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Oral Neglect as part of Child Neglect
Alison Cairns
Senior Clinical University Teacher/ Honorary Consultant in Paediatric
Dentistry
Oral Disease
• Chronic disease leading to pain and discomfort
• Young children with untreated dental caries weigh less
than controls
• Following treatment of dental caries in young children
there is rapid weight gain and improvement in quality of
life as well as cognitive development
• Weight gain attributed to an improvement in the quality
and variety of food the child is able to consume and due
to the removal of chronic inflammation known to
suppress growth through metabolic pathways
Obvious dental caries
Prevention of Dental Caries is Basic
• Brush twice daily with appropriately fluoridated
toothpaste (help and supervision until age 8)
• Restrict consumption of sugary food/drink to
mealtimes only
Dental Caries
• Like most other chronic childhood diseases dental
caries is predominantly a disease of the poor with the
lower socioeconomic groups having the majority share
of the problem
• Childsmile programmes have been successfully
targeting these groups with free brushes/paste, fluoride
varnish applications and dental health advice/support,
this programme is currently highly successful with a
decreasing caries rate in the general child population
Dental Neglect
• “wilful 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”
American Association of Paediatric Dentistry Sept 2010.
Dental Neglect
• “the persistent failure to meet a child’s basic oral health
needs, likely to result in the serious impairment of a
child’s oral or general health or development.”
British Society of Paediatric Dentistry 2009
BPSD: a policy document on dental neglect on children
Recommendations
• Gross dental caries in children should be a
healthcare priority
• Children at risk of abuse or neglect are also
at high risk of oral neglect/disease
• Dentists should follow local procedures and
refer when concerned about possible
significant harm
• Rigorous follow-up
BPSD: a policy document on dental neglect on children
Recommendations- Research
• More studies to look at the relationship
between oral health and child maltreatment
• Establish and test diagnostic criteria for
dental neglect and thresholds for intervention
• Investigate management strategies for
untreated dental caries
Child Abuse - Caries
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903 children, 5-13years
430 child abuse: 473 controls
DMFS -2 dentists
logistic regression analysis to control other variables
whilst the influence of abuse was evaluated on
untreated teeth
• Abused children 8 x more likely to have untreated
decayed teeth
Green at al. Paed Dent 1994
Child Abuse - Caries
• 66 children, 56% boys
• Children admitted to the Children’s Aid Society of
Toronto from 1991-2004
• Age 2-6 yrs (primary dentition)
• Untreated caries in- 57% ‘neglected’, 62%
physically/sexually abused
• General population of 5 yr olds in Toronto with
untreated decay = 30%
Valencia-Rojas et al 2008
Child Abuse - Caries
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52 witness to violence or subject of violence
65 eating disorder
120 controls
Abused children higher plaque index, higher
untreated decay, more evidence of gingival
bleeding than other 2 groups.
Montecchi et al 2009
Comprehensive Medical Assessments GGC
• CMA’s were being successfully set up in GGC
• Attended a meeting to pitch that a medical
assessment cannot be comprehensive if it does not
include a comprehensive oral assessment
• Answer was “yes”, now all I had to do was persuade
oral health directorate management!
• Was also lucky enough to get an MSc student on
board who undertook the development of the
pathway and gathered initial data (paper currently
being reviewed by Child Abuse Review- Harris,
Welbury and Cairns)
Research Question
• What is the prevalence of oral disease among children
referred for comprehensive oral assessments
• Data awaiting publication looks at children seen
between 2009- 2011, I can present today information
on children seen up until August 2013
Medical team alert dental
team re child with a
welfare concern
Local dental team
provide COA on same
day as CMA
Local or more remote
dental team may have to
arrange separate
appointment for COA
Dental notes completed
and dental appendix
passed onto medical
team
Treatment needs
coordinated with GDP,
community or hospital
dental services
More work required with
regard to long term dental
follow-up
Information we collect
• Demographics
• dmft/ dmfs scores
– D (decay) and quantifies the treatment need
– M (missing) which along with f (filled) quantifies past treatment
carried out
• Plaque and perio scores (oral cleanliness and gum
disease)
• Erosion, dental defects, soft tissue abnormalities etc
• Details of registration with dental services
Findings Dec 2009-Aug 2013
• 199 children seen for COA with age range from 4
months to 17 years (mean 6 years)
• Children examined over 9 different sites in Greater
Glasgow (majority in Bridgeton, Drumchapel and
Possilpark)
• All resided in areas with SIMD quintiles of 3 or less
(83.4% were from SIMD 1)
Findings Dec 2009-Aug 2013
• Number of caries free children aged 9 and younger was
32% and for those aged 10 and over was 17%.
