Sir, regarding the case report of self-injurious behaviour (SIB) presenting as gingivitis artefacta major (BDJ 2009; 206: 129–131) the authors mention the patient's non-attendance at CAMHS and dental appointments delaying appropriate intervention for a considerable period. This may have been avoided through effective communication with the CAMHS team at the time of referral and when the young person did not attend dental appointments. The authors also mention the patient's difficult background (neglect etc) but do not make clear whether social services were involved and if not this may have been appropriate in light of the presenting complaint, non-attendance at appointments and the patient's living arrangements. It is important to remember that failure to attend appointments can in itself be a child protection issue if it affects wellbeing. It is essential that dental health professionals have adequate child protection training and are aware of how to efficiently access their local Child and Adolescent Mental Health Services. The Laming report (The Victoria Climbié Inquiry) states that effective interagency working and communication are essential to safeguarding children.

Dr Christopher Millen responds on behalf of his co-authors: We would like to thank Drs Nisar and Aslam for their comments. We are in complete agreement with their statements regarding the safeguarding of vulnerable children and effective interagency communication in relation to child protection. The need for this approach has been highlighted in a number of guidelines over recent years 1, 2 and thus as a dental team we should both be aware of our responsibilities and have a heightened awareness of the signs and symptoms of child abuse. The dental team's role in the care of children and adolescents presenting with self harm is perhaps less well defined. Children and adolescents presenting with possible or actual self-harm are vulnerable and have complex needs, and thus there is also a need for an awareness of the presenting signs and symptoms and effective close interagency communication.

In presenting this case of self harm in a competent 15-year-old who accessed unscheduled care, the authors sought to raise the awareness of the dental team to one possible presentation of oral self-harm and to highlight management difficulties which can arise. Advice as to the appropriate path of referral was sought prior to making the referral, but, in this instance, there was a breakdown in communication. We would wholeheartedly agree with Drs Nisar and Aslam that there is a need for close follow up and continued interagency communication in such cases, beyond the usual 'automated' process. The need for an integrated care pathway for onward care when a child or adolescent presents at an emergency care site has recently been highlighted. 3 It would seem appropriate that Local Child Protection Referral Pathways should also include guidance as to where the dental team should source advice for concerns about cases of possible self harm.