|Year : 2013 | Volume
| Issue : 2 | Page : 64-68
Harbingers of child abuse: A complex healthcare issue for dentistry
Amandeep Chopra, Nidhi Gupta, Nanak Chand Rao, Shelja Vashisth
Department of Public Health Dentistry, Swami Devi Dyal Hospital and Dental College, Golpura, Barwala, Panchkula, Haryana, India
|Date of Web Publication||22-Oct-2013|
Department of Public Health Dentistry, Swami Devi Dyal Hospital and Dental College, Golpura, Barwala, Panchkula, Haryana
Child abuse or maltreatment constitutes all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child's health, survival, development or dignity in the context of a relationship of responsibility, trust or power. It permeates all ethnic, cultural and socio-economic segments of our society. Child abuse is a vicious cycle in which victims are at higher risk of becoming abusive parent repeating their childhood experiences. Studies have shown that approximately 60-75% of abused children have injuries to the head, face and mouth. Dentists are in the unique position to be able to diagnose these cases. The complete information about child abuse has been collected from various journals, books, online databases and various reports from international conferences for the time period of 1988-2012. This article presents an overview of child abuse, its types, identification and reporting of cases of abuse.
Keywords: Child abuse, dentists, maltreatment, neglect
|How to cite this article:|
Chopra A, Gupta N, Rao NC, Vashisth S. Harbingers of child abuse: A complex healthcare issue for dentistry. SRM J Res Dent Sci 2013;4:64-8
|How to cite this URL:|
Chopra A, Gupta N, Rao NC, Vashisth S. Harbingers of child abuse: A complex healthcare issue for dentistry. SRM J Res Dent Sci [serial online] 2013 [cited 2019 Nov 14];4:64-8. Available from: http://www.srmjrds.in/text.asp?2013/4/2/64/120180
| Introduction|| |
"Somewhere in the world a child is suffering deliberate harm, inflicted by someone who is supposed to care about them, at this very moment."
-J. Hinchliffe 
Child abuse and neglect (maltreatment) are a widespread problem that permeates all ethnic, cultural and socio-economic segments of our society. , Child abuse has been defined as mistreatment by a parent, guardian, caregiver or other person in a position of trust that results in injury or significant emotional or psychological harm to the child. 
Manifestations and extent of child abuse are painful and damaging.  Child abuse is a vicious cycle in which victims are at higher risk of becoming abusive parent repeating their childhood experiences.  Abused child often experience more social problems and perform less well in school. , According to World Health Organization (WHO): "Child abuse or maltreatment constitutes all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child's health, survival, development or dignity in the context of a relationship of responsibility, trust or power." 
Studies have shown that approximately 60-75% of abused children have injuries to the head, face and mouth. Dentists are in the unique position to be able to diagnose these cases. ,, Furthermore, it has been found out that the dentist and dental auxiliaries have regular contact with children and their families giving them opportunity to observe not only the physical and the psychological condition of the children, but also the family environment. 
In this review, literature was searched for various types of child abuse; their prevalence and etiology; role of the dental team in identifying child abuse. The complete information about child abuse has been collected from various journals, books, online databases and various reports from international conferences for the time period of 1984-2012. Finally, reporting and documentation of child abuse are being discussed.
| Types of Abuse|| |
- Physical abuse means any force or action that exceeds the force considered reasonable for disciplining a child and that results in non-accidental injury. . This may include burning, hitting, punching, shaking, kicking, beating or otherwise harming a child. There may be single or repeated incidents. ,
- Sexual abuse involves any sexual exploitation (non-consensual or consensual) including, but not limited to, intercourse, oral sex and fondling committed by a person responsible for the care of a child or related to the child. If a stranger commits these acts, it would be considered sexual assault and handled solely by the police and criminal courts. ,,
- Emotional abuse is also known as verbal abuse, mental abuse and psychological maltreatment. This includes acts of commission or omission by a parent that may lead to long-term and serious emotional disorders.  Examples include social isolation, rejection, humiliation and placing unrealistic demands on a child. 
