Systematic review highlights difficulty in clearly identifying dental neglect in children

The United Nations Convention on the Rights of the Child states that children are entitled to a standard of living that supports their physical, mental, spiritual, moral and social development. Parent(s) or others responsible for the child should, within their abilities and financial capacities, pursue the living conditions necessary for the child's development.1

Unfortunately, child maltreatment, including abuse and neglect, remains a problem in modern society and this neglect has dental and oral health manifestations.

The General Dental Council (GDC) published Standards for the Dental Team2 in September 2013, which set out the responsibilities of dental team members to ensure they take action where there is concern over possible abuse of children and vulnerable adults. The standards go on to state:

  • You must raise any concerns you may have about the possible abuse or neglect of children or vulnerable adults. You must know whom to contact for further advice and how to refer concerns to an appropriate authority such as your local social services department.

  • You must find out about local procedures for the protection of children and vulnerable adults. You must follow these procedures if you suspect that a child or vulnerable adult might be at risk because of abuse or neglect.

Moreover, there are a number of sources of child protection guidance for health professionals, including: the Department of Health;3 Scottish Government4 and the Scottish Clinical Effectiveness Programme (SDCEP) guidance for the dental team on caries prevention and management in children5 – which is currently being updated taking into account the new legislative background of the Children and Young People (Scotland) Bill.6

The subject of dental neglect remains poorly and inconsistently understood. The aim of the paper was to determine the scientific evidence underpinning the characteristics of dental neglect in children.

A clear, focused question was set ‘What are the features of oral neglect in children?’ and for the purposes of the literature search dental neglect was defined as: ‘Neglect refers to the failure of a parent or guardian to meet a child's basic oral health needs, such that the child enjoys adequate function and freedom from pain and infection, where reasonable resources are available to the family or caregiver’.

A robust global systematic literature search was conducted (including 15 databases from 1960-2012 and including unpublished and grey literature).

Studies were assigned a grade on the basis of their quality standards, although it is not clear within the text how this was assessed or the significance of the quality grades. Nine studies including data on a reasonably high number of children (n=1595) were eventually included in the narrative synthesis analysis. There was high heterogeneity of the included studies with varying definitions of dental neglect and oral criteria adopted.

The results suggested that there were common features of dental neglect including: (i) failure to seek or delay in seeking dental treatment; (ii) failure to comply with and or complete treatment; (iii) failure to implement basic oral care (oral hygiene, diet and dental attendance); (iv) symptoms such as pain and swelling. The issue of differentiating dental caries from dental neglect was highlighted and there were no specific patterns to dental caries associated with neglect.

The review is a good start at systematically appraising the limited literature in this area. However, the main disappointment in the review (or rather the evidence available) was that it was unable to set out a hierarchy of concern indicators, which could guide dental practitioners in how and when these concerns should be raised or shared more widely.

With legislative changes underscoring the importance and priority of this area, the forthcoming SDCEP guidance update will further help practitioners navigate these difficult decisions, but it will have to rely on best practice rather than best evidence.