The Open Dentistry Journal




ISSN: 1874-2106 ― Volume 13, 2019
REVIEW ARTICLE

Role of a Dentist in the Diagnosis of Child Abuse and Neglect: A Literature and Narrative Review



Maria Melo1, 2, Fadi Ata-Ali1, 3, *, Teresa Cobo3, José Diago1, María Teresa Chofré-Lorente1, Leticia Bagán1, Cristina Sanchez-Recio4, Javier Ata-Ali1, 5
1 Unit of Master's Degree in Advanced Orthodontics, Department of Dentistry, Faculty of Health Sciences, European University of Valencia. Valencia, Spain
2 Valencia University Medical and Dental School, University of Valencia Valencia, Spain
3 Department of Surgery and Medical-Surgical Specialities, Area of Orthodontics, University Medical and Dental School. University of Oviedo, Instituto Asturiano de Odontologia, Oviedo, Spain
4 Private Practive in Oral Surgery. Hospital de Manises, Valencia, Spain
5 Public Dental Health Service. Conselleria de Sanitat Universal i Salut Pública, Generalitat Valenciana, Valencia, Spain

Abstract

Background:

Child Abuse (CA) is defined as any physical or psychological harm inflicted upon children. The most commonly affected anatomical region in these cases is the orofacial complex, thereby placing dentists in a dominant position for detecting CA. The statistical figures referred to CA are high, and many cases go unreported.

Objective:

To determine the level of knowledge, the aptitudes and capacity of dentists in reporting cases of CA; the barriers facing the reporting of cases; and the key clinical characteristics for the detection of CA.

Methodology:

A search was made of the PubMed (MEDLINE), ScienceDirect, LILACS and SciELO databases for articles published up until March 2019, involving analytical observational and descriptive studies relevant to the objectives of our study. All articles were independently reviewed by two authors.

Results:

Injuries caused by CA are largely located in the orofacial region – the most prevalent being caries, burns and fractures. The most frequently identified risk factor is behavioral alterations on the part of the parents or caregivers. The reviewed studies reflect a discrepancy between suspected and reported cases of CA.

Conclusion:

Although dentists are able to detect injuries, there is a great lack of knowledge about how to report cases of CA to the authorities. It is interesting to establish guidelines for the detection and reporting of suspicious cases. Improved training in forensic and legal dentistry is needed, together with the establishment of detection and reporting protocols. The clinical signs detected in the case of CA and neglect include untreated caries, poor oral hygiene, traumatisms, burns, lacerations and biting. The recognition of such signs and correct case history compilation are essential for the detection of CA.

Keywords: Dental neglect, Dentists, Maltreatment, Diagnosis, Child abuse, Child neglect, Child protection.


Article Information


Identifiers and Pagination:

Year: 2019
Volume: 13
First Page: 301
Last Page: 307
Publisher Id: TODENTJ-13-301
DOI: 10.2174/1874210601913010301

Article History:

Received Date: 01/06/2019
Revision Received Date: 19/07/2019
Acceptance Date: 09/08/2019
Electronic publication date: 30/08/2019
Collection year: 2019

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© 2019 Melo et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: (https://creativecommons.org/licenses/by/4.0/legalcode). This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Correspondence: Address correspondence to this author at the Unit of Master's Degree in Advanced Orthodontics, Department of Dentistry, Faculty of Health Sciences, Universidad Europea de Valencia. C/General Elio, 2. 46010-Valencia, Spain and Department of Surgery and Medical-Surgical Specialities, Area of Orthodontics, University Medical and Dental School. University of Oviedo, Instituto Asturiano de Odontologia, Oviedo, Spain; Tel: +0034985966014;
E-mail: losataali@hotmail.com






1. INTRODUCTION

Child Abuse (CA) is complicated to define. In effect, the definition changes in different studies according to the context involved, since there is a lack of agreement in the scientific community that prevents homogenization of the different definitions. The definition of Child Neglect (CN) was done by Greenbaum et al. as the failure of the primary caregivers to meet the child’s basic intellectual, physical, or emotional needs [1Greenbaum J, Dubowitz H, Lutzker JR, Johnson KD, Orn K, Kenniston J. Practice guidelines: Challenges in the evaluation of child neglect 2008.], though no precise indication is given as to what the parents or caregivers have to do (or not do), or for how long, to cause immediate or potential harm [2Dubowitz H, Pitts SC, Litrownik AJ, Cox CE, Runyan D, Black MM. Defining child neglect based on child protective services data. Child Abuse Negl 2005; 29(5): 493-511.
[http://dx.doi.org/10.1016/j.chiabu.2003.09.024] [PMID: 15970322]
]. The Expanded Hierarchical Classification System (EHCS) is the most widely used tool and classifies child abuse into four broad categories: sexual abuse, physical abuse, neglect and emotional abuse [3Lau AS, Leeb RT, English D, et al. What’s in a name? A comparison of methods for classifying predominant type of maltreatment. Child Abuse Negl 2005; 29(5): 533-51.
[http://dx.doi.org/10.1016/j.chiabu.2003.05.005] [PMID: 15970324]
]. There are high comorbidity levels among these four categories [4Higgins DJ, McCabe MP. Multi-type maltreatment and the long-term adjustment of adults. Child Abuse Rev 2000; 9: 6-18.
[http://dx.doi.org/10.1002/(SICI)1099-0852(200001/02)9:1<6::AID-CAR579>3.0.CO;2-W]
].

It has been found that approximately 50-80% of all do-cumented cases of CA involve the head and neck region (traumatisms of the mouth, head and face), thereby placing dental professionals in a dominant position for detecting and diagnosing the physical and emotional manifestations of CA and reporting it to the competent authorities [5Kaur H, Chaudhary S, Choudhary N, Manuja N, Chaitra TR, Amit SA. Child abuse: Cross-sectional survey of general dentists. J Oral Biol Craniofac Res 2016; 6(2): 118-23.
[http://dx.doi.org/10.1016/j.jobcr.2015.08.002] [PMID: 27195209]
-12Murali P, Prabhakar M. Mantle of forensics in child sexual abuse. J Forensic Dent Sci 2018; 10(2): 71-4.
[http://dx.doi.org/10.4103/jfo.jfds_17_18] [PMID: 30745780]
]. Un-fortunately, according to Kaur et al. [5Kaur H, Chaudhary S, Choudhary N, Manuja N, Chaitra TR, Amit SA. Child abuse: Cross-sectional survey of general dentists. J Oral Biol Craniofac Res 2016; 6(2): 118-23.
[http://dx.doi.org/10.1016/j.jobcr.2015.08.002] [PMID: 27195209]
], 55% of the surveyed dentists did not have the capacity to interpret suspect cases and identify signs of abuse, due to a lack of training in the field and of knowledge about how to report such cases to the authorities. Child abuse thus constitutes a largely unknown and little reported social problem that affects all countries and social spheres [13Al Hajeri H, Al Halabi M, Kowash M, Khamis AH, Welbury R, Hussein I. Assessment of the knowledge of United Arab Emirates dentists of Child Maltreatment, protection and safeguarding. Eur J Paediatr Dent 2018; 19(2): 105-18.
[PMID: 29790774]
].

