with injuries to the oral mucosa, teeth, gingival tissues, and tongue following behind [49; 50]. Beyond the oral and perioral region, the neck should be included as a part of the comprehensive examination of the child. Bilateral bruise marks or rope burns on the neck may be the result of an attempt to strangle the child; bilateral bruising on a child’s arms may be indicative of shaking injury. Bruising and lacerations of the ears and the adjacent skin may be related to abuse; bilateral lesions and traumatic injuries to the ears are rarely accidental in nature. However, this may not be easily visible if hair extends over the ears. Hematomas within the oral cavity and in the perioral area can develop if a child is struck by a hand or a blunt object. Fractures or loss of multiple permanent or deciduous teeth may be the result of being slapped, punched, or struck. Child sexual abuse may also have oral and perioral manifesta- tions. Venereal warts ( Condyloma acuminatum ) from HPV infec- tion are suspicious for sexual abuse when they occur in a child’s oral cavity, but HPV can also be transmitted in non-sexual ways (e.g., during birth, autoinoculation from cutaneous lesions, fomites, breastfeeding, bathing) [49; 87]. Oral HPV has also been detected in newborns delivered via caesarean, indicating possible transmission through the placenta or amniotic fluid [87]. These warts appear as cauliflower-like lesions on the lips,
palate, and tongue. Forced oral-genital contact can also produce bruising and petechiae (i.e., small foci of hemorrhagic areas caused by trauma to and the rupture of small blood vessels); this most frequently occurs in the area of the soft palate [49]. REPORTING In many states, dental professionals are legally required or mandated to report any suspected cases of child abuse, maltreat- ment, and/or neglect that they encounter in their professional roles. However, studies have shown that many professionals who are mandated to report child abuse and neglect are con- cerned and/or anxious about reporting. Identified barriers to reporting include [51; 52; 53]: • Professionals may not feel skilled in their knowledge base about child abuse and neglect. In addition, they lack the confidence to identify sexual and emotional abuse. • Professionals may be frustrated with how little they can do about poverty, unemployment, drug use, and the intergenerational nature of abuse. • Although professionals understand their legal obligation, they may still feel that they are violating patient confidentiality. • Many professionals are skeptical about the effectiveness of reporting child abuse cases given the bureaucracy of Child Protective Services (CPS) and the large caseloads. • Practitioners may be concerned that they do not have adequate or sufficient evidence of child abuse. • Practitioners may have a belief that government entities do not have the right to get involved in matters within the family arena. • There may be some confusion and emotional distress in the reporting process. The failure to identify and report child abuse may result in continued abuse of the child and potentially severe conse- quences. Improved and ongoing education about child abuse and maltreatment has been shown to improve identification and reporting rates among dental professionals. The education should include [54]: • Management and outcomes • The role of the CPS investigator • The role of the physician/other reporting professional • The benefits of CPS involvement • The benefits of mandated education on identification/reporting • The benefits of professional debriefing for the reporter • The benefits of collaboration (e.g., with local emergency departments, pediatric specialists)
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