• Only 28% from the total 199 children were caries free
• Much lower than the current national averages (64% for
5 year olds and 62.6% for 12 year olds)
Findings Dec 2009-Aug 2013
• Dmft for children aged 9 and younger was 2.52 while
for the older age group (>10) it was 5.0
• Higher than local (1.85 for 5 year olds, 0.89 for 12 year
olds) and national (1.52 for 5 year olds, 0.7 for 12 year
olds) means
• For those >10 years the DMFT was 6 (national mean
for 12 year olds =2.4)
Findings Dec 2009-Aug 2013
• Proportions of children who have evidence of trauma
(7.4%) or hypoplasia (5.4%) was broadly similar to the
general population (5 – 40% for trauma, 2.4 - 40.2% for
hypoplasia)
• Evidence of tooth wear in 25% of children aged 9 years
and younger and 18% of those aged 10 years and over
• A care pathway for children with a welfare concern in
Greater Glasgow and Clyde has been developed but still
requires refinement especially when it comes to “closing
the loop”.
Recommendations
• COAs integral to CMAs
• Other professionals need to be made aware of the
type of input paediatric dentistry can give
• COA’s should be carried out by dentists who have
had extra training not by general dental
practitioners
• Role of co-ordinator of COAs needs to be
developed and always held by someone with
extensive knowledge of both the role of dental
practitioners in CP and CP systems
Recommendations
• Targeted prevention of dental caries should be
available for all children referred for CMA
• Continue efforts to improve pathways of care for dental
treatment for this group as these families often have
limited ability to engage (possibility of dental health
support workers?)
• Follow up of these children needs to be improved
through better inter agency working
Case Study 1
• 13 year old female
• Social worker contacts CPU for early sharing and to
request CMA
• Child already placed on Child Protection Register due to
chronic neglect
• Dental concerns
Case Study 1-Concerns
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Missed health appointments including dental
Concern raised by child’s new GDP
84% school attendance
Taking caring role for younger siblings
23 calls to Police from neighbour
Home conditions – “very poor cleanliness”
Bereavement issues
Otherwise well and healthy looking
Case 1- key learning points
• Missed dental appointments is one concern of many but
main concern in this case
• New GDP raised concerns that brought child to attention
of social worker
• Input from health services including dental is essential in
assessment of child’s circumstance
Case 1- Dental history
• Significant previous dental treatment including exposure
and bonding of gold chain to unerupted central incisor in
2009
• Missed 3 appts with hospital ortho dept, not seen for 18
months
• Letter sent to GDP re this
• Then seen again for 4 appts in hospital paed dental dept
and ortho dept
• “Social issues” noted in casenotes as reason for previous
missed appts
Case 1-Dental history
• Missed further 3 appts in paeds and 1 in ortho
• Standard letter sent no further hospital appts
• Siblings missed dental GAs
Case 1- Key learning points
• Social history important as is rigorous follow up
• GDPs hold info re family situations that dental hospitals
etc do not have information regarding e.g siblings
Case 1- social history
• Father died while mother acutely ill in hospital
• Mother had acute grief reaction but social workers
believe other issues
• No longer interested in children and cold towards them
Case 1- Outcomes
• Child and siblings accommodated with foster family
• Close contact with social worker to ensure attendance at
health appts especially dental
Case 2
• Siblings- Female 8 years, male 6 years, female 6 months
• Referred for comprehensive oral assessment as part of
comprehensive medical assessment
Case 2
Both older siblings
• obvious ingrained dirt on school uniforms
• skin and hair visibly dirty
• Smelly
• Active dental caries
Case 2
• 6 year old- poor oral hygiene
• 8 year old- good oral hygiene round anteriors, plaque
deposits on posteriors
• Very compliant for examination
• Father blames children- “they never brush their teeth
when I tell them to”
• Both registered with GDP
Case 2- learning points
• Extra oral appearance is important
• Children need assistance with toothbrushing until
approx 8 years of age
Case 2
• 6 month old- clean freshly laundered clothes
• Hair and skin appeared clean
• 2 lower incisors present and oral hygiene good
Case 2- Key Learning Points
• It may be not all children in a family who are abused/
neglected
Case 2
• Father made aware of dental needs of children and
elected to go to own GDP for treatment
• Copy of dental report sent to GDP
Case 2
• Also telephone call to GDP to check registration
• GDP confirmed registration but reports children failed to
complete treatment and were irregular attenders
(though compliant)
• Few weeks later GDP contacts to say children not
returned
Case 2- Key learning points
• Irregular attendance and failure to complete treatment
are alerting features (www.cpdt.org.uk)
• Dentists hold key information other professionals do not
• Information sharing essential- without dental report GDP
unaware their patient subject to CMA
Case 2- Outcome
• Children’s social worker contacted re failure to attend
subsequent dental appts
• Social worker reports children have been
accommodated in different health board and requests
permission to share dental report with new GDP
Where does Dentistry Sit in a Professional Capacity?
GDC statement on child protection and vulnerable adults
Friday, May 30, 2008
• The GDC expects all registrants to be aware
of the procedures involved in raising
concerns about the possible abuse or
neglect of children and vulnerable adults.
• All dental professionals have a responsibility
to raise concerns about the possible abuse
or neglect of children or vulnerable adults. It
is your responsibility to know who to contact
for further advice and how to refer to an
appropriate authority (such as your local
health trust or board).
Final Thoughts…
• We have received excellent feedback re the contribution
of the COA by the medical team and will work to improve
communication and pathway development
• We feel encouraged that we have managed to identify
and provide treatment for this hard to reach group
• Hopefully others will be encouraged to incorporate
dental into their CMA’s