The literature shows a discrepancy between suspected cases of CA and actually reported cases [14Al-Dabaan R, Newton JT, Asimakopoulou K. Knowledge, attitudes, and experience of dentists living in Saudi Arabia toward child abuse and neglect. Saudi Dent J 2014; 26(3): 79-87.
[http://dx.doi.org/10.1016/j.sdentj.2014.03.008] [PMID: 25057227]
-15Chadwick BL, Davies J, Bhatia SK, Rooney C, McCusker N. Child protection: training and experiences of dental therapists. Br Dent J 2009; 207(3)E6
[http://dx.doi.org/10.1038/sj.bdj.2009.666] [PMID: 19629144]
], thus in-dicating that although dentists are capable of recognizing and suspecting cases of CA, there is a lack of knowledge about how to proceed in such cases. This contradiction between suspicion and reporting shows the adequate management of children suffering CA to remain deficient. In order to address this problem, it is necessary to establish whether the theoretical knowledge of dentists is correct and sufficient to diagnose and report CA. Thus, the purpose of this study was to review the current literature in order to assess current perceptions, knowledge and attitudes among dental professionals in relation to CA; the barriers facing the reporting of cases; and the key clinical characteristics for the detection of CA.

2. METHODOLOGY

The PubMed (MEDLINE) database of the United States National Library of Medicine, ScienceDirect, LILACS and Sci-ELO were used to conduct a literature search of articles published up until March 2019. The search terms “dental neglect”, “dentistry”, “maltreatment”, “diagnosis”, “child abuse” and “child neglect” were used in different combi-nations. No restrictions were placed on the year or language of publication. The search was completed with a review of the references of the selected articles to identify additional studies not found in the initial literature search. All articles selected from the electronic and manual searches were independently assessed by the first and second authors of the present study, based on the established inclusion criteria.

Chosen full-text articles were required to meet the following criteria: descriptive (cross-sectional) or analytical observational (retrospective and prospective) studies pertinent to the objectives of the present study, and with a clear defini-tion of CA or CN. All studies involving health or non-health professionals other than dentists were excluded (Table 1).

3. RESULTS

The main physical injuries and psychological signs found were the presence of caries [16Duda JG, Biss SP, Bertoli FM, et al. Oral health status in victims of child abuse: A case-control study. Int J Paediatr Dent 2017; 27(3): 210-6.
[http://dx.doi.org/10.1111/ipd.12254] [PMID: 27434332]
-25Lincoln HS, Lincoln MJ. Role of the odontologist in the investigation of domestic violence, neglect of the vulnerable, and institutional violence and torture. Forensic Sci Int 2010; 201(1-3): 68-73.
[http://dx.doi.org/10.1016/j.forsciint.2010.03.027] [PMID: 20417041]
] and increased dental plaque and gingival inflammation scores [20Montecchi PP, Di Trani M, Sarzi Amadè 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.
[PMID: 20073544]
], reflecting the close relationship between abuse and/or neglect and poor oral hygiene and health [18Greene PE, Chisick MC, Aaron GR. A comparison of oral health status and need for dental care between abused/neglected children and nonabused/non-neglected children. Pediatr Dent 1994; 16(1): 41-5.
[PMID: 8015941]
, 19Kenney JP. Domestic violence: A complex health care issue for dentistry today. Forensic Sci Int 2006; 159(Suppl. 1): S121-5.
[http://dx.doi.org/10.1016/j.forsciint.2006.02.025] [PMID: 16545531]
, 21Hartung B, Schaper J, Fischer K, Ritz-Timme S. Care for children with dental neglect: Identification of problems and approaches to solving them. Int J Legal Med 2019; 133(2): 641-50.
[http://dx.doi.org/10.1007/s00414-018-1938-x] [PMID: 30232545]
]. Burns [7Kellogg N. Oral and dental aspects of child abuse and neglect. Pediatrics 2005; 116(6): 1565-8.
[http://dx.doi.org/10.1542/peds.2005-2315] [PMID: 16322187]
, 25Lincoln HS, Lincoln MJ. Role of the odontologist in the investigation of domestic violence, neglect of the vulnerable, and institutional violence and torture. Forensic Sci Int 2010; 201(1-3): 68-73.
[http://dx.doi.org/10.1016/j.forsciint.2010.03.027] [PMID: 20417041]
-27Maguire S, Moynihan S, Mann M, Potokar T, Kemp AM. A systematic review of the features that indicate intentional scalds in children. Burns 2008; 34(8): 1072-81.
[http://dx.doi.org/10.1016/j.burns.2008.02.011] [PMID: 18538478]
] and bone and dental fractures [19Kenney JP. Domestic violence: A complex health care issue for dentistry today. Forensic Sci Int 2006; 159(Suppl. 1): S121-5.
[http://dx.doi.org/10.1016/j.forsciint.2006.02.025] [PMID: 16545531]
, 23Kairys S. Oral and dental aspects of child abuse and neglect. Pediatrics 1999; 104(2 Pt 1): 348-50.
[PMID: 10429025]
, 25Lincoln HS, Lincoln MJ. Role of the odontologist in the investigation of domestic violence, neglect of the vulnerable, and institutional violence and torture. Forensic Sci Int 2010; 201(1-3): 68-73.
[http://dx.doi.org/10.1016/j.forsciint.2010.03.027] [PMID: 20417041]
, 28Le BT, Dierks EJ, Ueeck BA, Homer LD, Potter BF. Maxillofacial injuries associated with domestic violence. J Oral Maxillofac Surg 2001; 59(11): 1277-83.
[http://dx.doi.org/10.1053/joms.2001.27490] [PMID: 11688025]
, 29Garbin CA, Guimarães e Queiroz AP, Rovida TA, Garbin AJ. Occurrence of traumatic dental injury in cases of domestic violence. Braz Dent J 2012; 23(1): 72-6.
[http://dx.doi.org/10.1590/ S0103-64 4020 12000100013] [PMID: 22460319]
], as well as bacterial and viral infections [30Kui LL, Xiu HZ, Ning LY. Condyloma acuminatum and human papilloma virus infection in the oral mucosa of children. Pediatr Dent 2003; 25(2): 149-53.
[PMID: 12723841]
, 23Kairys S. Oral and dental aspects of child abuse and neglect. Pediatrics 1999; 104(2 Pt 1): 348-50.
[PMID: 10429025]
], fractures, lacerations, ma-locclusions [16Duda JG, Biss SP, Bertoli FM, et al. Oral health status in victims of child abuse: A case-control study. Int J Paediatr Dent 2017; 27(3): 210-6.
[http://dx.doi.org/10.1111/ipd.12254] [PMID: 27434332]
] due to traumatisms [31da 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(3): 152-7.
[PMID: 1528783]
], biting or contusions were also reported [7Kellogg N. Oral and dental aspects of child abuse and neglect. Pediatrics 2005; 116(6): 1565-8.
[http://dx.doi.org/10.1542/peds.2005-2315] [PMID: 16322187]
, 27Maguire S, Moynihan S, Mann M, Potokar T, Kemp AM. A systematic review of the features that indicate intentional scalds in children. Burns 2008; 34(8): 1072-81.
[http://dx.doi.org/10.1016/j.burns.2008.02.011] [PMID: 18538478]
, 29Garbin CA, Guimarães e Queiroz AP, Rovida TA, Garbin AJ. Occurrence of traumatic dental injury in cases of domestic violence. Braz Dent J 2012; 23(1): 72-6.
[http://dx.doi.org/10.1590/ S0103-64 4020 12000100013] [PMID: 22460319]
, 32Sarkar R, Ozanne-Smith J, Bassed R. Systematic Review of the Patterns of Orofacial Injuries in Physically Abused Children and Adolescents. Trauma Violence Abuse 2019; 101524838019827617
[http://dx.doi.org/10.1177/1524838019827617] [PMID: 30852989]
]. Children suffering CA also presented psychological disorders such as anxiety, depression or stress [33González-Chica DA, Licinio J, Musker M, et al. Bullying and sexual abuse and their association with harmful behaviours, antidepressant use and health-related quality of life in adulthood: A population-based study in South Australia. BMC Public Health 2019; 19(1): 26.
[http://dx.doi.org/10.1186/s12889-018-6367-8] [PMID: 30616538]
-35Jessee SA. Behavioral indicators of child maltreatment. ASDC J Dent Child 1999; 66(1): 17-22.]. The most frequent risk factor for abuse was behavioral alterations in the form of depression, personality alterations, anxiety, stress or social isolation [36Chapman DP, Whitfield CL, Felitti VJ, Dube SR, Edwards VJ, Anda RF. Adverse childhood experiences and the risk of depressive disorders in adulthood. J Affect Disord 2004; 82(2): 217-25.
[http://dx.doi.org/10.1016/j.jad.2003.12.013] [PMID: 15488250]
, 37Dubowitz H, Bennett S. Physical abuse and neglect of children. Lancet 2007; 369(9576): 1891-9.
[http://dx.doi.org/10.1016/S0140-6736(07)60856-3] [PMID: 17544 770]
]. A low socioeconomic level and alcohol and drug abuse were also associated with an increased risk of abuse [38Marco M, Gracia E, López-Quílez A, Freisthler B. Child maltreatment and alcohol outlets in Spain: Does the country drinking culture matters? Child Abuse Negl 2019; 91: 23-30.
[http://dx.doi.org/10.1016/j.chiabu.2019.02.010] [PMID: 30818249]
], in the same way as monoparental families or criminality [6Garrocho-Rangel A, Márquez-Preciado R, Olguín-Vivar AI, Ruiz-Rodríguez S, Pozos-Guillén A. Dentist attitudes and responsibilities concerning child sexual abuse. A review and a case report. J Clin Exp Dent 2015; 7(3): e428-34.
[http://dx.doi.org/10.4317/jced.52301] [PMID: 26330943]
, 39Atiqul Haque M, Janson S, Moniruzzaman S, et al. Children’s exposure to physical abuse from a child perspective: A population-based study in rural Bangladesh. PLoS One 2019; 14(2)e0212428
[http://dx.doi.org/10.1371/journal.pone.0212428] [PMID: 30779784]
, 40Nwabuzor Ogbonnaya I, Keeney AJ, Villodas MT. The role of co-occurring intimate partner violence, alcohol use, drug use, and depressive symptoms on disciplinary practices of mothers involved with child welfare. Child Abuse Negl 2019; 90: 76-87.
[http://dx.doi.org/10.1016/j.chiabu.2019.02.002] [PMID: 30769190]
].