- Neglect occurs when parents don't provide the requisites necessary for the child's emotional, psychological and physical development.  Emotional neglect involves the absence of feeling of being loved, safe and worthy. Physical neglect involves lack of proper nutrition, shelter, clothing, medical care and protection from harm. Psychological neglect includes the lack of any emotional support and love, never attending to the child, substance abuse including allowing the child to participate in drug and alcohol use. 
| Prevalence of Child Abuse|| |
WHO estimated that around 40 million children between 0 and 14 years of age suffer from abuse or neglect and require health or social care.  In United States it is estimated that in 6 million children were involved in 3.3 million child abuse reports and allegations. A report of child abuse is made every 10 s. Almost five children die every day as a result of child abuse. , In Europe, its prevalence varies from 5 to 30 cases/1,000 children annually, depending on the social background of the country. In Italy, there are an estimated 42,000 cases and child abuse and neglect growth forecast is about 8,100 new cases a year. ,,
Statistics reveal that magnitude of child abuse is common in India, across all strata's of the society. Results from the National Study on Child Abuse, undertaken by the Ministry of Women and Child Development, Government of India (2007), suggest that two out of every three children were physically abused (88.6% by their parents), 53.2% children face one or more forms of sexual abuse and every second child reported facing emotional abuse (83% of the cases parents were the abusers). Most children don't report the matter to anyone. 
The true incidence and prevalence of abuse in any given country can't be determined as so many cases of child abuse are not reported and investigated or are simply not recognized. 
| Etiology of Child Abuse|| |
Child abuse is influenced by a large range of contributory factors, from the personal characteristics of the child and/or perpetrator, to their cultural and physical environments and the wider community and society.  Typical problems include financial stress, family separation, illness, substance abuse, unemployment and overcrowded housing. ,
Other risks and contributory factors include disabled children, youngest in a large family, premature babies, low birth weight babies, unwanted pregnancy, social isolation of families, parental history of domestic abuse, young single parent. ,,, Infants and young children are more likely to be abused because of their defenselessness, fragility, inability to escape from an angry parent and lack of social contacts to keep them away from the caretaker for periods of time.  Studies have shown that most children are abused by family members or adults that they know.  One parent may be the abuser while the other may hide the abuse. Most of the family members are of normal intellect and mental illness is rarely a factor. 
| Role of Dental Team|| |
"You may have the ability to save someone's life today. Most dental professionals probably never think about that as they enter their offices."
- Linda Blackiston 
Child abuse, long neglected by both society and medicine is now a focus of public attention.  All health professionals are legally mandated to report suspected cases of child maltreatment to the proper authorities, consistent with the laws of the jurisdiction in which they practice.  Dentists assess the head and neck routinely and have a great chance in identifying an abuse.  Dentist are expected to act responsible with regards to the protection of children from violence, which requires the dentist to recognize, record, report, and refer - the four Rs. - such practice.  However, dentists as a group, have been fairly inactive participants in recognizing and reporting child maltreatment when compared with other health professionals.  This can be attributed to lack of training and experience in identifying, limited knowledge on how to intervene effectively, concerns with confidentiality and disclosure, fear of litigation, fear of dealing with angry parents or of getting involved, embarrassment about bringing up the topic or fear of detrimental effects on the individual's practice by loss of patients. ,,,,,
| Identification of Child Abuse|| |
The ability to detect child abuse requires in-depth knowledge and skill.  Screening for abuse should be an integral part of any clinical examination performed on a child.  The various signs of child abuse includes:
Although many injuries are not caused by abuse, dentists should always be suspicious of traumatic injuries.
- Injury (including timing and mechanism) not consistent with the history/explanation given.
- Injury not consistent with age and stage of development of the child.
- Multiple injuries at various stages of healing.
- Trauma to non-exposed and non-prominent sites of the body.
- Evidence of previous bone fractures.
- Bilateral bruising not consistent with the history.
- Patterned injuries, for example bites, belt marks.
- Significant delay in the presentation for care.
- Caregivers don't interact with the child in an appropriate manner and vice versa.
- Untreated illness or injury.
