Everyone has a responsibility in society to ensure that children are kept safe from harm and dental professionals have the responsibility to act on any concerns they may have about the safety of a child.
There are many forms of child abuse one of which is neglect, dental professionals should be aware of what general neglect and dental neglect is and how to respond to it appropriately. In 2003, the government published Every Child Matters (Department for Education and Skills) which identiﬁed ‘being healthy’ and ‘staying safe’ as two of the ﬁve most important outcomes for children and young people. A 10-year strategy for delivery of these outcomes was produced in 2004 (Department of Health). This document adopted safeguarding and promoting the welfare of children as one of its key standards. The perception of child neglect has changed significantly over time. It is now recognised as one of the most dangerous forms of abuse because of its harmful and sometimes fatal effects (Turney and Tanner, 2005). Child Protection Register (CPR) statistics indicate that neglect is the leading category for registration across the UK. The latest statistics for England, for example, show that in the year up to 31 March 2007, neglect was given as a reason for registration in 44 percent of cases, representing 14,800 children (DCSF, 2007). Neglect is also the most common reason for someone to contact the NSPCC (NSPCC, 2012).
What is Neglect?
Neglect is a difficult term to define, however the government guidance for England, Working together to safeguard children (HM Government, 2010), defines neglect as:
"…the persistent failure to meet a child's basic physical and/or psychological needs, likely to result in the serious impairment of the child's health or development. Neglect may occur during 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, clothing and shelter (including exclusion from home or abandonment); protect a child from physical and emotional harm or danger; ensure adequate supervision (including the use of inadequate care-givers); or ensure access to appropriate medical care or treatment. It may also include neglect of, or unresponsiveness to, a child's basic emotional needs."
Signs of General Neglect
• Failure to thrive
• Short Stature
• Ingrained dirt
• Developmental delay
• Inappropriate clothing (e.g. t-shirt in cold weather)
• Animal bites
• Frequent injuries
• Withdrawn or attention seeker
What is Dental Neglect?
There is currently no UK definition of dental neglect, however dental neglect is defined by the American Academy of Pediatric Dentistry as, “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 “
Dental Neglect can be categorised as general neglect or wilful neglect and this differentiation of the two may help to determine the most appropriate response.
Dental Neglect- General Neglect
General neglect can result from a parent’s or carers lack of knowledge or understanding of dental disease and it’s prevention or from difficulty implementing the dietary habits or oral hygiene measures that they would ideally want this can be due to poverty or a stressful family situation. This cannot necessarily be equated with wilful neglect of a child. When assessing whether multiple carious teeth and poor oral hygiene are an indicator of general neglect, the impact of dental disease on the individual child should be assessed. Severe dental disease can cause:
• disturbed sleep
• difficulty eating or change in food preferences
• absence from school
which may put a child at risk of:
• being teased because of poor dental appearance
• needing repeated antibiotics
• repeated general anaesthetic extractions
• severe infection.
Dental Neglect- Wilful Neglect
Wilful neglect is the term to describe a failure to respond to a known significant dental problem. The signs may include:
• a delay in the presentation
• discrepancies between the history and examination findings
• pain that has been left untreated
• irregular attendance and repeatedly failed appointments
• failure to complete planned treatment
• returning in pain at repeated intervals
• requiring repeated general anaesthesia for dental extractions
• developmentally inappropriate findings (does not fit with the age of the child)
• previous concerns about the child or siblings.
What is the responsibility of the dental team?
The Department for Education and Skills (2006) states that “all health professionals working directly with children should ensure that safeguarding and promoting their welfare forms an integral part of all stages of the care they offer.” and the General Dental Council’s Standards Guidance (2005) clearly states that the dental team have an ethical obligation to find out about local procedures for child protection. Registrants should make sure they follow these procedures if they suspect that a child may be at risk because of abuse or neglect. Additional to this, registrants must maintain appropriate boundaries in the relationships they have with patients and must not abuse those relationships to ensure that children are not at risk from members of our own profession and to take action to prevent this e.g. by safe staff recruitment. It is your responsibility as a GDC registrant to raise any concerns that you may have about colleague in regards to the safety of children.
Details of your local safeguarding board (in England and Wales) can be found here or you can find the telephone number for your local “social services and children’s services” in your local telephone directory, alternatively use an internet search engine to search for “LSCB” followed by your local council.
How to respond to Dental Neglect
Sidebotham et al (2006) said “members of the dental team are not responsible for making a diagnosis of child abuse or neglect, just for sharing concerns appropriately.” Continuing to say, “The most important thing to remember when you are faced with a child who may have been abused is that you do not need to manage this on your own.” Guidance produced by the British Society of Peadiatric Dentistry (2009) states that “when a diagnosis of dental neglect is under consideration, a thorough assessment should be carried out. The diagnosis is not purely based on clinical ﬁndings; several other dental and non-dental factors need to be taken into account.”