The suspicion and reporting of cases were seen to vary among the different studies [9Harris JC, Elcock C, Sidebotham PD, Welbury RR. Safeguarding children in dentistry: 1. Child protection training, experience and practice of dental professionals with an interest in paediatric dentistry. Br Dent J 2009; 206(8): 409-14.
[http://dx.doi.org/10.1038/sj.bdj.2009.307] [PMID: 19396200]
, 13Al Hajeri H, Al Halabi M, Kowash M, Khamis AH, Welbury R, Hussein I. Assessment of the knowledge of United Arab Emirates dentists of Child Maltreatment, protection and safeguarding. Eur J Paediatr Dent 2018; 19(2): 105-18.
[PMID: 29790774]
, 14Al-Dabaan R, Newton JT, Asimakopoulou K. Knowledge, attitudes, and experience of dentists living in Saudi Arabia toward child abuse and neglect. Saudi Dent J 2014; 26(3): 79-87.
[http://dx.doi.org/10.1016/j.sdentj.2014.03.008] [PMID: 25057227]
, 41John V, Messer LB, Arora R, et al. Child abuse and dentistry: A study of knowledge and attitudes among dentists in Victoria, Australia. Aust Dent J 1999; 44(4): 259-67.
[http://dx.doi.org/10.1111/j.1834-7819.1999.tb00230.x] [PMID: 1068 7235]
-55Ramos-Gomez F, Rothman D, Blain S. Knowledge and attitudes among California dental care providers regarding child abuse and neglect. J Am Dent Assoc 1998; 129(3): 340-8.
[http://dx.doi.org/10.14219/jada.archive.1998.0208] [PMID: 9529809]
]. The main barrier faced during the reporting of abuse was an uncertain diagnosis [41John V, Messer LB, Arora R, et al. Child abuse and dentistry: A study of knowledge and attitudes among dentists in Victoria, Australia. Aust Dent J 1999; 44(4): 259-67.
[http://dx.doi.org/10.1111/j.1834-7819.1999.tb00230.x] [PMID: 1068 7235]
, 45Al-Habsi SA, Roberts GJ, Attari N, Parekh S. A survey of attitudes, knowledge and practice of dentists in London towards child protectionAre children receiving dental treatment at the Eastman Dental Hospital likely to be on the child protection register? Br Dent J 2009; 206 1e5., 50Harris CM, Welbury R, Cairns AM. The Scottish dental practitioner’s role in managing child abuse and neglect. Br Dent J 2013; 214(9)E24
[http://dx.doi.org/10.1038/sj.bdj.2013.435] [PMID: 23660928]
, 54Uldum B, Christensen HN, Welbury R, Poulsen S. Danish dentists’ and dental hygienists’ knowledge of and experience with suspicion of child abuse or neglect. Int J Paediatr Dent 2010; 20(5): 361-5.
[http://dx.doi.org/10.1111/j.1365-263X.2010.01070.x] [PMID: 2064 2464]
], followed by concern about the con-sequences which reporting may have for the child [41John V, Messer LB, Arora R, et al. Child abuse and dentistry: A study of knowledge and attitudes among dentists in Victoria, Australia. Aust Dent J 1999; 44(4): 259-67.
[http://dx.doi.org/10.1111/j.1834-7819.1999.tb00230.x] [PMID: 1068 7235]
, 48Sonbol HN, Abu-Ghazaleh S, Rajab LD, Baqain ZH, Saman R, Al-Bitar ZB. Knowledge, educational experiences and attitudes towards child abuse amongst Jordanian dentists. Eur J Dent Educ 2012; 16(1): e158-65.
[http://dx.doi.org/10.1111/j.1600-0579.2011.00691.x] [PMID: 22251 340]
, 51Kilpatrick NM, Scott J, Robinson S. Child protection: A survey of experience and knowledge within the dental profession of New South Wales, Australia. Int J Paediatr Dent 1999; 9(3): 153-9.
[http://dx.doi.org/10.1046/j.1365-263x.1999.00130.x] [PMID: 10815 571]
, 54Uldum B, Christensen HN, Welbury R, Poulsen S. Danish dentists’ and dental hygienists’ knowledge of and experience with suspicion of child abuse or neglect. Int J Paediatr Dent 2010; 20(5): 361-5.
[http://dx.doi.org/10.1111/j.1365-263X.2010.01070.x] [PMID: 2064 2464]
], and a lack of knowledge of how to proceed in reporting CA [13Al Hajeri H, Al Halabi M, Kowash M, Khamis AH, Welbury R, Hussein I. Assessment of the knowledge of United Arab Emirates dentists of Child Maltreatment, protection and safeguarding. Eur J Paediatr Dent 2018; 19(2): 105-18.
[PMID: 29790774]
, 45Al-Habsi SA, Roberts GJ, Attari N, Parekh S. A survey of attitudes, knowledge and practice of dentists in London towards child protectionAre children receiving dental treatment at the Eastman Dental Hospital likely to be on the child protection register? Br Dent J 2009; 206 1e5., 54Uldum B, Christensen HN, Welbury R, Poulsen S. Danish dentists’ and dental hygienists’ knowledge of and experience with suspicion of child abuse or neglect. Int J Paediatr Dent 2010; 20(5): 361-5.
[http://dx.doi.org/10.1111/j.1365-263X.2010.01070.x] [PMID: 2064 2464]
] (Table 2). While no international standards or protocols are available, reporting to the authorities or the police was the most commonly used option among the surveyed dental professionals [25Lincoln HS, Lincoln MJ. Role of the odontologist in the investigation of domestic violence, neglect of the vulnerable, and institutional violence and torture. Forensic Sci Int 2010; 201(1-3): 68-73.
[http://dx.doi.org/10.1016/j.forsciint.2010.03.027] [PMID: 20417041]
, 43Laud A, Gizani S, Maragkou S, Welbury R, Papagiannoulis L. Child protection training, experience, and personal views of dentists in the prefecture of Attica, Greece. Int J Paediatr Dent 2013; 23(1): 64-71.
[http://dx.doi.org/10.1111/j.1365-263X.2012.01225.x] [PMID: 2242 9739]
, 45Al-Habsi SA, Roberts GJ, Attari N, Parekh S. A survey of attitudes, knowledge and practice of dentists in London towards child protectionAre children receiving dental treatment at the Eastman Dental Hospital likely to be on the child protection register? Br Dent J 2009; 206 1e5.].

