AMERICAN ACADEMY OF PEDIATRIC DENTISTRY

Oral and Dental Aspects of Child Abuse and

Neglect
Review Group
American Academy of Pediatric Dentistry, Council on Clinical Affairs, Council on Scientific Affairs, Ad Hoc Work Group on Child Abuse and Neglect;
and American Academy of Pediatrics, Section on Oral Health and Committee on Child Abuse and Neglect

Latest Revision
2017

Abstract
In all 50 states, health care providers (including dentists) are mandated to report suspected cases of abuse and neglect to social service
or law enforcement agencies. The purpose of this report is to review the oral and dental aspects of physical and sexual abuse and
dental neglect in children and the role of pediatric care providers and dental providers in evaluating such conditions. This report
addresses the evaluation of bite marks as well as perioral and intraoral injuries, infections, and diseases that may raise suspicion for
child abuse or neglect. Oral health issues can also be associated with bullying and are commonly seen in human trafficking victims.
Some medical providers may receive less education pertaining to oral health and dental injury and disease and may not detect
the mouth and gum findings that are related to abuse or neglect as readily as they detect those involving other areas of the body.
Therefore, pediatric care providers and dental providers are encouraged to collaborate to increase the prevention, detection, and treatment
of these conditions in children.

Children may be exposed to multiple kinds of maltreatment should be examined carefully by the appropriate provider at
that manifests in the mouth, so health care professionals some point during the course of the evaluation for signs of
(including dental providers) need to be aware of how to evaluate oral trauma, caries, gingivitis, and other oral health problems,
and address these concerns. Maltreatment includes physical which are more prevalent in maltreated children than in the
and sexual abuse and can include evidence of bite marks and general pediatric population.7
dental neglect. Bullying and the human trafficking of chil- Some authorities believe that the oral cavity may be a
dren also occur and can have serious long-term effects. These central focus for physical abuse because of its significance in
issues may be the presenting problem, noticed during a communication and nutrition.‍8 Oral injuries may be inflicted
physical examination, or children or adolescents may disclose with instruments such as eating utensils or a bottle during
information about experiencing abuse or neglect. It is im- forced feedings, hands, fingers, scalding liquids, or caustic sub-
portant for all health care providers (including dental providers) stances. This form of abuse may result in contusions; burns
to be alert to and knowledgeable about signs and symp- or lacerations of the tongue, lips, buccal mucosa, palate (soft
toms of child abuse and neglect and to know how to respond. and hard), gingiva, alveolar mucosa, or frenum; fractured,
Because different communities have different resources, not displaced, or avulsed teeth; or facial bone and jaw fractures.
all providers of a certain job specification may be available Naidoo‍9 cited the lips as the most common site for inflicted
everywhere, and thus, job roles may sometimes overlap. oral injuries (54 percent) followed by the oral mucosa, teeth,
gingiva, and tongue. Lacerations to the oral frena in premobile
Physical abuse infants are often the result of physical abuse and are frequently
Craniofacial, head, face, and neck injuries occur in more than associated with other findings of serious physical abuse.‍ 10
half of child abuse cases. 1-6 All suspected victims of abuse Trauma to the teeth may result in pulpal necrosis, leaving the
or neglect, including children in state custody or foster care, teeth gray and discolored.‍11,12 Gags applied to the mouth may
result in bruises, lichenification, or scarring at the corners of
the mouth.‍13 Some serious injuries of the oral cavity, including
To cite: Fisher-Owens SA, Lukefahr JL, Tate AR, American Academy of Pediatric Den- posterior pharyngeal injuries and retropharyngeal abscesses,
tistry, Council on Clinical Affairs, Council on Scientific Affairs, Ad Hoc Work Group on
Child Abuse and Neglect, American Academy of Pediatrics, Section on Oral Health may be inflicted by caregivers who fabricate illness in a child‍14
Committee on Child Abuse and Neglect. Oral and Dental Aspects of Child Abuse and
Neglect. Pediatr Dent 2017;39(4):278-83.

ABBREVIATIONS
This document was originally developed in collaboration by the American Academy
of Pediatrics Committee on Child Abuse and Neglect and the American Academy AAP: American Academy of Pediatrics. ABFO: American Board of
of Pediatric Dentistry and adopted in 1 999. This is a revision of the 2005 version Forensic Odontology.
which was reaffirmed in 2010 and 2016.

