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Child Abuse: A Dental Obligation

Child abuse cases have risen dramatically during the current COVID-19 pandemic. As licensed healthcare providers in the U.S., we have responsibilities when it comes to recognizing the signs of child abuse.

For example, in the state of Florida, we must certify that we regularly update our understanding of child abuse, and more recently, of human trafficking. I am a licensed dental hygienist and have been licensed in Florida for over 20 years. I simply complied the requirement without giving much thought to its practical value.

However, an experience at work recently has given me a new perspective to continue my education in the field of child abuse. I never imagined being faced with the realities seen in my home study courses.

Encounter with a Child Abuse case

Child Abuse

As a woman, I have an innate sixth sense that surfaces from time to time. As a mother, that sense is even keener when it comes to children. I can hear a baby cry and almost instinctively know what’s wrong. Trial and error teaches you how babies express their needs. Children, though older, are very similar to babies in how they express needs. So when I sense uneasiness in a child, my alarms start to go off.

This exact thing happened recently. I had a young patient of 11 years old who was accompanied by her father. Her behavior was peculiar for someone of her age group. She wouldn’t speak or respond without visual approval of her father. When she did speak, she was as silent as a mouse. Almost unintelligible. She looked at him for approval for every little thing. That was the first red flag that alerted me to look further for the signs of child abuse.

For example, before she accepted her pre-rinse, she looked at him for approval. Then, she did the unexpected during the session for oral hygiene instruction (OHI). After I handed her the hand mirror to follow along with my instructions, she gazed away and refused to look into it. That was my second flag.

As a result, I gave her OHI by palpating the areas she should work on instead of insisting she look in the mirror. This despite her teeth already being color disclosed for plaque detection.

Fishing for Answers

Another thing that I thought was very unusual was that she never removed her jacket while in the operatory. It was a cool day but definitely not cold and especially not in my operatory. Since I began to see her behavior as unusual, I thought to gently quiz her through small talk.

She let me know her age with no problem. However, she pursed her lips when I asked her what school she goes to and she refused to respond. Not a natural reaction at all. Her father quickly interjected with a comment to laugh off her response. I didn’t understand what he said and kept working.

Most importantly, the child sat lifeless, listless and distant, like a stone, during the entire appointment. I tried to reach her but couldn’t. It was then that I knew something was wrong and that I needed to act.

Behavior Suspicion in Child Abuse

Every person is different. Of course, not all 11 year old girls are chatterboxes and like to talk about their lives. However, there are behaviors that can be expected from this age group. Compliance from children is a given if they find something interesting.

That’s why, in all my pediatric experience, I have never had a child patient refuse to look at a mirror. Definitely not when their teeth are blue! They love that! All nationalities I have worked with and countries I have worked in taught me that kids are kids.

After disclosing their teeth and before beginning my instruction, I always tell them to focus on the blue, purple or pink. This creates anticipation and they are always curious. This is appropriate for children.

Adults, on the hand, do look away when I lose their interest. I can accept that adults either don’t want to be taught or don’t like to see the state of their own teeth. This variation is appropriate for adults.

Also, most children are curious about what I will do during the appointment. Many are also curious about the state of their teeth. They like to hear about where they clean well and some even like to know where they can do better. I got none of this reaction from this child.

Granted, special-needs kids need to be handled a bit differently depending upon their capacity. Nevertheless, even my special-needs kids like to be given the ‘job’ of taking care of their teeth.

My Obligation as a Dental Hygienist

Since my patient’s behavior left me unsettled, I took advantage of some breaks during the appointment to reach out to my coworkers. I needed help to know what should be done in this case in Germany.

My mind began to race about what really was wrong with that scenario. I couldn’t put my finger on it. I tried to remember what I knew about child abuse and the signs but I could only remember a few. Namely, that abused children are usually dressed in long clothes even when it isn’t appropriate.

I couldn’t remember specifics about behaviors to look out for but I did remember that ideally, we should try to get victims alone. This is for questioning and reassuring a suspected victim. However, I knew that wouldn’t happen with this child because her father even stood over me a couple of times while I was working. He wouldn’t let her out of his sight.

As he stood over me, I asked him if there was something that he was unsure of with her treatment. He said, “I just want to make sure that it won’t be too much for her”. Remember that the child was motionless the entire time. By this time, I had already started to size him up, so I dismissed his comment as a cover up. But maybe there was more behind it. More on the possible meaning of his comment later.

Searching for Support

After trying to get assistance from my coworkers, I realized that they thought I was over-reacting. I had to explain myself over and over (in German mind you!) about what was alerting me to her behavior. Then, after I explained myself a thousand times, no one still knew where to direct me. I started to look around the sterilization area, where we have all sorts of posters and notices. I hoped to see if there was some sort of GermanyAbuseHotline.com featured to report abuse. Nothing. It disappointed me so much.