Table 1
Strategy inclusion and exclusion criteria.


4. DISCUSSION

The present study was carried out to determine whether dentists are able to detect cases of CA based on a series of clinical data and proceed as required in confirmed cases of abuse. The percentage of reported cases was low in comparison with the number of suspected cases. Child abuse is difficult to address, for although the prevalence and incidence of CA are high, the exact number of cases is not known and there are no established diagnostic and reporting protocols for such situations. Despite the great relevance of the problem, CA has been seen to involve much uncertainty in the different studies published in the dental care setting [14Al-Dabaan R, Newton JT, Asimakopoulou K. Knowledge, attitudes, and experience of dentists living in Saudi Arabia toward child abuse and neglect. Saudi Dent J 2014; 26(3): 79-87.
[http://dx.doi.org/10.1016/j.sdentj.2014.03.008] [PMID: 25057227]
, 42Love C, Gerbert B, Caspers N, Bronstone A, Perry D, Bird W. Dentists’ attitudes and behaviors regarding domestic violence. The need for an effective response. J Am Dent Assoc 2001; 132(1): 85-93.
[http://dx.doi.org/10.14219/jada.archive.2001.0032] [PMID: 111944 05]
, 46Tornavoi D, Galo R, Silva R. Conhecimento de profissionais de odontología sobre violencia doméstica. Rev Sul Bras Odontol 2011; 8: 54-9.].

Table 2
Main findings of the studies included in the literature review.


The injuries associated with abuse are largely located in the orofacial region [28Le BT, Dierks EJ, Ueeck BA, Homer LD, Potter BF. Maxillofacial injuries associated with domestic violence. J Oral Maxillofac Surg 2001; 59(11): 1277-83.
[http://dx.doi.org/10.1053/joms.2001.27490] [PMID: 11688025]
, 56Paglia L. Child abuse: Awareness is the first step to action. Eur J Paediatr Dent 2018; 19(2): 89.
[PMID: 29790771]
]. As a result, dentists play a very important role in diagnosing CA [16Duda JG, Biss SP, Bertoli FM, et al. Oral health status in victims of child abuse: A case-control study. Int J Paediatr Dent 2017; 27(3): 210-6.
[http://dx.doi.org/10.1111/ipd.12254] [PMID: 27434332]
, 44Thomas JE, Straffon L, Inglehart MR. Knowledge and professional experiences concerning child abuse: An analysis of provider and student responses. Pediatr Dent 2006; 28(5): 438-44.
[PMID: 17036710]
, 45Al-Habsi SA, Roberts GJ, Attari N, Parekh S. A survey of attitudes, knowledge and practice of dentists in London towards child protectionAre children receiving dental treatment at the Eastman Dental Hospital likely to be on the child protection register? Br Dent J 2009; 206 1e5.]. The capacity of dental professionals to suspect and diagnose CA is a crucial issue [13Al Hajeri H, Al Halabi M, Kowash M, Khamis AH, Welbury R, Hussein I. Assessment of the knowledge of United Arab Emirates dentists of Child Maltreatment, protection and safeguarding. Eur J Paediatr Dent 2018; 19(2): 105-18.
[PMID: 29790774]
, 56Paglia L. Child abuse: Awareness is the first step to action. Eur J Paediatr Dent 2018; 19(2): 89.
[PMID: 29790771]
]. The results of the different studies reflect an important discrepancy between professionals that suspect CA and those that effectively report cases of abuse to the competent authorities.

