SAFEGUARDING CHILDREN AGAINST CHILD ABUSE AND DENTAL NEGLECT PROTEZIONE DEI MINORI DA MALTRATTAMENTO E TRASCURATEZZA DENTALE

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TAGETE 1-2008 Year XIV

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SAFEGUARDING CHILDREN AGAINST CHILD ABUSE AND DENTAL NEGLECT

PROTEZIONE DEI MINORI DA MALTRATTAMENTO E TRASCURATEZZA DENTALE

Dr. Emilio Nuzzolese^* - Dr.ssa Sara De Rosa^** - Dr.ssa Maria M. Lepore^***

Introduction

*Forensic Odontologist, Bari

**Paediatric Dentist, Matera

***Registered Dental Hygienist, Bari, Italy

ABSTRACT

Health, education and social services are placing increasing emphasis on preventing abuse and neglect by early intervention to support families where children and young people may be at risk.

Dentists, like all other health professionals, have a part to play in protecting children from those who would cause them harm. Dentist could fail to report suspected cases of abuse and neglect as there is not enough awareness on child maltreatment and, most important, its existence.

The purpose of this report is to review the oral and dental aspects of child abuse and dental neglect thus helping dentists in recognizing and diagnosing such conditions. In particular this report addresses the evaluation of bite marks as well as perioral and intraoral injuries, infections, early childhood caries and diseases that may be suspicious for child abuse or neglect in order to provide clinicians with minimal training in forensic odontology to detect dental aspects of abuse or neglect.

Therefore dentists are encouraged to become more aware of their moral, legal and ethical responsibilities, promoting prevention and recognizing and reporting cases of child abuse and neglect. This also means that dentists are ethically required to report suspected abuse and neglect as they are mandated to do so under Italian laws.

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2 Children’s rights are defined by the United Nations Convention on the Rights of the Child 1989 (UNCRC). This is an international human rights treaty that applies to all children and young people under the age of 18 years. The abuse and neglect (or maltreatment) of children is a worldwide problem, although its manifestations and extent vary. It is far more prevalent than is generally recognised. In 2002 statistics in Italy highlight 7462 of crimes or offences against children. In 2005 an Italian survey carried out by the national childhood observation centre revealed that 73,6% of adult women interviewed had suffered of maltreatment during their childhood.

Paediatrists are concerned about children’s health and safety have an important part to play to address this problem. Nevertheless many dentists are not aware of their role in prevention, treatment, and advocacy in children maltreatment. This is confirmed by the minimal training received in forensic odontology during the university education.

Physical abuse by parents or caregivers includes beatings, shaking, scalding, and biting.

Although some forms of corporal punishment are widely accepted, many people think of any injury beyond immediate redness as abuse. However, harm might not be immediately evident although it must have a systematic nature in order to be considered a possible maltreatment.

Child neglect is omission of care, such as health care, education, supervision, protection from environmental hazards, meeting physical needs (eg, clothing or food),and emotional support, resulting in actual or potential harm. Alternatively, neglect from a

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3 child’s perspective is not adequately meeting a child’s basic needs, regardless of the reasons. Several factors can contribute to neglect, such as parental depression, a child’s disability, family violence, or an absence of community resources. Full comprehension of the problems underpinning neglect helps interventions to be tailored to the specific needs of the child and family.

Dentists must be aware of their moral, ethical and legal responsibilities, promoting prevention, recognizing and reporting cases of child abuse and neglect. Italian ethical code (art. 32) and Italian penal law (art. 365) require to report any suspected case of child abuse and neglect.

Physical abuse

Craniofacial, head, face, and neck injuries occur in more than half of the cases of child abuse. A careful intraoral and perioral examination is necessary in all cases of suspected abuse and neglect. In addition, all suspected victims of abuse or neglect, should be examined carefully in order to detect not only signs of oral trauma but also caries, gingivitis, and other oral health problems. Some authorities believe that the oral cavity may be a central focus for physical abuse because of its significance in communication and nutrition.

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4 Oral injuries may be inflicted with instruments such as eating utensils or a bottle during forced feedings; hands; fingers; or scalding liquids or 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; fractured, displaced, or avulsed teeth; or facial bone and jaw fractures (Fig. 1, 2). Discolored teeth, indicating pulpal necrosis, may result from previous trauma. Gags applied to the mouth may result in bruises, lichenification, or scarring at the corners of the mouth. Some serious injuries of the oral cavity, including posterior pharyngeal injuries and retropharyngeal abscesses, maybe inflicted by caregivers with factitious disorder by proxy to simulate hemoptysis or other symptoms requiring medical care; regardless of caregiver motive, all inflicted injuries should be reported for investigation.

However unintentional or accidental injuries to the mouth are common and must be distinguished from abuse by judging whether the history, including the timing and mechanism of injury, is consistent with the characteristics of the injury and the child’s developmental capabilities. Multiple injuries, injuries in different stages of healing, or a discrepant history should arouse a suspicion of abuse. Consultation with or referral to a knowledgeable forensic odontologist may be helpful.

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5 Bitemark

Acute or healed bite marks may indicate abuse. Dentists trained as forensic odontologists can assist physicians in the detection and evaluation of bite marks related to physical and sexual abuse. Bite marks should be suspected when ecchymoses, abrasions, or lacerations are found in an elliptical or ovoid pattern (Fig. 3). Bitemarks may have a central area of ecchymoses (contusions) caused by two possible phenomena: positive pressure from the closing of the teeth with disruption of small vessels; or negative pressure caused by suction and tongue thrusting. Bites produced by dogs and other carnivorous animals tend to tear flesh. Whereas, human bites compress flesh and can cause abrasions, contusions, and lacerations but rarely avulsions of tissue. An intercanine distance measuring more than 3.0 cm is suspicious of an adult human bite (Fig. 4).

