”Somewhere in the world a child is suffering deliberate harm, inflicted by someone who is supposed to care about them, at this very moment. ”

-Hinchliffe¹

Child abuse is a grave violation of a child's fundamental rights and is a significant international public health concern. It does not differentiate between classes and masses and pervades all strata of society.

Caffey, an American Radiologist and Pediatrician, was the first to recognize child maltreatment as a social pathology.² He was later corroborated by Silverman (1953) and Kempe (1962). who also coined and defined battered child syndrome.³

Several definitions have been given over the years to define this heinous indulgence. The Centre for Disease Control and Prevention states that child maltreatment is “any act or series of acts of commission or omission by a parent or other caregiver that results in harm, potential for harm or threat of harm to a child. ”⁴ The Journal of Child Abuse and Neglect defines it as “any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation, an act or failure to act which presents an imminent risk of serious harm. ”⁵ As per the World Health Organization (WHO), “child abuse or maltreatment constitutes all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child's health, survival, development or dignity in the context of a relationship of responsibility, trust or power. ”⁶

Dentists are at a vantage point when it comes to identifying child abuse. Literature shows that about 60%–75% of child abuse victims present with head, face, and mouth injuries.⁷,⁸,⁹ Furthermore, dental practitioners and auxiliaries come in regular contact with children and their caregivers and thus have an opportunity to assess not just their physical and psychological conditions but also their family milieu.¹⁰ A dentist's onus in preventing child abuse and neglect was first taken up in the 1970s.¹¹ The American Dental Association appended the required recognition and reporting of perioral signs of child abuse to its Principles of Conduct and Code of Ethics. The code now states that dentists are obliged to familiarize themselves with perioral signs of child abuse to report suspected cases to appropriate authorities consistent with state law (House Resolution 23S-1B).¹² However, Human Rights Watch reports that no doctor (general practitioner, gynecologist, pediatrician, or dentist) in India has received any training vis-à-vis child abuse identification, examination, reporting, or rehabilitative procedures.¹³

This review attempts to summarize the available information on child abuse and the role of dentists in identifying, preventing, and protecting the rights of the victims.

Data were collected using the following key words: “Child abuse in dental settings, ” “role of dentist in child abuse, ” “reporting of abuse by dentists, ” and “prevalence of child abuse in India and globally ” on PubMed, PubMed Central, MEDLINE, Google scholar, and Google search engines. The reference list of selected papers was handsearched for further relevant articles. The search was limited to articles and books in English. A total of 27 articles meeting the search criteria were found. Since all the available literature was of a descriptive kind, all articles, case reports, and past reviews were included.

The term abuse has varied connotations across different cultures and socioeconomic status. The WHO provides descriptions for different kinds of abuse as follows:

Physical abuse

It is the inflicting of physical injury on a child and includes burning, hitting, kicking, punching, shaking, or otherwise harming a child. The parent or caretaker may not have intended to hurt the child. It may, however, be the result of overdiscipline or physical punishment that is inappropriate to a child's age.¹⁴

Sexual abuse

Improper sexual behavior with a child which includes fondling a child's genitals, making the child fondle an adult's genitals, intercourse, incest, rape, sodomy, exhibitionism, and sexual exploitation. To be considered child abuse, these acts have to be committed by a person responsible for the care of a child or related to the child. If a stranger commits these acts, it would be considered sexual assault and handled solely by the police and criminal courts.¹⁴

Emotional abuse

It is also known as verbal abuse, mental abuse, and psychological maltreatment. Acts or failure to act by parents or caretakers that have caused or could cause serious behavioral, cognitive, emotional, or mental trauma to a child are included in this.¹⁴

Neglect

It is the failure to provide for a child's basic needs. Neglect includes physical, educational, or emotional components.¹⁴

WHO (2002) surmises that almost 53,000 child deaths in 2002 were due to child homicide. About 20% and 65% children confess having been verbally or physically bullied in school. An estimated 150 million girls and 73 million boys under 18 have gone through sexual violence involving physical contact of some kind. The International Labor Organization estimates that 218 million children were involved in child labor in 2004, of whom 126 million were engaged in hazardous work. Only 2.4% of the world's children are legally protected from corporal punishment in all settings.¹⁴

In the Indian scenario, Kacker et al.¹⁴ report that 2 out of every 3 children are physically abused (88.6% by their own parents), 53.2% children face one or more forms of sexual abuse, and every second child reported facing emotional abuse (parents were the abusers in 83% of the cases).