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REFERENCE MANUAL V 40 / NO 6 18 / 19

to simulate hemoptysis or other symptoms requiring medical remains uncertain. Human papillomavirus infections may be
care. All findings in cases in which there is reasonable suspi- transmitted sexually through oral-genital contact, vertically
cion of abuse or neglect, regardless of mechanism, should be from mother to infant during birth, or horizontally through
reported for further investigation. Unintentional or accidental nonsexual contact from a child or caregiver’s hand to the
injuries to the mouth are common and can be distinguished genitals or mouth.28,29
from abuse by judging whether the history (including the Unexplained injury or petechiae of the palate, particularly
timing and mechanism of the injury) is consistent with the at the junction of the hard and soft palate, may result from
characteristics of the injury and the child’s developmental forced oral sex.‍30 As with all suspected child abuse or neglect,
capabilities. Multiple injuries, injuries in different stages of when sexual abuse is suspected or diagnosed in a child, the case
healing, or a discrepant history should arouse suspicion for must be reported to child protective services and/or law en-
abuse. Consultation with or referral to a knowledgeable dentist forcement agencies for investigation.‍ 31-34 A multidisciplinary
or child abuse pediatrician may be helpful. The clinical report child abuse evaluation for the child and family is preferred
from the American Academy of Pediatrics (AAP) entitled when available.
“The Evaluation of Suspected Child Physical Abuse” provides Children who present acutely with a recent history of sex-
additional guidance.‍15 ual abuse may require specialized forensic testing for semen
and other foreign materials resulting from assault. Specialized
Sexual abuse hospitals and child protection clinics equipped with protocols
Although the oral cavity is a frequent site of sexual abuse in and experienced personnel are best suited for collecting such
children,16 visible oral injuries or infections are rare. When specimens and maintaining a chain of evidence necessary for
oral-genital contact is suspected, referral to specialized clinical investigations. If a victim provides a history for oral-penile
settings equipped to conduct comprehensive examinations is contact, the buccal mucosa and tongue can be swabbed with
recommended. The AAP clinical report entitled “The Eval- a sterile, cotton-tipped applicator; the swab can be air dried
uation of Children in the Primary Care Setting When Sexual and packaged appropriately for laboratory analysis.
Abuse Is Suspected”17 provides information regarding these
examinations as does the “Updated Guidelines for the Medical Bite marks
Assessment and Care of Children Who May Have Been Acute or healed bite marks may indicate abuse. Dentists
Sexually Abused18.” trained as forensic odontologists can assist health care pro-
When oral-genital contact is confirmed by history or viders in the detection and evaluation of bite marks related
examination findings, universal testing for sexually transmitted to physical and sexual abuse.‍35 Bite marks should be suspected
infections within the oral cavity is controversial; the clinician when ecchymoses, abrasions, or lacerations are found in an
may consider risk factors (e.g., chronic abuse or a perpetrator elliptical, horseshoe shaped, or ovoid pattern.‍36 Bite marks
with a known sexually transmitted infection) and the child’s may have a central area of ecchymoses (contusions) caused by
clinical presentation when deciding whether to conduct such the following 2 possible phenomena: (1) positive pressure
testing. Accuracy to diagnose sexually transmitted infections from the closing of the teeth with disruption of small vessels
of the oral cavity is increased if evidence is collected within or (2) negative pressure caused by suction and tongue thrust-
24 hours of exposure in prepubertal children‍19 and within 72 ing. Bites produced by dogs and other carnivorous animals
hours in adolescents. Evidence collection should be repeated as tend to tear flesh, whereas human bites compress flesh and
clinically indicated. Oral and perioral gonorrhea in prepubertal can cause abrasions, contusions, and lacerations but rarely
children (which is diagnosed with appropriate culture techni- avulsions of tissue. An intercanine distance (i.e., the linear
ques and confirmatory testing) is pathognomonic of sexual distance between the central point of the cuspid tips) measuring
abuse but is rare.‍20,21 Rates are higher in sexually abused adoles- more than 3.0 cm is suspicious for an adult human bite.‍37
cents (12 percent with gonorrhea; 14 percent with Chlamydia).‍22 Bite marks found on human skin are challenging to inter-
Pharyngeal gonorrhea frequently is asymptomatic.23 Although pret because of the distortion presented and the time elapsed
culture has been considered the gold standard, nucleic acid between the injury and the analysis.‍36 Recent investigations
amplification tests are more commonly used now‍24 because they have led to questions about the scientific validity of forensic
are more sensitive, less invasive, and less expensive.‍25 Although patterned evidence (bite mark analysis in particular) and its
they have not been approved by the U.S. Food and Drug Ad- role in legal proceedings.‍38 The pattern, size, contour, and color
ministration for the prepubertal age group or for rectal or of a bite mark ideally can be evaluated by a forensic odon-
oropharyngeal swab specimens, the Centers for Disease Control tologist; a forensic pathologist can be consulted if a forensic
and Prevention does cite nucleic acid amplification tests on odontologist is not available. If neither specialist is available, a
vaginal swab specimens or urine as an alternative to cultures medical provider or dental provider experienced in identifying
in girls. However, culture remains the preferred method for the patterns of child abuse injuries may examine and document
testing urethral swab specimens or urine for boys and for the bite mark characteristics photographically with an identi-
extragenital swab specimens (pharynx and rectum) for all fication tag and scale marker (e.g., ruler) in the photograph.
children.‍26,27 Although human papillomavirus infection may The photograph should be taken such that the angle of the
result in oral or perioral warts, the mode of transmission camera lens is directly over the bite and in the same plane