The pattern, size, contour, and color of the bite mark should be evaluated by a forensic odontologist or a forensic pathologist if an odontologist is not available. If neither specialist is available, a physician or dentist experienced in the patterns of child abuse injuries should observe and document the bitemark characteristics photographically with an identification tag and scale marker in the photograph.

In addition to photographic evidence, every bite mark that shows indentations should have a polyvinyl siloxane impression made immediately after swabbing the bite mark for secretions containing DNA. This impression will help provide a 3-dimensional model of

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6 the bite mark. Written observations and photographs should be repeated daily for at least 3 days to document the evolution of the bite.

Even if saliva and cells have dried, they should be collected using the double-swab technique. First, a sterile cotton swab moistened with distilled water is used to wipe the area in question, dried, and placed in a specimen tube. A second sterile dry cotton swab cleans the same area, then is dried and placed in a specimen tube. A third control sample should be obtained from an uninvolved area of the child’s skin. All samples should be sent to a certified forensic laboratory for prompt analysis.

Documenting and interpreting the significance of bitemarks should be carried out by someone with training and experience in forensic odontology. Dental practitioners should be clear about their own limitations and only offer opinions within their level of expertise.

Child neglect

Dental neglect, as defined by the American Academy of Pediatric Dentistry is the “willful failure of 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”. However many adults visit the dentist only when in pain for emergency treatment and choose not to return for treatment to restore complete oral health. They

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7 may choose to use dental services in a similar manner for their children. Dental professionals have traditionally respected

this choice and not challenged this behaviour. This behaviour can be particularly painful in children affected by dental caries (severe early childhood caries formerly termed “baby bottle” or “nursing” caries), periodontal diseases, and other oral conditions, left untreated (Fig. 5). These undesirable outcomes can adversely affect learning, communication, nutrition, and other activities necessary for normal growth and development.

Neglect may also occur in pregnancy as a result of maternal substance abuse. Once a child is born, neglect may involve a parent or carer failing to provide adequate food and clothing, shelter, failing to protect a child from physical and emotional harm or danger, failure to ensure adequate supervision or the failure to ensure access to appropriate medical or dental care.

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.

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.

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8 The physician or dentist should be certain that the caregivers understand the explanation of the disease and its implications and, when barriers to the needed care exist, attempt to assist the families in finding financial aid, transportation, or public facilities for needed services.

In some cases parents’ lack of knowledge on dental diseases and dietary habits or even oral hygiene measures cannot be equated with wilful neglect of a child. If, despite these efforts, the parents fail to obtain therapy, the case should be reported to the appropriate child protective services agency. However, to avoid misunderstanding, it is advisable to use the term dental neglect for situations where there is a failure to respond to a known significant dental problem, as this is an area that requires forensic background, sensitivity and clinical judgment.

Conclusion

Dentists should be aware that children maltreatment may result in oral or dental injuries or conditions that sometimes can be confirmed by laboratory findings. Furthermore, injuries inflicted by one’s mouth or teeth may leave clues (bite marks) regarding the timing and nature of the injury as well as the identity of the perpetrator.

Dentists are encouraged to be knowledgeable about such findings and their significance and to meticulously observe and document them, thus ensuring appropriate testing, diagnosis, and treatment. For this reason there is a need for further training on forensic

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9 odontology among general dental practitioners, in order to avoid misunderstandings in this area that requires knowledge, sensitivity and clinical judgement.

Odontologists with experience in forensic odontology can and should make themselves available to physicians and to paediatric organizations as consultants and educators.

Such efforts will strengthen prevention and detection of child abuse and neglect and enhance children care and protection.

Corresponding Author Emilio Nuzzolese, DDS, PhD Viale J.F. Kennedy 77

I-70124 Bari

+39 080 5042555 emilionu@tin.it

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10 References

1. United Nations Convention on the Rights of the Child. Geneva, Switzerland: Office of the High Commissioner for Human Rights, 1989.

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5. Jessee SA. Physical manifestations of child abuse to the head, face and mouth: A hospital survey. J Dent Child 1995;62:245-249.

6. Vadiakas G, Roberts MW, Dilley DC. Child abuse and neglect: Ethical issues for dentistry. J Mass Dent Soc 1991;40:13-15.

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11 7. Naidoo S. A profile of the oro-facial injuries in child physical abuse at a children’s hospital. Child Abuse Negl 2000;24:521-534.

8. American Academy of Pediatrics, Committee on Child Abuse. Guidelines for the evaluation of sexual abuse of children: A subject review. Pediatrics 1999;103:186-191.

9. Harris J., Sidebotham P., Welbury R., et al., Child protection and the dental team, the Committee of Postgraduate Dental Deans and Directors, COPDEND 2006

10. Dubowitz H., Bennett S., Physical abuse and neglect of children, Lancet 2007; 369:

1891–99

11. Sfikas P.M., Reporting abuse and neglect, JADA, Vol. 130, December 1999 1797- 1799.

12. Sperber ND. Bite marks, oral and facial injuries: Harbingers of severe child abuse?

Pediatrician 1989;16:207-211.

13. Nuzzolese E., Lepore M.M., Marcario V., Valutazione legale del le lesioni da morso (article in italian), Prevenzione & Assistenza dentale 5/07, Masson-Elsevier (in press).

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12 14. American Academy of Pediatric Dentistry. Definition of dental neglect. Pediatr Dent 2003;25(suppl):7.

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15 Fig. 6.