Few dentists have received pre or postgraduate training or have learned about the subject in the course of their pro-fessional life [5Kaur H, Chaudhary S, Choudhary N, Manuja N, Chaitra TR, Amit SA. Child abuse: Cross-sectional survey of general dentists. J Oral Biol Craniofac Res 2016; 6(2): 118-23.
[http://dx.doi.org/10.1016/j.jobcr.2015.08.002] [PMID: 27195209]
, 14Al-Dabaan R, Newton JT, Asimakopoulou K. Knowledge, attitudes, and experience of dentists living in Saudi Arabia toward child abuse and neglect. Saudi Dent J 2014; 26(3): 79-87.
[http://dx.doi.org/10.1016/j.sdentj.2014.03.008] [PMID: 25057227]
, 15Chadwick BL, Davies J, Bhatia SK, Rooney C, McCusker N. Child protection: training and experiences of dental therapists. Br Dent J 2009; 207(3)E6
[http://dx.doi.org/10.1038/sj.bdj.2009.666] [PMID: 19629144]
, 44Thomas JE, Straffon L, Inglehart MR. Knowledge and professional experiences concerning child abuse: An analysis of provider and student responses. Pediatr Dent 2006; 28(5): 438-44.
[PMID: 17036710]
], even though knowledge of forensic dentistry is also essential in other settings [57Ata-Ali J, Ata-Ali F. Forensic dentistry in human identification: A review of the literature. J Clin Exp Dent 2014; 6(2): e162-7.
[http://dx.doi.org/10.4317/jced.51387] [PMID: 24790717]
, 58Melo M, Ata-Ali J. Accuracy of the estimation of dental age in comparison with chronological age in a Spanish sample of 2641 living subjects using the Demirjian and Nolla methods. Forensic Sci Int 2017; 270: 276.e1-7.
[http://dx.doi.org/10.1016/j.forsciint.2016.10.001] [PMID: 28029496]
]. Three studies [9Harris JC, Elcock C, Sidebotham PD, Welbury RR. Safeguarding children in dentistry: 1. Child protection training, experience and practice of dental professionals with an interest in paediatric dentistry. Br Dent J 2009; 206(8): 409-14.
[http://dx.doi.org/10.1038/sj.bdj.2009.307] [PMID: 19396200]
, 42Love C, Gerbert B, Caspers N, Bronstone A, Perry D, Bird W. Dentists’ attitudes and behaviors regarding domestic violence. The need for an effective response. J Am Dent Assoc 2001; 132(1): 85-93.
[http://dx.doi.org/10.14219/jada.archive.2001.0032] [PMID: 111944 05]
, 44Thomas JE, Straffon L, Inglehart MR. Knowledge and professional experiences concerning child abuse: An analysis of provider and student responses. Pediatr Dent 2006; 28(5): 438-44.
[PMID: 17036710]
] have respectively found that 43%, 73% and 85% of all dentists had received training in CA during their graduate years. In contrast, other authors have reported that most dentists (91%) have never received training in CA [49Manea 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(1): 19-25.
[http://dx.doi.org/10.17796/jcpd.32.1.f920721252jx3614] [PMID: 18 274465]
]. This discrepancy may be attributable to the different training or educational plans found in different countries. In this regard, the United Kingdom and the United States provide more training in this field than Brazil or Greece, according to Rodrigues et al. [59Rodrigues JLSA, Lima APB, Nagata JY, et al. Domestic violence against children detected and managed in the routine of dentistry - A systematic review. J Forensic Leg Med 2016; 43: 34-41.
[http://dx.doi.org/10.1016/j.jflm.2016.07.006] [PMID: 27441984]
]. There is an important discrepancy between studies that consider dentists to have sufficient knowledge and capacity to detect cases of CA [9Harris JC, Elcock C, Sidebotham PD, Welbury RR. Safeguarding children in dentistry: 1. Child protection training, experience and practice of dental professionals with an interest in paediatric dentistry. Br Dent J 2009; 206(8): 409-14.
[http://dx.doi.org/10.1038/sj.bdj.2009.307] [PMID: 19396200]
, 14Al-Dabaan R, Newton JT, Asimakopoulou K. Knowledge, attitudes, and experience of dentists living in Saudi Arabia toward child abuse and neglect. Saudi Dent J 2014; 26(3): 79-87.
[http://dx.doi.org/10.1016/j.sdentj.2014.03.008] [PMID: 25057227]
, 44Thomas JE, Straffon L, Inglehart MR. Knowledge and professional experiences concerning child abuse: An analysis of provider and student responses. Pediatr Dent 2006; 28(5): 438-44.
[PMID: 17036710]
, 47Azevedo MS, Goettems ML, Brito A, et al. Child maltreatment: a survey of dentists in southern Brazil. Braz Oral Res 2012; 26(1): 5-11.
[http://dx.doi.org/10.1590/S1806-83242012000100002] [PMID: 2234 4331]
, 55Ramos-Gomez F, Rothman D, Blain S. Knowledge and attitudes among California dental care providers regarding child abuse and neglect. J Am Dent Assoc 1998; 129(3): 340-8.
[http://dx.doi.org/10.14219/jada.archive.1998.0208] [PMID: 9529809]
] and those that consider knowledge and preparation to be insufficient [6Garrocho-Rangel A, Márquez-Preciado R, Olguín-Vivar AI, Ruiz-Rodríguez S, Pozos-Guillén A. Dentist attitudes and responsibilities concerning child sexual abuse. A review and a case report. J Clin Exp Dent 2015; 7(3): e428-34.
[http://dx.doi.org/10.4317/jced.52301] [PMID: 26330943]
, 43Laud A, Gizani S, Maragkou S, Welbury R, Papagiannoulis L. Child protection training, experience, and personal views of dentists in the prefecture of Attica, Greece. Int J Paediatr Dent 2013; 23(1): 64-71.
[http://dx.doi.org/10.1111/j.1365-263X.2012.01225.x] [PMID: 2242 9739]
, 46Tornavoi D, Galo R, Silva R. Conhecimento de profissionais de odontología sobre violencia doméstica. Rev Sul Bras Odontol 2011; 8: 54-9.]. According to different authors [43Laud A, Gizani S, Maragkou S, Welbury R, Papagiannoulis L. Child protection training, experience, and personal views of dentists in the prefecture of Attica, Greece. Int J Paediatr Dent 2013; 23(1): 64-71.
[http://dx.doi.org/10.1111/j.1365-263X.2012.01225.x] [PMID: 2242 9739]
, 60Crespo M, Andrade D, Alves AL, Magalhães T. O papel do médico dentista no diagnóstico e sinalização do abuso de crianças. Acta Med Port 2011; 24(Suppl. 4): 939-48.
[PMID: 22863503]
], approximately 50% of those surveyed considered themselves to be in a key position for detecting CA, but almost 78% were not prepared to report the detected cases. Despite this difference, and regardless of whether the professionals considered themselves capable of detecting abuse or not, the great majority agreed on the importance of their role as dentists in clinical practice were aware of the legal importance of reporting and acknowledged the crucial relevance of training in this field [25Lincoln HS, Lincoln MJ. Role of the odontologist in the investigation of domestic violence, neglect of the vulnerable, and institutional violence and torture. Forensic Sci Int 2010; 201(1-3): 68-73.
[http://dx.doi.org/10.1016/j.forsciint.2010.03.027] [PMID: 20417041]
, 41John V, Messer LB, Arora R, et al. Child abuse and dentistry: A study of knowledge and attitudes among dentists in Victoria, Australia. Aust Dent J 1999; 44(4): 259-67.
[http://dx.doi.org/10.1111/j.1834-7819.1999.tb00230.x] [PMID: 1068 7235]
, 43Laud A, Gizani S, Maragkou S, Welbury R, Papagiannoulis L. Child protection training, experience, and personal views of dentists in the prefecture of Attica, Greece. Int J Paediatr Dent 2013; 23(1): 64-71.
[http://dx.doi.org/10.1111/j.1365-263X.2012.01225.x] [PMID: 2242 9739]
, 45Al-Habsi SA, Roberts GJ, Attari N, Parekh S. A survey of attitudes, knowledge and practice of dentists in London towards child protectionAre children receiving dental treatment at the Eastman Dental Hospital likely to be on the child protection register? Br Dent J 2009; 206 1e5.]. Increased knowledge has been observed in professionals specialized in pediatric dentistry [51Kilpatrick NM, Scott J, Robinson S. Child protection: A survey of experience and knowledge within the dental profession of New South Wales, Australia. Int J Paediatr Dent 1999; 9(3): 153-9.
[http://dx.doi.org/10.1046/j.1365-263x.1999.00130.x] [PMID: 10815 571]
] versus general dentists. The former are more informed about when and where to report CA, but are unaware of their legal responsibility if they fail to report cases of abuse [44Thomas JE, Straffon L, Inglehart MR. Knowledge and professional experiences concerning child abuse: An analysis of provider and student responses. Pediatr Dent 2006; 28(5): 438-44.
[PMID: 17036710]
].