- Consistently poor hygiene (unclean body and hair, dirty clothes).
- Disclosure by the child (or someone else). ,,,
| Identification: Physical Abuse|| |
Craniofacial, head, face and neck injuries occur in more than half of the cases of child abuse. There is a necessity of careful intraoral and perioral examination in suspected case of abuse.  Physical abuse, injuries often cause blunt trauma and are inflicted using an instrument (kitchen tools, hands, fingers) or scalding liquids and caustic substances.  The abuse may result in: contusions, burns or lacerations of the tongue, lips, buccal mucosa, palate (soft and hard), gingiva, alveolar mucosa or frenum.  Other clinical manifestations include fractured, displaced, or avulsed teeth; or facial bone and jaw fractures. Malocclusion may be a result of this type of injury. , Lips were the most common site for inflicted oral injuries (54%) followed by the oral mucosa, teeth, gingiva and tongue. 
Head injuries involve injuries on the scalp and hair (subdural hematomas, traumatic alopecia, subgaleal hematomas and bruises behind the ears), eyes (retinal hemorrhage, ptosis, and periorbital bruising), ears (bruising of the auricle and tympanic membrane damage), nose (nasal fractures or an injury resulting in clotted nostrils). 
Bite marks should be suspected when ecchymosed, abrasions or lacerations are found in an elliptical or ovoid pattern.  An area of hemorrhage, representing a "suck" or "thrust" mark, may be found between tooth marks, suggesting physical or sexual abuse. Bites produced by dogs and other carnivorous animals tend to tear the skin. Whereas, human bites compress flesh and can cause abrasions, contusions and lacerations but rarely avulsions of tissue.  Although marks may occur anywhere on a child's body, the most common sites are the cheeks, back, sides, arms, buttocks and genitalia. In suspected cases of bite mark photographic documentation of the injury (including use of a millimetric reference scale), saliva collection using the double-swab technique (even if cells have dried) and polyvinyl siloxane impression made immediately after swabbing the bite mark for secretions containing deoxyribonucleic acid. ,,
| Identification: Sexual Abuse|| |
The WHO reports that one out of every 10 children is sexually abused in India.  While dentists are not as involved as other health professionals in the diagnosis of sexual abuse, they should remain alert for the signs and symptoms of sexual abuse.  In sexual abuse, the presence of oral or perioral gonorrhea; syphilis (in prepubertal children) or herpes simplex is pathognomonic. Unexplained erythema or petechiae in the palate, especially at the junction of the hard and soft palate, can indicate forced oral sex, making the mouth the most frequent place where sexual abuse can be detected in children. Bite marks can also be a sign of both sexual and physical abuse.  If forced oral sex is suspected swabs should be used to swab the buccal mucosa and tongue, with the swabs preserved appropriately for laboratory analysis of the presence of semen. 
| Identification: Emotional Abuse|| |
Emotional abuse is the persistent emotional maltreatment of a child to cause severe and persistent adverse effects on the child's emotional development and wellbeing.  It may involve making the child feel worthless, ignoring, isolating, humiliating, frightening or shouting at the child.  Various indicators which help diagnose emotional abuse includes lack of self-esteem, poor social skills, often antisocial, developmentally delayed, passive and aggressive - behavioral extremes, have trouble in bonding and pronounced nervousness, often manifested in habit disorders such as sucking and rocking and self-inflict injuries such as lip or cheek biting. ,,
| Identification: Neglect|| |
Neglect includes depriving the child of food, shelter, clothing, adequate supervision or education and failing to protect the child from harm or danger. Interestingly, it may also apply to the failure to seek and access appropriate medical and dental care/treatment.  Dental neglect, as defined by the American Academy of Pediatric Dentistry is "the willful failure of a parent or guardian 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."  Dental neglect includes untreated rampant caries easily detected by a lay person, untreated pain, infection, bleeding, or trauma affecting the orofacial region or history of lack of continuity of care in the presence of identified dental pathology.  These undesirable outcomes can adversely affect learning, communication, nutrition and other activities necessary for normal growth and development. 
