The “Neglected” Relationship Between Child Maltreatment and Oral Health? An International Scoping Review of Research

Establishing and exploring the relationship between poor oral health and child maltreatment

Exploring the relationship between dental neglect and other forms of maltreatment was a central theme of the included papers. By comparing children already affected by maltreatment with a general population sample, several papers found evidence that maltreated children had significantly poorer dental health than children in the general population (Baptista et al., 2017; da Silva-Júnior et al., 2018; Duda et al., 2017; Keene, Skelton, Day, Munyombwe & Balmer, 2015; Kvist, Malmberg, Boovist, Larheden & Dahllof, 2012; Lourenco, de Lima Saintrain & Gomes Fernandes Vieira, 2013; Valencia-Rojas, Lawrence & Goodman, 2008), although one study did not identify this association (Badger, 1986). Duda et al. (2017), for example, found that maltreated children had a higher incidence of dental caries, missing primary teeth and untreated permanent decay. Drawing on social service data, Kvist, Malmberg, Boovist, Larheden and Dahllof (2012) identified that children in contact with social services (because of maltreatment concerns) had higher rates of dental caries, fillings in permanent teeth, and missed dental appointments. Keene, Skelton, Day, Munyombwe and Balmer (2015) also found that children on a child protection plan had poor levels of dental health and dental health care. These papers highlighted that the relationship between child maltreatment and poor oral health is consistently found. Nevertheless, these papers were retrospective in focus in that they were examining the oral health of children who had already been abused or neglected. Thus, it is questionable whether dental neglect was a signifier or an outcome of maltreatment. To this end, several papers identified the need for further theoretical and empirical inquiry to better understand the intersection between child maltreatment and poor dental health and to provide a more robust basis for clinical diagnosis (e.g., Bhatia et al., 2014; Lorber et al., 2017).

Head and neck trauma: Indicators of potential physical and sexual abuse

Several papers explored rates and characteristics of head and neck trauma among maltreated children (da Fonseca, Feigal & ten Bensel, 1992; da Silva, Goettems & Azevedo, 2016; Greene, Chisick & Aaron, 1994; Maguire et al., 2007; Phillips & van der Heyde, 2006). Auditing hospital child protection files, da Fonseca et al (1992), found that 37.5% of children had experienced head or neck trauma, while da Silva et al (2016) found that maltreated children had more frequent oral and facial injuries than children in the general population. Maguire et al. (2007) also found evidence of higher rates of intra-oral injuries among maltreated children, including lip, gum, tongue and palate wounds, fractures, intrusions and bites. In an audit of autopsies performed on children who had died because of abuse or neglect, Phillips and van der Hyde (2006) found that several children had suffered head and neck injuries, including bruised lips, lacerations to the mouth, torn frenum, and avulsed teeth. This small body of papers highlighted the connection between oral, facial, and neck injuries and children’s experiences of (often serious) physical and sexual abuse. This is an important finding for professionals working outside of dentistry who may not recognize the vulnerability of the head and neck region.

The oral health impact of childhood abuse and adversity across the life course

A small group of studies explored the views and experiences of children and adults affected by childhood abuse. This marked a shift in focus from that of the immediate safety and welfare of children to that of trauma and its oral health implications over time. Bright, Alford, Hinojosa, Knapp and Fernandez-Baca (2015), Matsuyama et al. (2016), and Nicolau, Marcenes and Sheiham (2003), for example, found that adverse and traumatic childhood experiences were associated with poorer adult dental health. Exploring the impact of early life adversity on oral health, Mattheus (2010) identified that adopting a socially informed, ecological approach to oral health assessment could lead to interventions in infancy that would seriously reduce dental health needs in later childhood and adulthood.

Three studies investigated the dental treatment experiences of women affected by childhood sexual abuse (Hays & Stanley, 1996; Leeners et al., 2007; Willumsen, 2004). Hays and Stanley (1996) found that adult survivors had difficulty keeping dental appointments and experienced a higher level of stress-related symptoms, particularly during intrusive examinations. Leeners et al. (2007) similarly found that if women experienced discomfort and feelings of loss of control within the dental consultation, this could lead to the recall of past traumas including childhood abuse. These papers highlight that survivors of childhood abuse and adversity may have additional and complex needs in regard to their oral health and ability to engage in oral health care.

