Dental Neglect

Abstract

Dental neglect can be an indicator of general child neglect. Inadequately treated dental disease may have significant long-term impacts on the physical and psychological well-being of children. Primary care providers play a critical role in the prevention of dental neglect, and should be aware of the manifestations of dental caries and dental trauma. When diagnosing dental neglect, health professionals should ensure the child’s caregivers have demonstrated an understanding of the condition, its consequences, and the recommended treatment and then failed to comply with the treatment. Attempts should be made to eliminate any barriers preventing caretakers from complying with professional advice. Dental neglect is a form of child maltreatment and, if suspected, should be reported to the appropriate child protective agencies.

Dental neglect is the “willful failure of a parent or guardian to seek or follow through with treatment necessary to ensure a level of oral health essential for adequate function and freedom from pain and infection,” as defined by the AAPD (American Academy of Pediatric Dentistry 2010). Higher levels of tooth decay can be found in abused and physically neglected children compared to those in the general population (Valencia-Rojas et al. 2008). Greene et al. (1994) found that children with a history of abuse were eight times more likely to have untreated caries involving permanent teeth compared to non-abused children. Although dental neglect may exist in isolation, inadequately treated dental disease can be an important indicator of broader child neglect (Bradbury-Jones et al. 2013).

Dentists and other health professionals are often hesitant to report suspected cases of dental neglect due to a lack of certainty about the diagnosis or fear of consequences from reporting, including potential impact on their practice and possible litigation (Welbury et al. 2003; Al-Habsi et al. 2009). Other factors affecting clinicians’ decisions to not report suspected cases of maltreatment include concerns for compromising the patient/family-physician relationship and doubts regarding the benefits of reporting to child protective services (Jones et al. 2008). Flaherty et al. (2008) demonstrated that not all suspicions of child maltreatment are reported, even when the level of suspicion is high. This, along with the paucity of studies on dental neglect, raises concern that this important aspect of child maltreatment is often under-detected and under-reported (Bhatia et al. 2014). Recognizing and reporting dental neglect is important as it may be an early sign of general physical neglect in addition to a potential cause of significant pain and a loss of oral function (Acs et al. 1992; Bradbury-Jones et al. 2013).

Types of Dental Neglect

Untreated Dental Caries

Caries is considered an infectious disease, most commonly associated with Streptococcus mutans. These bacteria adhere to the tooth’s enamel, produce acid and decrease the pH, causing demineralization (Loesche 1986). Consumption of carbohydrates, especially sucrose, plays a large role in the development of caries, as the bacteria ferment these sugars to produce an acidic environment. The main source of Streptococcus mutans in infants are the mothers, with vertical transmission (passing the bacteria from a caregiver through saliva) or horizontal transmission (passing the bacteria between various family members or close contacts) (Douglass et al. 2008; Van Loveren et al. 2000).

Initially, white spot lesions appear on the enamel, followed by cavitation as the tooth continues to demineralize. There is a characteristic pattern of decay that can be attributed to the eruption sequence of primary teeth, and therefore, the amount of time they are exposed to decay-causing substances. The upper primary incisor teeth are the most severely affected, and can lead to amputation of the tooth at the gingival crest (Fig. 1). The primary first molar teeth are typically the subsequent teeth affected, followed by the primary second molars and canines. Although the primary lower incisor teeth are normally the first to erupt, they are the teeth least likely to decay due to their position in the mouth, protected by the tongue when sucking and by copious salivary secretion from the nearby submandibular salivary gland ducts (Raphael 1999).

Fig. 1.

Severe early childhood caries with amputation at the gingival crest. (Courtesy Jeffrey Mabry, DDS)

The failure to provide treatment for carious teeth is the most common type of dental neglect (Christian and Mouden 2009). Since the 1970s, the prevalence of dental caries in children has declined; however, it remains the most prevalent chronic disease of childhood (U.S. Department of Health and Human Services 2000). Early childhood caries (ECC), previously referred to as “nursing bottle caries” and “baby bottle tooth decay”, is a disease commonly found in neglected children. The AAPD defines ECC as “the presence of one or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in a child under the age of six” (AAPD 2014, p. 60). These findings typically result from habitually placing a child in bed with a bottle or allowing the child to fall asleep while breast feeding. Prolonged nocturnal breast-feeding can be harmful to primary teeth due to the decreased rates of salivation and swallowing during sleep, prolonging the contact milk has with dental surfaces. The development of caries is also associated with breastfeeding more than seven times daily in toddlers older than 12 months of age (Feldens et al. 2010).