Failure to seek or obtain proper dental care may result from factors such as family isolation, lack of finances, parental ignorance, or lack of perceived value of oral health. 
It is the role of the dental team (along with the provision of appropriate treatment) to educate and encourage parents/caregivers to make the correct choices for their child and understand the benefits of regular dental visits, good oral hygiene, a balanced diet and fluoride toothpastes/varnishes. 
The point at which to consider a parent negligent and to begin intervention occurs after the parent has been properly alerted by a health care professional about the nature and extent of the child's condition, the specific treatment needed and the mechanism of accessing that treatment. 
| Reporting and Documentation|| |
Whenever suspicions of abuse arise, a routine protocol should be followed, which includes questions about patient history and how the accident occurred and all relevant information should be documented with radiographs, photographs and impressions when necessary. Photographs should include a ruler placed beside the injury to help record its size. ,,, Detailed written notes should be made in the dental chart with respect to the location, appearance, severity and distribution of the injuries.  Other Staff member should be present to act as a witness and assist in documentation.  In case of any doubt consultation with dental colleague, patient's physician, a social worker or local authorities is recommended and its record should be maintained.
In India, where there is the absence of mandatory reporting provisions and child protection services the reporting can be done to police, the local Child Welfare Committee and even to the child line. Under Juvenile Justice (Care and Protection) Act (JJ Act), 2000 (amended 2006) the Child Welfare Committee can declare any parent or guardian, who grossly abuses a child or fails to protect a child from being abused, as unfit persons and order for the removal of the child from the custody of such persons. The offences under this act are cognizable and the special police officer or any of his subordinate may arrest a person without a warrant and search the premises without a warrant.  Child abuse hotline number: 1-800-633-5155.
| Conclusion|| |
Child abuse can justifiably be viewed as a public health problem with immediate and long-term health consequences. There is a need to break the silence about this "taboo" issue and act toward prevention and treatment of child abuse by imparting knowledge of normal child development and the negative health consequences of abuse to the individual, family and society. It benefits not only the child, but society as well.
Given the high prevalence of child abuse and neglect in India and the high percentage of oral and facial wounds as a result of child maltreatment, it is crucial for dental health care providers not only recognize suspected cases, but also know how to proceed if they have a child in their chair who shows signs of being abused or neglected. Preventing the suffering of child is one step making the world a safer place.
| References|| |
|1.||Hinchliffe J. Forensic odontology, part 5. Child abuse issues. Br Dent J 2011;210:423-8. |
|2.||Jessee SA. Child Abuse and Neglect: Implications for the Dental Professional. Continuing Education Course. Revised 2009. Available from: http://www.dentalcare.com/media/en-US/education/ce49/ce49.pdf. [Last accessed on 2012 Aug 8]. |
|3.||Dubowitz H, Bennett S. Physical abuse and neglect of children. Lancet 2007;369:1891-9. |
|4.||Province of British Columbia. Inter-ministry Child Abuse Handbook: An Integrated Approach to Child Abuse and Neglect. Victoria (BC): Ministry of Social Services and Housing; 1988. |
|5.||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;7:96-101. |
|6.||Herbert CP. Family violence and family physicians: Opportunity and obligation. Can Fam Physician 1991;37:385-90. |