Germany is such an efficient country when it comes to providing nets to support its residents. There are all sorts of insurance schemes to protect people from the collateral effects of catastrophic life events.

Of course, these nets benefit those who manage to get off on a good foot in life. I thought surely there must be a net as well for the most vulnerable. I later found such a net, albeit full of gaping holes. I’m left wondering if it will be of any use to my patient whom I so wish to help.

Societal Negligence in Child Abuse

Child abuse concerns

I spoke to both of the dentists working that evening and explained what my concern was in particular. Again, no direction. I feared that we were losing time. I wanted to intervene somehow professionally, that day, as I knew that negligence towards child abuse should be avoided at all costs.

That was probably the longest child prophy appointment of my life. Since I got no direction on where to turn in the event of suspected abuse, I released the patient reluctantly. It was devastating for me.

She went over to the dentist for an exam. The dentist obviously noticed the strange behavior that I alerted her to. She did her own form of fishing to see if she could find something out. She did this without any training in recognizing suspected abuse or in how to address it.

I wasn’t in the room for the exam but I knew she had tipped the father off. Many cavities were diagnosed in her mixed dentition. The father took the child after the exam was complete and refused to schedule any further appointments. He left quickly with her stating that he had no time to schedule. So, not only did I suspect abuse but now neglect as well.

Performing my Moral Duty

Since I had raised such a stink about the matter, they told me to research what to do in the event of suspected abuse in Germany. Before doing that, however, I took it upon myself to refresh my memory on family violence.

I now feel a moral obligation to that patient and others like her. As dental hygienists, we spend a lot of time with our patients, get to know them well and get to see them frequently. We must use this advantage to help suspected victims.

Out of all of my courses on abuse and trafficking, I could not remember the telltale signs of abuse. The latest courses that I took were on “Domestic Violence: The Florida Requirement” currently offered by NetCE and The Dental Team’s Role in Indentifying and Preventing Family Violence (2013) from dentalcare.com.

Concerns Related to Child Abuse

One of the first statements in “The Dental Team’s Role in Identifying and Preventing Family Violence” course was that “dental care providers must remember that child abusers may love their children very much, even if they do not love their children very well”.

After reading that statement, I thought back to the father’s concern for the child during the treatment. Could it be that he really did want to protect her? We checked her records and she was a patient in this office since she was a small child. No one seems to ever have suspected anything was abnormal about their behavior. Perhaps because she was younger. Parents’ wishes generally influence small children.

The article continues to mention that “while abusive parents often do not take the child to the same physician (fearing the physician will recognize the abuse), they tend to return to the same dentist.” This could explain her long treatment history in our office despite the fact that her mouth was full of decay.

It further mentions that so many cases of family violence go undetected by dental professionals because we miss the signs. I can imagine this to be a problem in Florida where we are trained in detection, but what does it say for places where no training is mandated at all?

Interestingly, only certain US state laws towards child abuse mandate reporting for the average person. All states, however, mandate reporting for healthcare providers. But even when no one mandates, anyone can report. Therefore, we must be able to recognize the signs of abuse.

This course also mentions some disorders that could be mistaken for abuse. We must familiarize ourselves with these disorders as well.

Knowing the Signs

Taken from “The Dental Team’s Role in Identifying and Preventing Family Violence”

1. Emotional Abuse:

“Abused or neglected children may be extremely apprehensive and inordinately fearful of an oral exam. On the other hand, some abused victims are extremely eager to please; they have learned that less than perfect behavior may result in more abuse. One way to determine if a child’s behavior is appropriate is to judge against personal experience with children of a similar maturity (Note: Maturity is often different from chronological age) in similar circumstances.”

2. Repeated injuries, multiple bruises, bilateral injuries to the face, or injuries that are inconsistent with the history given may all signal instances of abuse.

3. Be familiar with bleeding disorders and syndromes or conditions that cause discoloration of the skin that are not related to abuse.

4. Injuries to both eyes or cheeks are always suspicious because accidents are most typically unilateral.

5. Grab marks, slap marks, cigarette burn marks, immersion burns on the limbs.

6. Delay in seeking treatment is often seen in cases of family violence (neglect).

7. Cases of child sexual abuse may exhibit indicators in the perioral region, such as oral STDs in children.

8. Petechiae of the hard or soft palate are sometimes seen in cases of forced oral sex.

9. In a survey of pediatric dentists throughout the nation, the principal dental injuries reported in cases of child abuse included missing and fractured teeth (32 percent of reported cases) (Figure 9), oral bruises (24 percent), oral lacerations (14 percent) (Figure 10), jaw fractures (11 percent), and oral burns (5 percent).

10. Human bite marks, which should be easily identifiable by all dental professionals, carry a high index of suspicion of child abuse.