Important discrepancies have been found in the reviewed literature. Dentists have different attitudes and positions with respect to the handling and reporting of cases of abuse: some prefer to inform the police or call telephone help services for cases of abuse, while others prefer to talk with the parents or caregivers or contact the authorities. In turn, others prefer to consult cases of this kind with colleagues or other specialists before deciding any measures or to contact social services, lawyers, or the reference hospital of the child. Lastly, some dentists decide not to report cases of abuse. The most common practice is reporting to the police or pertinent authorities, followed by consultation with other specialists [25Lincoln HS, Lincoln MJ. Role of the odontologist in the investigation of domestic violence, neglect of the vulnerable, and institutional violence and torture. Forensic Sci Int 2010; 201(1-3): 68-73.
[http://dx.doi.org/10.1016/j.forsciint.2010.03.027] [PMID: 20417041]
, 41John V, Messer LB, Arora R, et al. Child abuse and dentistry: A study of knowledge and attitudes among dentists in Victoria, Australia. Aust Dent J 1999; 44(4): 259-67.
[http://dx.doi.org/10.1111/j.1834-7819.1999.tb00230.x] [PMID: 1068 7235]
-43Laud A, Gizani S, Maragkou S, Welbury R, Papagiannoulis L. Child protection training, experience, and personal views of dentists in the prefecture of Attica, Greece. Int J Paediatr Dent 2013; 23(1): 64-71.
[http://dx.doi.org/10.1111/j.1365-263X.2012.01225.x] [PMID: 2242 9739]
, 45Al-Habsi SA, Roberts GJ, Attari N, Parekh S. A survey of attitudes, knowledge and practice of dentists in London towards child protectionAre children receiving dental treatment at the Eastman Dental Hospital likely to be on the child protection register? Br Dent J 2009; 206 1e5.]. A minority prefer to talk with parents or caregivers [14Al-Dabaan R, Newton JT, Asimakopoulou K. Knowledge, attitudes, and experience of dentists living in Saudi Arabia toward child abuse and neglect. Saudi Dent J 2014; 26(3): 79-87.
[http://dx.doi.org/10.1016/j.sdentj.2014.03.008] [PMID: 25057227]
, 52van Dam BA, van der Sanden WJ, Bruers JJ. Recognizing and reporting domestic violence: attitudes, experiences and behavior of Dutch dentists. BMC Oral Health 2015; 15: 159.
[http://dx.doi.org/10.1186/s12903-015-0141-4] [PMID: 26667115]
]. However, according to Manea et al. [49Manea 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(1): 19-25.
[http://dx.doi.org/10.17796/jcpd.32.1.f920721252jx3614] [PMID: 18 274465]
] and Sfikas et al. [61Sfikas PM. Does the dentist have an ethical duty to report child abuse? J Am Dent Assoc 1996; 127(4): 521-3.
[http://dx.doi.org/10.14219/jada.archive.1996.0249] [PMID: 8655876]
], among other investigators, a large proportion of those surveyed claimed that they would report cases of abuse to the authorities, but had no clear idea of what authorities should be contacted. Uncertainty regarding which authorities to inform about cases of abuse is conditioned to the country involved, since mandatory reporting to the social services is in force in some countries, while others require reporting to childhood protection services or have no specific protocol for such situations [62Mouden LD, Bross DC. Legal issues affecting dentistry’s role in preventing child abuse and neglect. J Am Dent Assoc 1995; 126(8): 1173-80.
[http://dx.doi.org/10.14219/jada.archive.1995.0339] [PMID: 7560576]
]. In a study carried out in Australia, only 24% of the responders knew that they are not legally required to report child abuse in Victoria. However, 74% of them knew that they could be called to testify in juvenile court [41John V, Messer LB, Arora R, et al. Child abuse and dentistry: A study of knowledge and attitudes among dentists in Victoria, Australia. Aust Dent J 1999; 44(4): 259-67.
[http://dx.doi.org/10.1111/j.1834-7819.1999.tb00230.x] [PMID: 1068 7235]
]. No common standards or protocols apply to all, and here again, a multi-disciplinary setting could play a key role, together with adequate training in how to proceed in such situations.