|7.||Tsang A, Sweet D. Detecting child abuse and neglect - Are dentists doing enough? J Can Dent Assoc 1999;65:387-91. |
|8.||World Health Organization. Child abuse and neglect by parents and other caregivers. World Report on Violence and Health. Ch. 3. Available from: http://www.who.int/violence_injury_prevention/violence/global_campaign/en/chap3.pdf. [Last accessed on 2012 Aug 10]. |
|9.||Cairns AM, Mok JY, Welbury RR. Injuries to the head, face, mouth and neck in physically abused children in a community setting. Int J Paediatr Dent 2005;15:310-8. |
|10.||Jessee SA. Physical manifestations of child abuse to the head, face and mouth: A hospital survey. ASDC J Dent Child 1995;62:245-9. |
|11.||da Fonseca MA, Feigal RJ, ten Bensel RW. Dental aspects of 1248 cases of child maltreatment on file at a major county hospital. Pediatr Dent 1992;14:152-7. |
|12.||Stavrianos C, Stavrianou I, Kafas P, Mastagas D. The responsibility of dentists in identifying and reporting child abuse. Internet J Law Healthc Ethics 2007;5. Available from: http://archive.ispub.com/journal/the-internet-journal-of-law-healthcare-and-ethics/volume-5-number-1/the-responsibility-of-dentists-in-identifying-and-reporting-child-abuse.html#sthash.7TAFN3x7.dpbs [Last accessed on 2012 Aug 08]. |
|13.||World Health Organization. Preventing Child Maltreatment: a Guide to Taking Action and Generating Evidence; 2006. Available from http://www.whqlibdoc.who.int/publications/2006/9241594365_eng.pdf. [Last accessed on 2012 Aug 10]. |
|14.||Kacker L, Varadan S, Kumar P. Study on Child Abuse: India 2007. Delhi: Ministry of Women and Child Development, Government of India; 2007. Available from: http://www.wcd.nic.in/childabuse.pdf. [Last accessed on 2012 Aug 10]. |
|15.||Childhelp. Available from: http://www.childhelp.org/pages/statistics. [Last accessed on 2012 Aug 10]. |
|16.||Blackiston L. Saving a life: Recognizing the signs of human trafficking, abuse, and neglect. RDH 2011;31:58-60. Available from: http://www.rdhmag.com/articles/print/volume-31/issue-1/features/saving-a-life.html [Last accessed on 2012 Aug 10]. |
|17.||Facchin P. Regional policies in Veneto region. In: Proceedings of the European Conference on Reducing Social Inequalities in Health among Children and Young People; Dec 9-10. Copenhagen, Denmark: United Nations; 2002. |
|18.||James AC, Neil P. Juvenile sexual offending: One-year period prevalence study within Oxfordshire. Child Abuse Negl 1996;20:477-85. |
|19.||Halpérin DS, Bouvier P, Jaffé PD, Mounoud RL, Pawlak CH, Laederach J, et al. Prevalence of child sexual abuse among adolescents in Geneva: Results of a cross sectional survey. BMJ 1996;312:1326-9. |
|20.||Hunter WM, Jain D, Sadowski LS, Sanhueza AI. Risk factors for severe child discipline practices in rural India. J Pediatr Psychol 2000;25:435-47. |
|21.||Waldman HB. Child abusers, the abused, and the murdered: In our nation and your state. ASDC J Dent Child 1997;64:169-75, 165. |
|22.||Kotch JB, Browne DC, Ringwalt CL, Stewart PW, Ruina E, Holt K, et al. Risk of child abuse or neglect in a cohort of low-income children. Child Abuse Negl 1995;19:1115-30. |
|23.||García-Ballesta C, Pérez-Lajarín L, Castejón-Navas I. Prevalence and etiology of dental trauma: A review. RCOE 2003;8:131-41. Available from: http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1138-123X2003000200002 [Last accessed on 2013 September 11]. |
|24.||Contreras CI. Management of patients with child abuse. In: Guidelines for Pediatric Dentistry Handling. [United Nations]: Universidad Nacional de Colombia, OSCE Issues; 1998. |
|25.||Ghosn J. The dentists role in detecting child abuse. Ontario Dentist 2008;85:25-7 |
|26.||Regis JD. Early detection of child maltreatment. Dent Hyg (Chic) 1985;59:62-4. |
|27.||Bagic IC. The role of dentists in recognition of child abuse. Acta Stomatol Croat 2010;44:285-92. |