The true prevalence of child abuse is difficult to determine as many cases are never reported/investigated or simply not recognized.

Current global statistics about recognition and reporting of child abuse by dentists is not available. However, earlier reports show that there is inadequate identification of child abuse cases and its reporting is low.¹⁵

The situation is not much different in India. A large proportion of child abuse cases go unreported. It is seen that dental graduates are not well prepared to recognize such cases, and even if they can do that, they do not have adequate knowledge about how or where to report them.¹⁶,¹⁷

Thus, it is imperative to outline some of the easily recognized signs of abuse¹⁴,¹⁸ Table 1 and Table 2.{Table 1}{Table 2}

(Injuries in different stages of healing with misleading or ambiguous explanation should rouse suspicion of child abuse).

Neglect

Negligence in meeting fundamental needs of a child also falls under maltreatment. Among the various forms of maltreatment mentioned above, a significant one from a dental perspective is dental neglect.

Dental neglect

The American Academy of Pediatric Dentistry defines it as the “willful failure of parent or guardian, despite adequate access to care, 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. ”¹⁹

Dental neglect can manifest orally as unattended dental caries that can be easily visually identified by an average individual, ulcers in the oral cavity, and extraorally, dental problems that impact the child directly.²⁰ The child also exhibits behavioral problems which are indicative of not just dental but other types of isolation problems as well.

As a precaution from overreporting, it is important to distinguish dental neglect from dental caries. There might be neglect when it comes to oral health but not necessarily a neglectful attitude.²¹ A history of improper dietary habits and poor dental hygiene practices apart from direct observations may help in diagnosis.²⁰

Some peculiar signs of neglectful parents, which help in identification of dental neglect, might be the following:²²

Causing delayed attendance and repeated missed appointments for scheduled dental assessment

Apart from the types discussed, there exist two rare forms of neglect. These bizarre entities are opposite ends of the same spectrum dealing with medical care. Medical care neglect is a condition in which caregivers fail to provide the required treatment to infants or children with life-threatening or other grave/chronic medical conditions. Its exact opposite is Munchausen syndrome by proxy – an unusual disorder in which a caregiver, usually the mother, either simulates or creates the symptoms or signs of illness in a child. The child can present with a long list of medical problems or often bizarre recurrent complaints. Fatal cases have been reported.²³

Child abuse does not usually occur without reason and is a result of different factors/causes. Careful probing generally reveals background factors which lead to individuals resorting to such tendencies. Some of the commonly agreed on risk factors are:⁴

Children with special health care needs – learning disabilities, developmental disorders, chronic illnesses, mental retardation, etc

It is to be, however, noted that, children from all socioeconomic backgrounds and not just low-income families are at risk of being maltreated.

A few signs that indicate child abuse can be:¹⁵

Lack of parental concern for the child

Abuse is not an isolated, one-time event. It can have devastating, long-lasting effects on the victims. Often, the lingering effects affect an individual not just physically but mentally as well. These victims may suffer from:²⁴

Physical health consequences – Impaired brain development and poor physical health

Apart from these, dental neglect can also adversely affect a child in the following ways:²²

Dental pain

These not just affect the child's oral functions but lead to negative effects on nutrition, learning capacity, and other activities which are fundamental for normal growth and development.

Thus, child abuse, affects the sufferer in more ways than one and results in a life-long battle with the self.

