call for providers to
children in state cus-
tody or foster care,
Dental neglect, which is a form of child
abuse, can be difficult to differentiate
from lack of access to dental care, said
Anupama Rao Tate, D.M.D., M.P.H., a
lead author of the report and a pediatric
dentist. The clinical report outlines factors
to consider when evaluating for neglect.
Some patients with oral/dental ev-
idence of abuse could be victims of
human trafficking or bullying. Often,
children with orofacial or dental ab-
normalities are bullied, which may lead
to mental health issues. Children who
report being bullied or who have been
physically or sexually abused also can
have poor dental health.
Clinicians have a role to play in asking children and families how things are
going at school, etc., providing the opportunity to bring up bullying, Dr. Tate
said. “If nothing else,” she said, “it’s a
resource for the child and shows support
by opening that conversation.”
Signs, symptoms of abuse
Oral injuries can be inflicted with
hands, instruments, scalding liquids or
other caustic substances. This may result
in contusions; burns or lacerations of the
tongue, lips, buccal mucosa, palate, gin-
giva, alveolar mucosa or frenum; frac-
tured or avulsed teeth; or facial bone and
jaw fractures. Trauma to the teeth can
cause pulpal necrosis, leaving the teeth
with a gray discolored appearance. Gags
applied to the mouth may leave bruises
or scarring at the corners of the mouth.
Lacerations to the oral frena in infants
who are not yet walking often are signs
“Soft tissue injuries that are subtle
in nature — and especially in infants
— can be sentinel events or precursor
events to larger physical abuse issues or
escalate to abuse issues that may well
present with more definitive clinical
findings,” Dr. Tate said.
“It’s the force-feeding with the spoon,
the bottle shoved in the mouth that often escalate to abuse issues,” she said.
While the oral cavity is a frequent site
of child sexual abuse, it’s rare to notice
visible signs of injury or infection, the
report points out. However, unexplained
injury or petechiae of the palate may be
a result of forced oral sex. If oral-genital
contact is suspected, refer the patient to
a specialized clinical setting for comprehensive examinations. A multidisciplinary child abuse evaluation for the
child and family is recommended.
Bitemarks are challenging to interpret
because of the distortion presented and the
time elapsed between the injury and the
analysis. They should be suspected when
ecchymoses, abrasions or lacerations are
found in an elliptical, horseshoe-shaped
or ovoid pattern. However, it is rare to
directly link a bitemark to a perpetrator.
• Physicians and dentists are among
those required to report injuries suspicious for child abuse or neglect. Because abusive injuries often involve the
face and mouth, dental providers may
be first to detect such problems.
• Sexual abuse may involve the mouth,
and health care professionals must
know how to conduct a history and
document other evidence to support
forensic investigations. Be aware of
specialists in the area for specialized
forensic interviews and specimen collection.
• Ask patients about bullying, and advocate for prevention programs.
• Know risk factors for human trafficking to help identify potential victims
(female and male).
• Work with colleagues to link families
to support when maltreatment has
AAP clinical report The Evaluation of
Suspected Child Physical Abuse, http://