As has been mentioned, there is a discrepancy between the number of suspected cases of CA and the proportion of cases that are actually reported. A number of studies have found the reporting rates to be very low in comparison with the per-centages of suspected cases: 18% versus 34% [15Chadwick BL, Davies J, Bhatia SK, Rooney C, McCusker N. Child protection: training and experiences of dental therapists. Br Dent J 2009; 207(3)E6
[http://dx.doi.org/10.1038/sj.bdj.2009.666] [PMID: 19629144]
], 12% versus 59% [48Sonbol HN, Abu-Ghazaleh S, Rajab LD, Baqain ZH, Saman R, Al-Bitar ZB. Knowledge, educational experiences and attitudes towards child abuse amongst Jordanian dentists. Eur J Dent Educ 2012; 16(1): e158-65.
[http://dx.doi.org/10.1111/j.1600-0579.2011.00691.x] [PMID: 22251 340]
] or 10% versus 59% [14Al-Dabaan R, Newton JT, Asimakopoulou K. Knowledge, attitudes, and experience of dentists living in Saudi Arabia toward child abuse and neglect. Saudi Dent J 2014; 26(3): 79-87.
[http://dx.doi.org/10.1016/j.sdentj.2014.03.008] [PMID: 25057227]
]. This discrepancy may be due to a number of factors, including the existence of different barriers that complicate the task of dentists in this scenario [13Al Hajeri H, Al Halabi M, Kowash M, Khamis AH, Welbury R, Hussein I. Assessment of the knowledge of United Arab Emirates dentists of Child Maltreatment, protection and safeguarding. Eur J Paediatr Dent 2018; 19(2): 105-18.
[PMID: 29790774]
], particularly diagnostic uncertainty or doubts; concern about the consequences of reporting for the child; fear of offending the parents or caregivers; a lack of clear and simple protocols; scant training in CA; and the possible consequences of reporting for their clinical practice [63Kvist T, Wickström A, Miglis I, Dahllöf G. The dilemma of reporting suspicions of child maltreatment in pediatric dentistry. Eur J Oral Sci 2014; 122(5): 332-8.
[http://dx.doi.org/10.1111/eos.12143] [PMID: 25039643]
]. The most frequently cited barriers are diagnostic uncertainty or doubts [42Love C, Gerbert B, Caspers N, Bronstone A, Perry D, Bird W. Dentists’ attitudes and behaviors regarding domestic violence. The need for an effective response. J Am Dent Assoc 2001; 132(1): 85-93.
[http://dx.doi.org/10.14219/jada.archive.2001.0032] [PMID: 111944 05]
, 43Laud A, Gizani S, Maragkou S, Welbury R, Papagiannoulis L. Child protection training, experience, and personal views of dentists in the prefecture of Attica, Greece. Int J Paediatr Dent 2013; 23(1): 64-71.
[http://dx.doi.org/10.1111/j.1365-263X.2012.01225.x] [PMID: 2242 9739]
, 46Tornavoi D, Galo R, Silva R. Conhecimento de profissionais de odontología sobre violencia doméstica. Rev Sul Bras Odontol 2011; 8: 54-9.] and concern about the consequences of reporting for the child [6Garrocho-Rangel A, Márquez-Preciado R, Olguín-Vivar AI, Ruiz-Rodríguez S, Pozos-Guillén A. Dentist attitudes and responsibilities concerning child sexual abuse. A review and a case report. J Clin Exp Dent 2015; 7(3): e428-34.
[http://dx.doi.org/10.4317/jced.52301] [PMID: 26330943]
, 14Al-Dabaan R, Newton JT, Asimakopoulou K. Knowledge, attitudes, and experience of dentists living in Saudi Arabia toward child abuse and neglect. Saudi Dent J 2014; 26(3): 79-87.
[http://dx.doi.org/10.1016/j.sdentj.2014.03.008] [PMID: 25057227]
, 48Sonbol HN, Abu-Ghazaleh S, Rajab LD, Baqain ZH, Saman R, Al-Bitar ZB. Knowledge, educational experiences and attitudes towards child abuse amongst Jordanian dentists. Eur J Dent Educ 2012; 16(1): e158-65.
[http://dx.doi.org/10.1111/j.1600-0579.2011.00691.x] [PMID: 22251 340]
]. Improved training and preparation of the professionals are therefore needed in relation to the detection and reporting of abuse, as well as more legal information about this subject. Dentists must be aware of the legality of their actions and of the existence of legal support of the reporting of cases [9Harris JC, Elcock C, Sidebotham PD, Welbury RR. Safeguarding children in dentistry: 1. Child protection training, experience and practice of dental professionals with an interest in paediatric dentistry. Br Dent J 2009; 206(8): 409-14.
[http://dx.doi.org/10.1038/sj.bdj.2009.307] [PMID: 19396200]
, 41John V, Messer LB, Arora R, et al. Child abuse and dentistry: A study of knowledge and attitudes among dentists in Victoria, Australia. Aust Dent J 1999; 44(4): 259-67.
[http://dx.doi.org/10.1111/j.1834-7819.1999.tb00230.x] [PMID: 1068 7235]
, 42Love C, Gerbert B, Caspers N, Bronstone A, Perry D, Bird W. Dentists’ attitudes and behaviors regarding domestic violence. The need for an effective response. J Am Dent Assoc 2001; 132(1): 85-93.
[http://dx.doi.org/10.14219/jada.archive.2001.0032] [PMID: 111944 05]
, 61Sfikas PM. Does the dentist have an ethical duty to report child abuse? J Am Dent Assoc 1996; 127(4): 521-3.
[http://dx.doi.org/10.14219/jada.archive.1996.0249] [PMID: 8655876]
, 64Cukovic-Bagic I, Welbury RR, Flander GB, Hatibovic-Kofman S, Nuzzolese E. Child protection: Legal and ethical obligation regarding the report of child abuse in four different countries. J Forensic Odontostomatol 2013; 31(1): 15-21.
[PMID: 24776437]
]. In the study published by Laud et al., 21% of the participants were formally trained on the topic during undergraduate education and 12% during graduate education [43Laud A, Gizani S, Maragkou S, Welbury R, Papagiannoulis L. Child protection training, experience, and personal views of dentists in the prefecture of Attica, Greece. Int J Paediatr Dent 2013; 23(1): 64-71.
[http://dx.doi.org/10.1111/j.1365-263X.2012.01225.x] [PMID: 2242 9739]
]. However, these percentages increased in the study carried out by Harris et al. [9Harris JC, Elcock C, Sidebotham PD, Welbury RR. Safeguarding children in dentistry: 1. Child protection training, experience and practice of dental professionals with an interest in paediatric dentistry. Br Dent J 2009; 206(8): 409-14.
[http://dx.doi.org/10.1038/sj.bdj.2009.307] [PMID: 19396200]
], where 26% of the respondents reported that child protection had been included as a class during undergraduate education. In turn, in the study of Sonbol et al. [48Sonbol HN, Abu-Ghazaleh S, Rajab LD, Baqain ZH, Saman R, Al-Bitar ZB. Knowledge, educational experiences and attitudes towards child abuse amongst Jordanian dentists. Eur J Dent Educ 2012; 16(1): e158-65.
[http://dx.doi.org/10.1111/j.1600-0579.2011.00691.x] [PMID: 22251 340]
], 34% of those surveyed reported having formal training to recognize and report child abuse, and 42% presented qualification on the topic. Al Habsi et al. found 80% of the respondents to consider this topic to be extremely important for their work, and 79% of the sample expressed a wish to learn more about the issue [45Al-Habsi SA, Roberts GJ, Attari N, Parekh S. A survey of attitudes, knowledge and practice of dentists in London towards child protectionAre children receiving dental treatment at the Eastman Dental Hospital likely to be on the child protection register? Br Dent J 2009; 206 1e5.]. All dentists must report suspected child abuse or neglect. The procedure can include an immediate report to the police or pertinent authorities orally by telephone or through electronically. Within 48 hours, a written report form should be completed.