Any child abuse incident should be reported to the local police. The Indian constitution recognizes the vulnerable position of children and their right to protection.¹⁴ Several laws have been framed through many international and national conventions toward this end. However, the implementation of these strategies remains elusive. Citizens are grossly unaware of these legal aids and often feel thwarted when it comes to dealing with child abuse. The Ministry of Women and Child Development reported the national prevalence of child abuse in 2007,¹⁴ and several measures to safeguard children from abuse were framed after that. One of them is the Integrated Child Protection Scheme. The main objectives of this are:

Creating database and knowledge base for child protection services

Also, a new National Policy For Children (2012) has replaced the earlier 1974 policy.²⁵ Apart from these, several schemes are currently in operation for catering to child protection.¹⁴ The Indian Parliament, in one of its biggest moves toward child protection, passed the Protection of Children from Sexual Offences (POSCO) act in 2012. Under this, all forms of sexual abuses are specific criminal offenses. If a clinician suspects that a child has been or is being sexually abused, he/she is required to report this to the authorities. Failure to do so will result in imprisonment of up to 6 months, with/without fine.⁴

Several nongovernmental organizations (NGOs) in India are also working toward rehabilitation, feeding and education of underprivileged and abused children. Details of these can be easily accessed through the online link: http://www.ngosindia.com.⁴

Dentists are at an advantage when it comes to identifying child abuse. As most of the characteristic signs can be visualized in the craniofacial and oral regions²⁶ (as discussed above), the identification and reporting of abuse becomes not just a moral but legal responsibility as well.²⁷ Not just this, it is observed that perpetrators keep changing the hospitals and clinicians to avoid suspicion; however, they visit the same dentist repeatedly.⁴

It is important to report child abuse to save such children from further harassment. In some cases, these victims may repeat the pattern of abuse with their own children. Such reporting is not only required for ethical reasons but has been mandated under Section 21 (1) of the POSCO act, 2012. Failure to report a suspicion of child abuse is punishable. Furthermore, reporting is required irrespective of whether the information was acquired through professional duties or within a confidential relationship of information.⁴

Incomplete history or inadequate explanations of injuries should raise concern of maltreatment. Delay in seeking treatment, history of multiple injuries, an adult other than the parent(s) seeking treatment, and injuries attributed to a sibling are all possible indicators of abuse, especially when there are discrepancies between clinical findings and history provided.²⁸

Further probing should be done when children exhibit violent behavior, withdrawal from touch, oblivious of environment, wary of adults, watchful, unusual sexual behavior or knowledge, wearing unusual clothing for the season. The dental team should begin observing a child as soon as he/she enters the dental clinic for signs of limp, favoring a particular limb/body part, ability to sit with/without difficulty apart from their emotional/mental state. A responsible dental team follows 4 Rs – recognize, record, report, and refer when it comes to child abuse.²⁷

It is seen that dentists generally shy away when it comes to reporting child abuse cases. Although majority of them confirm that they can identify abuse, ironically, the same majority is hesitant to report it to appropriate authorities.²⁹ A few reasons why this might be the case are as follows:²⁸

Fear of legal entanglement

Dentists should know that they are mandated to report suspected cases of child maltreatment, with immunity granted to voluntary reporters acting in good faith.³⁰

It is seen that dentists who can identify signs of abuse often act as sleuths themselves and instead of finding out “if something happened? ” try to find out “who did it? ”³¹

It is important that a proper protocol be developed and followed when a suspicious case comes along. Interviewing the parents and the child together and documenting this activity is the prime step in recognizing and reporting child abuse. A few other pointers are:⁴

A gross assessment of the child should begin as soon as he/she walks in the clinic

The details to be included in an abuse report include:⁴

Names and address of the child and its parents

Child abuse is odious act deserving the severest of censure. Dentists can easily recognize it and must take a proactive role in helping the victims. Healthcare providers (including dental health professionals) should be aware of signs of child abuse. It is important that documentation of suspicious injuries along with relevant proofs be properly done. They should also know that injuries caused by a perpetrator's mouth or teeth may leave clues which should be meticulously evidenced. Interdisciplinary coordination is needed with pediatric dentists or with a person with formal training in forensic odontology to ensure proper testing, diagnosis, and treatment.

Based on the discourse and observations above, some recommendations are being given for improving the understanding of dental professionals regarding handling a case of child abuse:

Provision of courses on child abuse identification and reporting in undergraduate and postgraduate dental curricula in the country

Such endeavors will bolster our ability to prevent and identify child abuse and neglect and pave the way for better care and protection of our children.

Financial support and sponsorship

Nil.

Conflicts of interest

The authors of this manuscript declare that they have no conflicts of interest, real or perceived, financial or non-financial in this article.