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The dentist’s dilemma with dental neglect
Even in this modern era of preventive dental care, dentists often see children with a mouthful of dental cavities. Whilst the initial and often emotive conclusion is that the child is suffering from dental neglect and hence child abuse it is important to look at each individual case and apply national guidelines. Dental neglect can be defined as the persistent failure to meet a child’s basic oral health needs, likely to result in the serious impairment of a child’s oral or general health or development.
The initial steps as with all cases of suspected abuse are to discuss the case with the named practice safeguarding lead. The main factor to consider is the matter of significant harm. In other words is the condition likely to or is causing physical suffering, developmental or psychological issues. In the case of gross or multiple dental decay, the child is likely to be suffering from toothache, disturbed sleep, difficulty eating or change in food preferences, impaired growth and absence from school. Dental disease may put a child at risk of being teased because of poor dental appearance, needing repeated antibiotics, repeated general anaesthetic extractions and severe infection. There may be damage to permanent successors and orthodontic implications of early loss of teeth.
The second factor is to consider that the child’s parent or carer has some responsibility for that harm. There are several factors to consider before attributing blame and responsibility to the parent. It is a surprising fact that there are parents who do not understand the connection between sugar, dental hygiene and decay. There are people from different cultures where teeth especially primary teeth are not a high priority. It will also surprise many readers that there are families in the UK who don’t even own a toothbrush and in some cases, siblings will share one. Many parents lack a basic knowledge of concepts such as ‘five a day’. How many times have you seen a child waiting at a bus stop at 7am with a can of cola and a packet of crisps in their hands? One assumes that the parent must have given their child some money to buy a healthy snack so it is important to consider the autonomy of the child here. How many children actually do what they are instructed whether in relation to diet or dental hygiene. It is also important to remember that some children are more susceptible to dental decay and there are many cases of variation amongst siblings in relation to dental decay despite similar diets and hygiene. In London, it is easy to walk along any high street and access a NHS dentist. However, there are several parts of the UK where it is difficult to access NHS dentistry and it may be that the child did not have suitable access. So it may be a case of education and signposting to help the parent and child.
The third factor is that there must be a significant connection between the parent or carer’s on-going responsibility for the child and continued harm to the child. The dentist will have pointed out all the dental problems and discussed the causes of dental decay as well as prevention techniques including diet and oral hygiene. Follow-up appointments will have been arranged however the child only presents with dental emergencies such as abscesses or pain. Planned treatments are ignored and referral letters are lost or there is non-attendance at referral clinics. There is a risk that the child will have to undergo potentially hazardous general anaesthesia for dental extractions. If all this is happening despite continuing education and access to dental care then the dentist must consider dental neglect. The National Institute for Health and Care Excellence states that “clinicians must consider neglect if parents or carers have access to but persistently fail to obtain NHS treatment for their child's dental caries (tooth decay)”. One should, of course, include private practices in this statement as there should be no difference in managing neglect. So the factors to consider are the presence of harm or continuing harm despite intervention and assistance being offered and the possibility of a wider picture of neglect then the dental team has a duty to raise concerns and follow local guidelines.
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