The main physical and psychological consequences of abuse were found to be the presence of caries, poor oral hygiene, bruises, burns, bacterial and viral infections, fractures, lacerations, malocclusions due to traumatisms, biting and psyc-hological alterations such as anxiety, depression or stress. With regard to oral health and the presence of caries, Duda et al. [16Duda JG, Biss SP, Bertoli FM, et al. Oral health status in victims of child abuse: A case-control study. Int J Paediatr Dent 2017; 27(3): 210-6.
[http://dx.doi.org/10.1111/ipd.12254] [PMID: 27434332]
] found the number of treated caries and the number of primary teeth lost by victims of CA to be significantly greater than in the group of children without abuse. Children suffering neglect have poorer oral health and a higher prevalence of caries [16Duda JG, Biss SP, Bertoli FM, et al. Oral health status in victims of child abuse: A case-control study. Int J Paediatr Dent 2017; 27(3): 210-6.
[http://dx.doi.org/10.1111/ipd.12254] [PMID: 27434332]
, 18Greene PE, Chisick MC, Aaron GR. A comparison of oral health status and need for dental care between abused/neglected children and nonabused/non-neglected children. Pediatr Dent 1994; 16(1): 41-5.
[PMID: 8015941]
, 21Hartung B, Schaper J, Fischer K, Ritz-Timme S. Care for children with dental neglect: Identification of problems and approaches to solving them. Int J Legal Med 2019; 133(2): 641-50.
[http://dx.doi.org/10.1007/s00414-018-1938-x] [PMID: 30232545]
, 22Jenkins GW, Bresnen D, Jenkins E, Mullen N. Dental Abscess in Pediatric Patients: A Marker of Neglect. Pediatr Emerg Care 2018; 34(11): 774-7.
[http://dx.doi.org/10.1097/PEC.0000000000001611] [PMID: 302118 38]
, 43Laud A, Gizani S, Maragkou S, Welbury R, Papagiannoulis L. Child protection training, experience, and personal views of dentists in the prefecture of Attica, Greece. Int J Paediatr Dent 2013; 23(1): 64-71.
[http://dx.doi.org/10.1111/j.1365-263X.2012.01225.x] [PMID: 2242 9739]
]. Dental traumatisms and fractures are among the most common clinical findings (59.7%), with the upper incisors being the most frequently affected teeth [65Jackson A. Let the record speak: Medicolegal documentation in cases of child maltreatment. Clin Pediatr Emerg Med 2006; 7: 181-5.
[http://dx.doi.org/10.1016/j.cpem.2006.05.001]
]. Long-evolving caries and abscesses are indicative of neglect [22Jenkins GW, Bresnen D, Jenkins E, Mullen N. Dental Abscess in Pediatric Patients: A Marker of Neglect. Pediatr Emerg Care 2018; 34(11): 774-7.
[http://dx.doi.org/10.1097/PEC.0000000000001611] [PMID: 302118 38]
-24Sillevis Smitt H, de Leeuw J, de Vries T. Association Between Severe Dental Caries and Child Abuse and Neglect. J Oral Maxillofac Surg 2017; 75(11): 2304-6.
[http://dx.doi.org/10.1016/j.joms.2017.05.004] [PMID: 28586637]
, 32Sarkar R, Ozanne-Smith J, Bassed R. Systematic Review of the Patterns of Orofacial Injuries in Physically Abused Children and Adolescents. Trauma Violence Abuse 2019; 101524838019827617
[http://dx.doi.org/10.1177/1524838019827617] [PMID: 30852989]
], while infections and sexually transmitted diseases such as syphilis, condylomas and palatal petechiae are indicative of sexual abuse [66Mathur S, Chopra R. Combating child abuse: The role of a dentist. Oral Health Prev Dent 2013; 11(3): 243-50.
[PMID: 23534033]
, 67American academy of pediatric dentistry council on clinical cffairs. Guideline on oral and dental aspects of child abuse and neglect. Pediatr Dent 2005-2006; 27: 64-7.]. With regard to burns, those caused by flame or fire are the most prevalent in CA, as evidenced by Andronicus et al. [26Andronicus M, Oates RK, Peat J, Spalding S, Martin H. Non-accidental burns in children. Burns 1998; 24(6): 552-8.
[http://dx.doi.org/10.1016/S0305-4179(98)00062-X] [PMID: 97760 94]
]. Maguire et al. [27Maguire S, Moynihan S, Mann M, Potokar T, Kemp AM. A systematic review of the features that indicate intentional scalds in children. Burns 2008; 34(8): 1072-81.
[http://dx.doi.org/10.1016/j.burns.2008.02.011] [PMID: 18538478]
] likewise studied burns in CA and found the most frequent presentation to consist of symmetrical lesions with regular margins and of the same depth. In the case of biting, the intercanine distance is typically greater than 3 mm, with an ovoid shape and central ecchymosis [68Golden GS. Bite-Mark and Pattern Injury Analysis: A Brief Status Overview. J Calif Dent Assoc 2015; 43(6): 309-14.
[PMID: 26126346]
]. On the other hand, Chapman et al. [36Chapman DP, Whitfield CL, Felitti VJ, Dube SR, Edwards VJ, Anda RF. Adverse childhood experiences and the risk of depressive disorders in adulthood. J Affect Disord 2004; 82(2): 217-25.
[http://dx.doi.org/10.1016/j.jad.2003.12.013] [PMID: 15488250]
] documented the prevalence of psychological and depressive disorders in children exposed to abuse. A number of studies [12Murali P, Prabhakar M. Mantle of forensics in child sexual abuse. J Forensic Dent Sci 2018; 10(2): 71-4.
[http://dx.doi.org/10.4103/jfo.jfds_17_18] [PMID: 30745780]
, 32Sarkar R, Ozanne-Smith J, Bassed R. Systematic Review of the Patterns of Orofacial Injuries in Physically Abused Children and Adolescents. Trauma Violence Abuse 2019; 101524838019827617
[http://dx.doi.org/10.1177/1524838019827617] [PMID: 30852989]
] coincide that the most important element in the detection of these clinical manifestations is to take into account the aforementioned characteristics, together with discrepancies between the clinical data and the story told; suspicious behavior on the part of the parents; the behavior of the child with emotional problems [34Warren AS, Goldsmith KA, Rimes KA. Childhood gender-typed behavior and emotional or peer problems: A prospective birth-cohort study. J Child Psychol Psychiatry 2019; 60(8): 888-96.
[http://dx.doi.org/10.1111/jcpp.13051] [PMID: 30907437]
, 35Jessee SA. Behavioral indicators of child maltreatment. ASDC J Dent Child 1999; 66(1): 17-22.]; and the presence of bilateral injuries in different stages of healing or with a specific pattern indicative of abuse [22Jenkins GW, Bresnen D, Jenkins E, Mullen N. Dental Abscess in Pediatric Patients: A Marker of Neglect. Pediatr Emerg Care 2018; 34(11): 774-7.
[http://dx.doi.org/10.1097/PEC.0000000000001611] [PMID: 302118 38]
]. Victims of CA are scantly cooperative in the dental clinic [20Montecchi PP, Di Trani M, Sarzi Amadè 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.
[PMID: 20073544]
], and are at an increased risk of suffering emotional and psychological disorders [33González-Chica DA, Licinio J, Musker M, et al. Bullying and sexual abuse and their association with harmful behaviours, antidepressant use and health-related quality of life in adulthood: A population-based study in South Australia. BMC Public Health 2019; 19(1): 26.
[http://dx.doi.org/10.1186/s12889-018-6367-8] [PMID: 30616538]
, 35Jessee SA. Behavioral indicators of child maltreatment. ASDC J Dent Child 1999; 66(1): 17-22.] in both childhood and adult life. With this data, it is interesting to develop universal guidelines for dentists where they can systematically review the signs that can be found. Thus, the presence of caries, dental trauma, bitemarks, perioral and intraoral injuries as abrasions, lacerations and burns, infections (gonorrhea or syphilis) and diseases with an inconsistent history are indicators of child abuse or neglect.

Most of the reviewed studies coincide in the need for collaboration between physicians and dentists and underscore the important role of the professional in preserving the safety of the child. Improved preparation is required for the diagnosis of these signs, with greater training of dentists in forensic dentistry. The discrepant findings of the different studies reflect the lack of standardized and homogeneous protocols for the diagnosis of CA among dentists.

CONCLUSION

It can be concluded that dentists effectively suspect cases of CA in their clinical practice, but few report such cases. This important discrepancy between the number of suspected cases and the cases actually reported is due to the existence of a series of barriers that complicate the task of the dental professional - thus underscoring the need to improve training in this setting, since cases of CA may persist over time if adequate measures are not taken. The clinical signs of CA or neglect identified in the present study include burns, untreated caries, lacerations, biting, traumatisms, dental avulsions, bruises and psychological and behavioral disorders. Careful compilation of the case history is essential. Likewise, standardized guidelines and strategies are needed to help dentists detect cases of CA, as well as multidisciplinary work with other health professionals in both the public and the private settings. The definition of reporting protocols and improved training in CA are crucial for reducing morbidity-mortality among these children.

CONSENT FOR PUBLICATION

Not applicable.

FUNDING

None.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

Declared none.

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