The position of children in the society is well defined by the United Nations Convention on the Rights of the Child from 1989, applied to all under the age of 18 years. Now, 196 countries are party to it, including every member of the United Nations except the United States.
There are four fundamental rights of a child: education, protection, participation and development. Our role as healthcare professionals are connected mostly to protection and development. The right to protection safeguards children from abuse and exploitation, while the right to development emphasizes access to nutrition, healthcare, and opportunities that promote physical, mental, and emotional well-being.
According to WHO data, nearly 3 in 4 children aged 2-4 years regularly suffer physical punishment and/or psychological violence at the hands of parents or caregivers, and 1 in 5 women and 1 in 13 men report having been sexually abused as a child. Every year, there are estimated more than 40 000 homicide deaths in children under 18 years of age, some of which are likely due to child maltreatment. It is not unexpected that number of PubMed publications related to child abuse are strongly increasing, especially in the last 5-10 years.
Approximately one fourth of forensic dentistry work is connected to assessing abuse cases, very frequently connected to children who are trafficking victims also. According to the United Nations Global Report on Trafficking in Persons from 2022, they are twice as likely to face manyfold abuse and exploitation than adults during migration and refugee flows.
Dental Health Professionals had a Low Frequency of Reporting of Child Physical Abuse
Studies across many countries (including Croatia) show that there is primarily a lack of knowledge about recognizing and identifying the early signs of abuse and because of insecurity in diagnosing; the cases are not reported to social services. In the same time results show the willingness of medical/dental students and medical/dental doctors to learn more about the issue, which emphasize the importance of comprehensive education across the dental curriculum about child abuse.
Dentists are in the unique position when it comes to identifying child abuse. About 60 to 75% of child abuse victims have head, face, neck or oral injuries. Physical abuse may involve hitting, burning, kicking, shaking, punching, etc. It is always important to remember that a child with one injury may have further injuries, so, where possible, arrangements should be made for the child to have a comprehensive medical and dental examination.
Accidental injuries typically involve bony prominences, should match the history, usually are unilateral and are in keeping with the phase of child's growth and development.
Concerns for non accidental injuries are raised by bilateral injuries, so visible at the same time to both sides of the body, injuries to soft tissue, injuries with particular patterns, any injuries that don’t fit the explanation, injuries with delays in presentation and untreated injuries. We should be suspicious if we notice black eyes, injuries of soft tissues of the cheeks, intraoral injuries, inner sides of forearms, injuries of chest and abdomen, inner parts of legs, ears, back and side of trunk and injury in the triangle of safety. The injury in this region is always alarming and very typical for non-accidental or intentional injury.
Emotional abuse is not very visible to us, but could cause severe and persistent adverse effects on the child’s emotional development.
Sexual abuse could be contacted or non-contacted, penetrative or non-penetrative, and could include other inappropriate activitIes. The signs of sexual abuse which could be seen intraorally, are: erythema, ulceration and vesicle formation arising from sexually transmitted diseases/infections, as well as erythema and petechiae at the junction of the hard and soft palate.
Neglect is the most frequent type of abuse – it is the failure to provide for a child’s basic needs and affects a child adversely both physically, educationally, psychologically, socially, and medically.
AAPD has defined dental neglect as a 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. Dental neglect is a specific type of medical neglect and has 3 main indicators: untreated/rampant caries/oral pain, infection or orofacial trauma and irregular attendance and repeatedly failed appointments.
If you think that you are faced with a child who may have been abused you have to follow proper protocol. The first step is to interview the child and parent. Are there any strange child’ behavior or interactions with parents? When interviewing, you should have a witness (dental assistant). Open ended, general questions should be asked. You have to see if there is a delay in seeking dental treatment and why. Then, does the history differ through the time or between the child and parent?
Clinical Examination: Are There Any Injuries Which Are Not Explainable?
If you are not an experienced examiner, discuss the case with experienced colleagues. If you still have concerns, then talk to the child and parent about it, inform them about your intention to share the information. Refer for medical examination if necessary, and keep full clinical records. Refer to social services or police - be prepared to write a report for a case conference and arrange dental follow up. Every report is an important document which is to be used for further actions in social services or court procedures.
We need to spend more time on a holistic approach to our children, following the professional, moral, ethical, and legal rules. Only by raising awareness of professional responsibility and working on education can contribute to more effective recognition of the earliest symptoms of abuse and neglect as well as to reporting, and thus helping this vulnerable group. Preventing child maltreatment before it starts is possible, but requires a continuous education and intensive multi sectoral work.