Untreated Dental Trauma

A failure to seek treatment after trauma to the mouth can also be considered dental neglect. Up to 75% of injuries in physically abused children involve the head and neck region (daFonseca et al. 1992). Those injuries involving trauma to the oral cavity can be characterized in three groups: injuries to the teeth, injuries to the soft tissue, and injuries to the jaw including fractures of the mandible or maxilla. Approximately 10% of children between the ages of 18 months and 18 years experience significant tooth trauma (Tinanoff 2011). Children between the ages of one and three are most likely to sustain injuries to teeth from falls or physical child abuse. Tooth injuries may involve the hard dental tissues, the dental pulp (nerve), or the periodontal structure which includes the surrounding bone and attachment apparatus. As with cases of ECC, the teeth most commonly affected in cases of dental trauma are the maxillary incisors. If fractures of the teeth involve the pulp, they are considered complicated, as opposed to dental fractures which are confined to the hard tissues. Bacterial contamination is possible when the pulp is exposed, leading to infection with a periapical abscess or pulp necrosis. These teeth may appear to be bleeding or have a small red spot (Fig. 2). Complicated fractures typically require root canal therapy. The normal development of the permanent dentition can be affected by these injuries to the primary dentition. Therefore, it is often necessary to extract primary incisor teeth if they have sustained a significant injury. Any tooth trauma should be evaluated by a dentist as soon as possible to assess the probability of any future complications, which include infection and deleterious effects to permanent teeth. Fractures involving the pulp require immediate referral to dentistry, with the goal of minimizing contamination in order to improve the prognosis (Josell and Abrams 1991; Tinanoff 2011).

Fig. 2.

Complicated fracture of a maxillary central incisor. (Courtesy Jeffrey Mabry, DDS)

Trauma to the teeth may involve the periodontal structures. These injuries are more common in primary teeth compared to permanent teeth, and typically manifest as teeth that are mobile or displaced following a traumatic injury. Concussions result from minor damage to the periodontal ligament, and cause tenderness but no movement of the tooth. Primary incisors that have sustained a concussion may become discolored as a result of pulpal degeneration. Subluxations are more significant injuries and typically manifest with hemorrhage surrounding the neck of the tooth at the gingival margin. Subluxated teeth demonstrate horizontal and/or vertical mobility without displacement of the tooth. In order to ensure proper repair of the periodontal ligament, a subluxated tooth may require immobilization with a splint. Pulp necrosis with tooth discoloration can develop following a subluxation. Intrusions result when teeth are impacted into their socket. An x-ray is necessary in these cases to differentiate intrusion from avulsion, as these severely intruded teeth may have a knocked-out appearance and the tooth may appear to be absent. Extrusions occur when the tooth is partially displaced from its socket, typically toward the tongue, involving fracture of the wall of the alveolar socket. Without immediate treatment, extruded permanent teeth will likely become fixed in the displaced position. Extruded primary teeth usually require extraction, as repositioning and splinting of the affected tooth may negatively affect the development of the permanent teeth (Tinanoff 2011).

Consequences of Dental Neglect

ECC is an aggressive disease and has the ability to quickly cause cavitation in demineralized teeth. The dental pulpal tissue can become infected, which can then penetrate the alveolar bone and gingiva, resulting in an abscess (Fig. 3). In more serious cases, there may be fascial plane involvement which has the potential to be life-threatening (AAPD 2014). ECC can also cause developmental defects of enamel in succeeding permanent teeth (Broadbent et al. 2005).

Fig. 3.

A well-circumscribed and fluctuant tooth abscess involving a maxillary incisor. (Courtesy Jeffrey Mabry, DDS)

ECC is associated with dental pain and difficulty eating with a loss of oral function leading to negative effects on nutrition and weight (Acs et al. 1992). The effects of dental neglect also lead to difficulty sleeping and poor performance in school in addition to disfigurement, resultant low self-esteem, with an overall compromise in quality of life (Ramazani 2014; Blumenshine et al. 2008). Poor dentition, including untreated malocclusion, has been associated with bullying in school children, which can result in long-term psychological consequences (Al-Omari et al. 2014).

Dental extraction is often required when carious teeth become painful or infected, putting victims of dental neglect at risk for complications associated with general anesthesia, which is often required for operative procedures in small children. The premature loss of primary teeth can result in many occlusion problems including space loss, rotated or misplaced adjacent teeth and the need for antagonist tooth extrusion (Lourenço et al. 2013).

Diagnosis of Dental Neglect

Differentiating dental caries from dental neglect is difficult. There is no evidence to support a threshold number of caries in order to diagnose dental neglect. Common features of dental neglect include a failure to provide basic oral care (oral hygiene, proper diet, and establishment of a dental home), failure to seek treatment for oral pain, and untreated infection (Noble et al. 2014). Once dental pathology is identified, a history of missed appointments indicating a lack of continuity of care supports dental neglect (Raphael 1999). The presence of untreated, rampant caries should cause a medical provider to consider the possibility of dental neglect, taking into consideration that the presence of caries may reflect a lack of caregivers’ knowledge or resources rather than a neglectful attitude (Souster and Innes 2014). The lack of perceived value of oral health can explain a caregiver’s failure to seek appropriate dental care, as many individuals do not acknowledge the importance of primary teeth and may even consider dental decay as an unavoidable natural phenomenon (Lourenço et al. 2013; Stevens 2011).