Firstly the child should be assessed, a thorough history should be taken, the child should be examined carefully, talk to the child and write down what is said in the child’s own words, discuss with an appropriate colleague and decide on the level of concerns if any. Decide whether the concern level is low, moderate or high and respond accordingly.
Taking a thorough history includes taking details of:
• presenting complaint
• past dental history
• medical history
• family and social circumstances (including intervention of social services)
Any concerns could be discussed with an experienced dental colleague, a consultant paediatrician, chid protection nurse, social services (on an informal basis), with child’s health visitor or school nurse.
Low Level of Concern
This would be indicated by the following:
• Widespread disease
• No infection
• Poor oral hygiene
• Late presentation
This situation would require a preventative education approach. The parent or carer should be advised of the concerns regarding the child’s dental health and/or general wellbeing. Tooth brush instruction and oral health education should be given in a way suited to the parent/carer and child. Setting targets allows the parent/carer to show that they can ensure proper care of the child. An emphasis on the importance of attending appointments should be placed, because if they were to stop attending this may escalate the cause for concern. This child should then be monitored locally unless there are any other causes for concern.
Moderate Level of Concern
This would be indicated by the following:
• Failure to attend appointments
• Not taking information given on board
• Multiple general anaesthetics to extract teeth due to not putting prevention in place
• In social care
• The child has CAF involvement (care assessment framework)
If there is a moderate concern, provide urgent dental care, concerns should be discussed with the child and parents/carers and it should be advised that other agencies already involved with the family may be contacted. Agencies involved with the child should be contacted about any concerns such as social services, school nurses, health visitors etc and a multiagency approach taken to develop a joint plan. Ensure full clinical records are well kept to document this process.
High Level of Concern
This would be indicated by one or both of the following:
• Failed preventative multi agency management
• Significant concerns of dental neglect
If a multiagency approach hasn’t worked or there are significant concerns of dental neglect for the child then a child protection referral is indicated. A discussion should take place to advise the parents/carers of the concerns and preferably the consent of the parents or carers gained to make the referral. Once a referral has been made over the phone, this should be followed up in writing within 48 hours. Social services should acknowledge receipt of the referral; decide on a course of action within one working day and feedback to the referrer. This should later be followed up to ensure the referral has been acted upon. Thorough clinical records are essential, it may be necessary to write a report for case conference if requested.
Neglect is the most prevalent form of abuse in children and dental professionals may witness the effects of this neglect. As a member of society and as a GDC registrant, dental professional have the responsibility to help protect children. If a dental professional suspects neglect general or dental they must assess their level of concern, raise any concerns with the appropriate agencies and make a direct referral to child protection services where this is absolutely necessary. They should be aware of their local safeguarding children procedures and refer to them if they have any concerns. It is important to keep up to date on the recommendations and training in recognising neglect and all other forms of child abuse to help protect children.
American Academy of Pediatric Dentistry. (2005) Definition of Dental Neglect. Pediatric Dental Reference Manual 2004-2005; 13.
Department for Education and Skills. (2003) Every Child Matters.London: Online HERE [accessed 20/02/2013].
Department for Education and Skills (2006) Working Together to Safeguard Children. Nottingham, DCSF Publications.
Department for Children, Schools and Families (2007) Referrals, assessments and
children and young people who are the subject of a child protection plan or are on
child protection registers, England – year ending 31 March 2007. Statistical First
Release 28/2007, accessed HERE [accessed 20 /02/2013]
Department of Health. (2004) National Service Framework for Children, Young People and Maternity Services: Core Standards. London: Department of Health.
General Dental Council (2005) Standards for Dental Professionals. London, General Dental Council.
Harris, J, C., Balmer, R, C., Sidebotham, P, D. (2009) British Society of Paediatric Dentistry: a policy document on dental neglect in children. International Journal of Paediatric Dentistry. Oxford, Blackwell Publishing Ltd.
Harris, J., Sidebotham, P., Welbury, R., et al. (2006). Child protection and the dental team: an introduction to safeguarding children in dental practice. Oxford, COPDEND.
HM Government (2010) Working Together to Safeguard Children: a guide to inter-agency working to safeguard and promote the welfare of children. London: Department for Children, Schools and Families (DCSF).
NSPCC (2012) Helpline highlight: more people contacting the NSPCC with concerns about neglected children. NSPCC London.
Turney, D. and Tanner, K. (2005). Understanding and working with neglect. Research in Practice: Every Child Matters Research Briefings 10: 1-8.