Many adults visit the dentist only for emergency treatment when they are in pain and choose not to return for treatment to restore complete oral health. They may choose to use dental services in a similar manner for their children. Dental professionals have traditionally respected this choice and not challenged this behaviour. However, children may suffer ongoing dental pain, infection or other adverse consequences as a result and, when young, are reliant on their carers to seek treatment for them. Anecdotally, it is reported that other health professionals who work regularly with children are shocked that the dental team often fails to rigorously follow up such children.
With the rise of the safeguarding children agenda, this topic has become a topical issue.51,52 In the context of increasing emphasis on preventing maltreatment, improving multi-agency working and encouraging early intervention, rather than intervening only when a crisis occurs, the dental profession has had to reconsider the diagnosis and management of child dental neglect.
Dental neglect is defined by the British Society of Paediatric Dentistry50 as:
Dental neglect may occur in isolation or may be an indicator of a wider picture of child maltreatment. The focus of this definition is on identifying unmet need so that the family can receive the support they need, rather than on apportioning blame. Children have a right to oral health, which forms an integral part of their general health. To maintain optimal oral health, children need:
- fluoride – a regular source, usually supplied by twice daily use of fluoride toothpaste
- diet – limited frequency of sugary snacks and drinks
- oral hygiene – facilities, supervision and assistance
- dental visits – to benefit from preventive care and treatment when needed
Impact on the child
When assessing a child with dental disease it is important to assess the impact of the disease on the individual. Severe untreated dental disease can cause:
- disturbed sleep
- difficulty eating or change in food preferences
- absence from school and interference with play and socialisation
and may put a child at risk of:
- being teased because of poor dental appearance
- needing repeated antibiotics
- repeated exposure to the morbidity associated with general anaesthesia
- severe acute infection which can cause life-threatening systemic illness.
In addition, there is a growing body of evidence indicating that untreated caries in pre-school children is associated with lower body-weight, growth and quality of life.49
How common is it?
It is known that dental caries is a very common finding in children. Even when extensive, it does not always indicate neglect. A 2003 survey found that by the age of 5 years, 43% of UK children had obvious decay58 and 5% had had teeth extracted under general anaesthesia. However there is little information available on how common dental neglect is. In 2005, 60% of UK dentists with an interest in paediatric dentistry reported seeing children with neglected dentitions once daily or more often.51 In the same year, an epidemiological study of dental neglect in young people reported a prevalence of between 40 and 50% in 15-16 year-olds at secondary schools in a deprived inner-city area.57 More research is needed.
Dental disease, like any other finding in cases of suspected abuse or neglect, should never be interpreted in isolation but always assessed in the context of the child’s medical and social history and developmental stage. Therefore care should be taken to consider this in the context of other relevant factors, such as:
- the multi-factorial causation of dental caries
- variation in individual susceptibility to dental disease
- differences in the treatment dentists provide (for example, whether they choose to manage caries in primary teeth by monitoring or restoration or extraction)
- respect for autonomy in healthcare decision-making when caring for older children and young people (who may decide to decline or delay treatment advised by the dentist)
- inequalities in dental health (for example, regional or social class differences in caries experience)
- inequalities in access to dental services and treatment (for example, in inner city and rural areas).52
It is suggested that, in order to avoid misunderstanding, the term dental neglect should be reserved for situations where there is a failure to respond to a known significant dental problem. This is an area that requires sensitivity and clinical judgment. There is a need for further research to inform the dental team in making these decisions and in managing dental neglect.
Features of particular concern
In summary, the features that give cause for particular concern after dental problems have been pointed out to parents and appropriate and acceptable treatment offered are:
- severe untreated dental disease, particularly that which is obvious to a layperson or other non-dental health professional
- dental disease resulting in a significant impact on the child
- parents or carers have access to but persistently fail to obtain treatment for the child, as may be indicated by:
- irregular attendance and repeated missed appointments
- failure to complete planned treatment
- returning in pain at repeated intervals
- requiring repeated general anaesthesia for dental extractions
This 4-year old boy has caries in his primary incisors. Your clinical records show that the decay is not getting worse. He has never complained of toothache. He is due to start school soon. His parents are unconcerned by the appearance of his teeth. He cooperates well with dental treatment but sometimes misses appointments.
He obviously has untreated carious teeth – but is it dental neglect?
You need to consider:
What is the impact of dental disease on the child?
What other information do you need to make a decision?
What records would you make of your observations and decisions?