|28.||Kassebaum DK, Dove SB, Cottone JA. Recognition and reporting of child abuse: A survey of dentists. Gen Dent 1991;39:159-62. |
|29.||Kellogg N, American Academy of Pediatrics Committee on Child Abuse and Neglect. Oral and dental aspects of child abuse and neglect. Pediatrics 2005;116:1565-8. |
|30.||Murphy JM, Welbury RR. The dental practitioner′s role in protecting children from abuse. 1. The child protection system. Br Dent J 1998;184:7-10. |
|31.||Nair MK. Child abuse. Indian Pediatr 2004;41:319-20. |
|32.||Morin AA. Mandatory CE for our children? Would a required course increase reporting of child abuse? RDH 2008;30:56-68. Available from: http://www.rdhmag.com/articles/print/volume-30/issue-9/features/mandatory-ce-for-our-children.html. [Last accessed on 2012 Aug 14]. |
|33.||American Academy of Pediatrics Committee on Child Abuse and Neglect and American Academy of Pediatric Dentistry. Guideline on oral and dental aspects of child abuse and neglect. Ref Manual 2010;34:158-61. Available from: http://www.aapd.org/media/Policies_Guidelines/G_Childabuse.pdf [Last accessed on 2013 September 11]. |
|34.||Recognition of physical child abuse. American College of Surgeons Committee on Trauma September, 1997. Available from: http://www.facs.org/trauma/publications/childabuse.pdf [Last accessed on 2012 Aug 14]. |
|35.||Manea S, Favero GA, Stellini E, Romoli L, Mazzucato M, Facchin P. Dentists′ perceptions, attitudes, knowledge, and experience about child abuse and neglect in northeast Italy. J Clin Pediatr Dent 2007;32:19-25. |
|36.||Haug RH, Foss J. Maxillofacial injuries in the pediatric patient. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:126-34. |
|37.||Bernat JE. Dental trauma and bite mark evaluation. In: Ludwig S, Kornberg AE, editors. Child Abuse: a Medical Reference. New York: Churchill Livingstone; 1992. p. 175-90. |
|38.||Dorion RB. Bitemark Evidence. New York: Marcel Dekker; 2005. |
|39.||Nuzzolese E, Lepore MM, Marcario V. Legal bitemark evaluation: issues for the dental hygienist (article in Italian). Prev Assist Dent 2008;3:15-9. |
|40.||Mark L. Bernstein nature of bitemarks. In: Dorion RB, editor. Bitemark Evidence. New York: Mercel Dekker; 2005. p. 63. |
|41.||Bowers C. Michael forensic dental evidence. San Diego, California, USA: Elsevier; 2004. |
|42.||Harris J, Sidebotham P, Welbury R, Townsend R, Green M, Goodwin J, et al. Child Protection and the Dental Team: an introduction to safeguarding children in dental practice. Committee of Postgraduate Dental Deans and Directors (UK); 2006. p. 2.1. |
|43.||Sharma BR, Gupta M. Child abuse in Chandigarh, India, and its implications. J Clin Forensic Med 2004;11:248-56. |
|44.||Terezhalmy GT, Riley CK, Moore WS. Oral lesions secondary to fellatio. Quintessence Int 2000;31:361. |
|45.||Allen DM, Tarnowski KJ. Depressive characteristics of physically abused children. J Abnorm Child Psychol 1989;17:1-11. |
|46.||American Academy of Pediatric Dentistry. Oral health policies. American Academy of Pediatric Dentistry. Pediatr Dent 2003;25:11-49. |
|47.||Sanger RG, Bross DC. Clinical management of child abuse and neglect: A guide for the dental professional. Chicago, IL: Quintessence Publishing Co, Inc.; 1984. |
|48.||Sibbald P, Friedman CS. Child abuse: Implications for the dental health professional. J Can Dent Assoc 1993;59:909-12. |
|49.||Thomas JE, Straffon L, Inglehart MR. Knowledge and professional experiences concerning child abuse: An analysis of provider and student responses. Pediatr Dent 2006;28:438-44. |
|50.||Sakelliadis EI, Spiliopoulou CA, Papadodima SA. Forensic investigation of child victim with sexual abuse. Indian Pediatr 2009;46:144-51. |
|51.||Aggarwal K, Dalwai S, Galagali P, Mishra D, Prasad C, Thadhani A, et al. Recommendations on recognition and response to child abuse and neglect in the Indian setting. Indian Pediatr 2010;47:493-504. |