Sir, I was interested in the article by McDonnell and Mackie (BDJ 2008; 205: 593–595) about a suspected case of child abuse. A 3-year-old child had been referred because of an allegation made by a mother that her husband had harmed their daughter by pushing a metal nail into the girl's gum. The 'nail' turned out to be a flat metallic disc lying on the gingival surface, perhaps a sequin, and was therefore not a nail. The accusation made by the woman, who was separating from her husband at the time the allegation was made, was therefore unfounded. The authors conclude that 'there was no abuse'.

I wonder if the authors had considered the possibility of fabricated illness. The cardinal feature of fabricated illness is the production or feigning of symptoms in another person. The victim of fabricated illness is often a child. The individual who has fabricated illness gains secondary benefit in some way, for example by getting attention, or by establishing close links with healthcare personnel. The Diagnostic and statistical manual of mental disorders (DSM)1 is the standard classification of mental disorders used by mental health professionals in the United States, and it is widely used in the UK. Fabricated illness is not listed separately in it, but can be classified as a factitious disorder not otherwise specified. Fabricated illness can be perpetrated by parents, carers or healthcare professionals. Fabricated illness is regarded as a form of child abuse.

Since the metallic object on the surface of the patient's gum was not a nail pushed into the gum, by the father, at least two possible scenarios exist. The first is that the mother was genuinely mistaken, and believed the father had deliberately harmed his daughter (even if he had not) and that she had acted appropriately in the circumstances. Another scenario is that she deliberately placed the metallic disc on the gum herself, with the intention of implicating the father during the separation process. The first scenario indicates how badly the relationship with her daughter's father has deteriorated, but also suggests that she may need psychological support. The second scenario is suggestive of fabricated illness, itself a form of child abuse.

Although dentists can detect child abuse and non-accidental injuries, often such diagnoses are notoriously difficult, and often, regrettably, retrospective. The diagnosis is often the result of a jigsaw of small segments of clinical contacts with different healthcare professionals over a period of time being pieced together.

The authors are to be congratulated on following procedures on child protection, and are correct in their assertion that the dental team has a vital role in child protection. Perhaps fabricated illness ought to have been considered in this particular case, and it is always important to inform the child's GP that there had been suspicions of abuse, or an unusual clinical contact.