Screening questions for children when assessing for dental neglect should include the following:

• Do you have any problems eating certain foods, like hard, cold, hot, or chewy foods?

• When do you brush your teeth?

• Does anyone help you brush your teeth?

• Do you ever get teased or bullied at school?

• What do they tease you about?

• Have you ever hurt any of your teeth?

Screening questions for parents when assessing for dental neglect should include the following:

• Does anyone in your family have a history of dental problems?

• When was the last time anyone in your family went to the dentist?

• Has your child ever been to a dentist?

• What have you noticed about your child’s teeth?

• Do you brush your child’s teeth?

• Does your child ever have a bottle or sippy cup in bed?

• Have you ever noticed bleeding from anywhere in your child’s mouth?

A thorough oral examination is an essential component of a child’s physical exam. When examining an apprehensive younger child, a useful technique is to place the child in the caregiver’s lap facing the caregiver, and the child’s head is reclined into the examiner’s lap while the caregiver holds the child’s hands. A systematic approach should assess the following: integrity of the enamel, presence of caries, appearance of the gingivae, and the appearance of the frenula. A tongue depressor, light source, and a gloved hand may be used to ensure adequate visual access to all of the intraoral areas. If a lack of appropriate weight gain is noted in association with poor dentition, the physician should consider oral pain as a factor.

Caregivers should be considered negligent when they have been properly informed of the extent of the child’s condition by a health care professional, demonstrated understanding of important dental instructions and treatment, and failed to comply with important medical/dental advice. This information should also include the specific treatment needed and clear instructions on how to access that treatment (Berger and California Society of Pediatric Dentistry 1989). If bullying is identified, the framework presented by Lyznicki et al. (2004) for approaching bullying with patients and parents can be helpful. If socioeconomic barriers exist, efforts should be made to assist families in finding financial aid and transportation for the recommended healthcare services. If caregivers fail to follow through with treatment despite these efforts, and after healthcare providers have made reasonable effort to ensure that caregivers fully understand the disease and the possible consequences, the caregivers should be reported to the appropriate child protective services agency (Berger and California Society of Pediatric Dentistry 1989).

Prevention

Children should be referred to a dentist to establish a dental home within 6 months after the first tooth eruption, but no later than 1 year of age. Eighty percent of 3 to 4 year old children have met the number of well-child visits recommended by the American Academy of Pediatrics, compared to the 26% who have met the number of dental visits recommended by the American Academy of Pediatric Dentistry (Yu et al. 2002). Primary care providers, therefore, have the opportunity to play a critical role in the promotion of oral health and the prevention of dental neglect. The 20% of 3 to 4 year old children who do not receive regular medical care are at an increased risk for dental neglect.

New parents should be instructed to avoid: the use of a bottle as a pacifier, allowing an infant or toddler to fall asleep with a bottle containing decay-causing substances such as milk or juice, and frequent consumption of sugar-containing drinks and snacks. Teeth should be cleaned regularly as soon as they erupt, typically around 6 months of age. This can be accomplished by wiping a child’s teeth and gums with a damp cloth, followed by the introduction of a soft toothbrush around 12 months of age. Twice-daily brushing with fluoridated toothpaste reduces the risk for development and progression of caries. An adult’s supervision is necessary up to the age of seven, as children in this age group lack the manual ability to effectively brush their teeth alone (Lourenço et al. 2013). Children less than 3 years of age should receive a “rice-size” amount of fluoridated toothpaste, which is approximately 0.1 mg fluoride. Children between the ages of 3 and 6 years of age should receive a “pea-size” amount of fluoridated toothpaste, which is approximately 0.25 mg fluoride. In order to maximize the beneficial effect of the fluoride, rinsing the mouth after brushing is not encouraged. Early preventive interventions are critical, as caries-conducive dietary practices are established by 12 months of age (AAPD 2014). In addition to health professionals, other child professionals, such as those involved in child welfare and school counselors, may also contribute to the prevention and identification of dental neglect by using the recommended screening questions.

Conclusion

Dental neglect is a common but under-recognized condition of childhood. Clinical presentations include untreated caries and untreated dental trauma, which can significantly impact a child’s function, appearance, comfort, and quality of life. Clinicians have the opportunity to prevent these common and deleterious outcomes by improving detection and optimizing treatment of childhood dental diseases and injuries.

Compliance with Ethical Standards

Disclosure of Interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.