In assessing situations of suspected maltreatment, the dental professional needs to examine and consider the presenting problem or injury in light of the surrounding circumstances based on the child’s age and history.7
A key indicator of abuse or neglect is a significant discrepancy between the history given for the presenting problem/injury and the clinical findings. In addition to the signs and symptoms outlined above, the dental professional should monitor for multiple injuries over time or injuries in different stages of healing.
If you as a dental professional, suspect maltreatment based on physical injuries and/or other concerning signs or symptoms as outlined above, the child should be given an opportunity to provide information outside the hearing of the parent or caregiver.16 Caution is advised, however, when seeking information from the child. Detailed interviews of the child should be left to child protection, law enforcement, and/or a forensic specialist. When talking with the child, the dental professional’s job is to collect only those minimal facts sufficient to making an adequate mandated report as follows:23
Ask the child what happened and who was involved, utilizing open-ended questions in a non-threatening way; listen to the child’s response without interrupting; give the child your undivided attention
Ask follow-up questions only as necessary to find out what happened and who was involved and then stop asking questions
Consider the child’s development; use age appropriate language
Use the child’s words; do not substitute adult words, thinking you know what the child means; clarify without leading
Remain neutral; your response could have a lasting impact on the child’s further ability/desire to disclose abusive situations; do not make promises to the child
Examples of possible open-ended inquiry:
Child presents with two broken teeth and bruises about the face: “I see you have two broken teeth, tell me about what happened.” After child has explained what happened, ask who else was there and who did what to whom.
Child presents with labial or lingual frenum tears: “How did that happen?”
Child presents with ulcers, lesions, blisters that suggest a sexually transmitted disease: “Tell me about these blisters,” and “Who knows about the blisters?”
Six-year-old child presents with a red mark on the child’s neck that looks like a “hickey:” “Tell me about that red mark.” Suppose child says that Ricky likes to play a sucking game: “Tell me about the sucking game,” and “Tell me about Ricky.”
Eight-year-old child presents with multiple cavities, terrible breath, gingivitis, sores in the mouth that are indicative of poor dental hygiene rather than sexually transmitted disease. Additionally, your receptionist told you that the child has been begging for snacks, hitting younger siblings, and ripping pages out of the magazines while the caregiver talked on the phone and did not interact with the child or the younger siblings. You can and should try to assess child’s general care as well as the child’s dental care, using an open invitation “Tell me about…” For example, “Tell me about brushing teeth” or “Tell me about the food you eat.”
When the dental exam is completed, reassure the child by thanking him/her for talking to you; ask if the child has any concerns, and as appropriate, ask what the child does if the child is scared or needs help.16
Do not ask the child to repeat any disclosures to others in your office or share the child’s disclosures with others, including the caregiver.
The caregiver may have already given a reason/history for obvious injuries before the examination. If this reason/history is not consistent with your observations and/or the child’s information, you should document the facts that were presented to you, using the caregiver’s own words and the child’s own words. You should not confront the caregiver.16If the caregiver has not given a reason/history before the examination and/or the presenting problem is ambiguous (for example, a bite mark on the cheek that child would not explain), a brief inquiry into the problematic finding can be sought from the caregiver, but a detailed interrogation should not be undertaken by the dental professional.
Assess the need for medical attention and assess the immediate risk of harm to the child.