11. Child neglect versus simple lack of care (use caution here).

*** Dentists and dental staff are not the professionals charged with determining whether abuse or neglect has actually occurred. Their responsibility is only to report suspected cases.***

Download P.A.N.D.A. Coalition Brochure (training to help dental professionals identify neglect)

How to Report Child Abuse

Dentists are required to report suspected cases of child abuse in all US states. Dental hygienists as healthcare providers are also required to report. Always look at your reporting as taking a stand for a child. The “Dental Team’s Role” article mentions that even if your suspicion is not found to be valid, a child may still be at risk. “If sufficient evidence was not found, information from the initial inquiry may be useful in future investigations to benefit the child.”

Even if you chose to report anonymously, your report could be what was needed to add credibility to a previous or a future suspicion. Proof of abuse is not necessary to report.

Reporting requires courage. Some countries make reporting easier than others. Sometimes there is a hotline or a webform to report anonymously. However, reporting in Germany or Switzerland may be a bit more complicated as anonymity may not be guaranteed.

Reporting In Germany

In Germany, you do not contact the police for cases of suspected abuse. You should contact the local German Youth Welfare Office or Jugendamt. Bigger cities, like Berlin, have non-profits with multiple language options where you can also report. Each town has a Jugendamt. This means you must speak at least some German in order to contact them.

I attempted to contact my local Jugendamt anonymously. First, I did a bit of a Google search and found their contact information. Then, I decided to send an anonymous email. The lady answered my email swiftly. However, she wanted to speak with me directly to ask questions and gather specific information about my suspicion. Even if you don’t give your name, still your call number gets documented of course.

The worker handling my call appeared to want concrete signs of abuse to go on. She asked me if I saw any abnormal behavior in the father or signs of sexual abuse with the child. I reminded her that we were in a public setting in the dental office. Naturally, the father would be on his best behavior.

The child’s behavior was indicative of emotional trauma and not physical. I also told her that the child was fully dressed and no signs of trauma were obvious on her head or neck region. I feel I fulfilled my moral obligation.

She kindly let me know that as a normal person, my anonymity may be guaranteed. However, if one calls on behalf of a dental practice, the practice cannot logically remain anonymous.

Therefore, while working in Germany, let your employer know what your suspicions are and that you would like to report to the authorities. This way he or she can be prepared for questioning by the authorities.

Reporting Quick List

There are national reporting agencies and groups that advocate for the protection of children around the world. Sometimes a simple Google search is all that it takes.

United States

P.A.N.D.A. “Prevention of Abuse and Neglect through Dental Awareness” Delta Dental of Arkansas

  • (855) 407-2632

Download the training brochure from the P.A.N.D.A. Coalition. “Prevention of Abuse and Neglect through Dental Awareness”

dental hygienists abroad download button
“Prevention of Abuse and Neglect through Dental Awareness”

Download the P.A.N.D.A. Dental Office Protocol Guide

dental hygienists abroad download button
Download P.A.N.D.A. Dental Office Protocol Guide

State Child Abuse and Neglect Reporting Numbers – childwelfare.gov

Childhelp National Child Abuse Hotlinehttp://www.childhelphotline.org

  • (800) 4-A-Child or (800) 422-4453

Canada

Canadian Center for Child Protection

Canadian Child Welfare Research Portal – cwrp.ca

  • (800) 267-1291 or (613) 957-2938

U.K.

NSPCC – nspcc.org.uk

  • 0808 800 5000

Report child abuse http://www.gov.uk/report-child-abuse

  • call 101 (a free call)
  • report online to the police

Germany

(note that anonymity is not a guaranteed)

The German Youth Welfare Office Handbook (Jugendamt)

Berlin Emergency Child Protection Service

  • or call 030-610066 (multiple languages available)

Wildwasser Non-profit for reporting Sexual Abuse – http://www.wildwasser.de

Download the Brochure Combating Child Abuse and Neglect Child Protection in Germany

dental hygienists abroad download button
Download Combating Child Abuse and Neglect Child Protection in Germany

Switzerland

(note that anonymity is not guaranteed)

Swiss Foundation for the protection of children

Download the Brochure from the Swiss Foundation for the Protection of Children

dental hygienists abroad download button
Download the Brochure from the Swiss Foundation for the Protection of Children

ISSInternational Social Service (Switzerland) ssi-suisse.org

Sources:

The Dental Team’s Role in Identifying and Preventing Family Violence. Mouden, L. D., DDS, MPH, FICD, FACD. Dentalcare.com. 30 Sept. 2013.

While this course is no longer valid for CEUs, the information is still practical for dental professionals. You can download a copy of this course here.

dental hygienists abroad download button
Download The Dental Team’s Role in Identifying and Preventing Family Violence

Featured photo by Kat J on Unsplash

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