2. Professional knowledge, attitudes, and responses to CAN

Improving knowledge and confidence among dentists

Dental practitioners’ knowledge and attitudes about child maltreatment was the most common investigative focus in the reviewed literature. Despite the geographic and cultural diversity of the studies, their findings were strikingly similar. That is, a majority of studies identified worrying disparities between dentists’ self-reported knowledge and their clinical abilities diagnosing signs of abuse and neglect. Cukovic-Bagic et al. (2015) found dental practitioners’ knowledge of CAN to be limited and that, concomitantly, there were high levels of uncertainty and hesitation among practitioners when diagnosing and reporting suspected cases. Several studies found, like Cukovic-Bagic et al. (2015), that this could lead to misattribution errors in diagnosis and/or result in inconsistent documentation of potential signs of abuse and neglect (da Fonseca et al., 1992; Hazar Bodrumlu, Avsar & Arslan, 2018; Kvist, Annerback & Dahllof, 2018; Preethi, Einstein & Sivapathasundharam, 2011). Similar findings were made by Deshpande et al. (2015), Hussein, Ahmad, Ibrahim, Yusoff and Ahmad (2016), Kaur et al. (2016), Malpani et al. (2017), Mogaddam, Kamal, Merdad and Alamoudi (2016), Al-Jundi, Zawaideh and Al-Rawi (2010), Sonbol et al. (2012), Thomas, Straffon and Inglehart (2006), Tilvawala, Murray, Farah and Broadbent (2014), and Uldum, Christensen, Welbury and Poulsen (2010).

There was also evidence of intraprofessional differences in how practitioners used and shared their knowledge about CAN. For example, Jahanimoghadam, Kalantari, Horri, Ahmadipour and Pourmorteza (2017) found that pediatric dentists had more detailed knowledge and greater confidence engaging with CAN issues than a comparison group of general dentists. O’Callaghan (2012) also found that although dentists had considerable expertise in relation to oral health, they had poor knowledge of CAN issues in comparison to doctors and nurses. Lastly, Thomas et al. (2006) found that dental students’ knowledge and skills about CAN was better than those of dental hygiene students. These intraprofessional studies suggest that training, coupled with familiarization and frequency of exposure to CAN cases, shapeD practitioners’ confidence AND aptitude to diagnose and follow-up CAN-related concerns.

Barriers to accurate diagnosis and consistent reporting practice

Across the studies, common themes were identified relating to the barriers and challenges experienced by dental practitioners diagnosing and reporting concerns about CAN. Problems included: fear of parental reprisal toward the concerned child; violence or litigation against the dental practitioner; professional uncertainty about accuracy of diagnosis; and poor knowledge of reporting procedures (Al-Dabaan, Newton & Asimakopoulou, 2014; Al-habsi, Roberts, Attari & Parekh, 2009; Bankole, Denloye & Adeyemi, 2008; Cukovic-Bagic et al., 2015; Mogaddam, Kamal, Merdad & Alamoudi, 2016; Sonbol et al., 2012; Tilvawala, Murray, Farah & Broadbent, 2014; Uldum, Christensen, Welbury & Poulsen, 2010). Kvist et al. (2014) identified that practitioners regularly experienced dilemmas and felt uncertain when engaging with child protection issues. Practitioners identified tensions between supporting families, reporting child protection concerns and differentiating between child welfare and child maltreatment issues (Kvist et al., 2014).

Several papers called for child protection training to become a mandatory and continuous feature of undergraduate and postgraduate dental education (e.g., Flander, Tarabic & Cukovic-Bagic, 2015; Gutmann & Solomon, 2002; Jessee & Martin, 1998; Malpani et al., 2017), and four papers reported on evaluations of CAN-focused training programs. Al-Dabaan, Asimakopoulou and Newton (2016) and Shapiro, Anderson and Lal (2014) piloted online training modules and reported an improvement in practitioners’ knowledge following completion of the program. Evaluations were also conducted on a classroom-focused child protection module (Harmer-Beem, 2005) and an interactive training program (Soldani, Robertson & Foley, 2008): both studies reported improved levels of practitioner knowledge and confidence post-intervention.

In terms of assessing current levels of dentists’ knowledge, Brattabo, Bjorknes and Astrom (2018) found high levels of awareness that persistent non-attendance and severe dental caries could be indicators of dental and global neglect. Similarly, Harris, Welbury and Cairns (2013) found improved rates of knowledge about, and reporting of, CAN among a cohort of dentists over a seven-year period. deMattei and Sherry (2011) noted an improvement in practitioners’ knowledge of CAN between 1994 and 2009; however, the authors cited concerns that this did not consistently result in accurate diagnosis or timely reporting (deMattei & Sherry, 2011). Soldani, Robertson and Foley (2008) reported similar concerns that training needed to be continuous and bespoke if dentists’ attitudes and approaches to CAN were to change in the long term. These studies indicate that dentists’ knowledge and attitudes toward child protection and child welfare have changed over the last 20 years. Nevertheless, the sample sizes were small, and many relied on self-report measures.

3. Future directions and noteworthy findings

Interdisciplinary practice

Several papers explored the quality and consistency of working relationships between dentists and professions such as public health nursing, social work and pediatric medicine. These studies were predicated on the view that an integrated approach was necessary to meet the complex oral health and social needs of children affected by CAN (Al-Dabaan, Asimakopoulou & Newton, 2016; da Silva-Junior et al., 2018; Duda et al., 2017; Lourenco et al., 2013; Ramazani, 2014). Studies highlighted concerns about contemporary practice. For example, Brattabo et al. (2018) found that although dental practitioners were making increased numbers of referrals to child welfare services, they were infrequently given feedback about what action had been taken, following referral, and the rationale for these decisions. The authors suggest that this may damage nascent relationships between dental practitioners and children’s social services (Brattabo, Bjorknes & Astrom, 2018). Similarly, Kvist et al. (2012) found that a lack of trust was a major inhibiting factor to dentists making referrals to child welfare services, as did Harris, Firth and Chadwick (2017). Similarly, Bradbury-Jones, Innes, Evans, Ballantyne and Taylor (2013) found that public health nurses used proxy measures alongside opportunistic investigation to investigate concerns about children’s oral health. Nurses identified that there were gaps in their knowledge about the link between untreated dental caries and child neglect and limited opportunities to work with, or even communicate regularly with, dentists (Bradbury-Jones, Innes, Evans, Ballantyne & Taylor, 2013). When combined with a relative paucity of established reporting systems, these limitations in inter-professional communication and trust could result in children “slipping through the net” between dental and child protection services (Harris, Firth & Chadwick, 2017).

Several papers highlighted how inconsistent policy and guidance had a negative effect on inter-professional practice and the translation of research into practice (Adair et al., 1997; Laud, Gizani, Maragkou, Welbury & Papagiannoulis, 2013; Mogaddam et al., 2016). For example, Kvist, Annerback and Dahllof (2018) investigated how different Swedish localities implemented national law and policy guidance and found high levels of variation. They found that dental surgeries or departments that had developed their own policies consistently made more child protection referrals to social services. Those who had not developed local protocols had consistently lower rates of referral. Similarly, Kaur et al. (2016) found that despite mandatory guidance to report child protection issues, dental practitioners had limited knowledge about how to do so and this in turn resulted in low reporting rates. These papers thus identify that there continues to be a fragmented and ad hoc nature to service provision, despite the growing body of empirical evidence that links child maltreatment and poor oral health.

New directions and issues

There were many cross-cutting themes in the included papers; however, there were also papers that broke new ground, studying populations or issues that had hitherto received limited research focus. For example, Al-habsi, Roberts, Attari and Parekh (2009) and Kvist, Zedren-Sunemo, et al. (2014) identified an association between children requiring anesthesia in dental care—often as the result of more complex dental treatment needs and poor dental health—and children who had experienced abuse or neglect. Alongside dental caries and repeat extractions (Sillevis Smitt, de Leeuw & de Vries, 2017), anesthesia may therefore be another way of identifying children at risk of abuse or neglect. Kivisto, Alapulli, Tupola, Alaluusua and Kivitie-Kallio (2014) found that children whose parents used Buprenorphine had significantly higher levels of dental caries, decayed, missing and filled teeth as well as lower levels of dental care from their parents and carers. Finally, Melbye, Huebner, Chi, Hinderberger and Milgrom (2013) found that although children in foster care often had significant dental health needs, they received sporadic and inadequate dental care because of dentists' concerns about payment of their treatment costs, the children's relative transience (moving between homes and therefore dental practices), and the low priority given to their oral health by foster parents and social workers. These studies raise questions about whether it is appropriate to develop targeted interventions to better recognize and prevent poor oral health for some, particularly vulnerable, groups of children and young people.