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 AMERICAN ACADEMY OF PEDIATRIC DENTISTRY

of the bite to avoid distortion.‍39 A special photographic scale recruitment, harboring, transportation, provision, or obtaining
was developed by the American Board of Forensic Odontology of a person for labor or services through the use of force,
(ABFO) for this purpose as well as for documenting other fraud, or coercion for the purpose of subjection to involun-
patterned injuries (ABFO No. 2 Reference Scale). ABFO- tary servitude, peonage, debt bondage, or slavery” ([22 USC
certified odontologists and the ABFO bite mark analysis flow §7102(9)]).48 Of these, children most commonly experience
sheet can be found on the ABFO website (www.abfo.org). In sex trafficking, “in which a commercial sex act is induced
addition to photographic evidence, every bite mark that shows by force, fraud, or coercion, or in which the person induced
indentations ideally will have a polyvinyl siloxane impression to perform such act has not attained 18 years of age” ([22
made immediately after swabbing the bite mark for secretions USC §7102(9)]). Sex trafficking is considered “commercial
containing DNA. This impression will help provide a three- sexual exploitation of children” as are pornography and sur-
dimensional model of the bite mark. Written observations and vival sex (defined as the exchange of sexual activity for basic
photographs should be repeated at intervals to best document necessities such as shelter, food, or money).49,50
the evolution of the bite.‍39 Because each person has a charac- Precise numbers of children experiencing human or sex
teristic bite pattern, a forensic odontologist may be able to trafficking are difficult to obtain because of the complicated
match dental models (casts) of a suspected abuser’s teeth with nature of these definitions and underreporting. However, it is
impressions or photographs of the bite. (This is the responsi- estimated that >100,000 children are victims of prostitution
bility of the police and not the health care provider.) each year in the United States51; see the AAP Clinical Report
DNA is present in oral epithelial cells and may be depo- entitled “Child Sex Trafficking and Commercial Sexual Ex-
sited in bites. Even if saliva and cells have dried, they can be ploitation: Health Care Needs of Victims” for more inform-
collected by using the double-swab technique. First, a sterile ation on identifying and serving these patients.50 The average
cotton swab moistened with distilled water is used to wipe the age of children who are exploited for sex is 12 years old, and
area in question, then dried and placed in a specimen tube. A children as young as 6 years old are targeted.46,51 Children who
second control sample is collected by swabbing the victim’s are or have been in foster care,49 are homeless,52 are runaways,50
buccal mucosa to distinguish his or her DNA from that of or are incarcerated in juvenile detention facilities50 are more
the perpetrator.‍ 39 All evidence should be collected, docu- likely to be victims of human trafficking (particularly if they
mented, and labeled according to standards with a clear chain are experiencing survival sex); this can include international
of custody and submitted for forensic analysis.‍39 Questions abduction, although geographical dislocation is not required
regarding the evidentiary procedure should be directed to a in the definition of trafficking.52
law enforcement agency. Although children who are victims of human trafficking
are often disenfranchised from most of society, more than
Bullying one-quarter of them still will see a health care professional
Thirty percent of children in the sixth to 10th grades report while in captivity.53 Victims of trafficking have complex psy-
having been bullied and/or having bullied others.40 Children chosocial and physical challenges that affect how they perceive
with orofacial or dental abnormalities (including malocclu- and respond to a given situation. Rescued victims often have
sion) are frequently subjected to bullying41,42 and, as a result, complex health needs, including infectious diseases, reproduc-
may suffer serious psychological consequences, including tive health problems, substance abuse, and mental health
depression and suicidal ideation.43-45 Children who reported problems. Dental problems also rank high in this list: for
physical abuse, intimate partner violence, forced sex, and trafficked women and adolescents in Europe, 58 percent re-
bullying were found to also report poor oral health.46 Also of ported tooth pain.54 In the United States, more than half (54.3
great concern are the more subtle psychosocial consequences percent) of women and adolescents reported dental problems,
that can be associated with bullying behavior.  Health care most commonly tooth loss (42.9 percent).55 Child trafficking
providers (including dental providers) can ask patients about victims have twice the risk for dental problems because they
bullying and advocate for antibullying prevention programs “often suffer from inadequate nutrition leading to retarded
in schools and other community settings.44 Health care pro- growth and poorly formed teeth, as well as dental caries, infec-
viders can become familiar with “Connected Kids: Safe, tions and tooth loss.”56 For older children, dental problems may
Strong, Secure,” the primary care violence prevention protocol trace back to their situation of origin, with limited access to
from the AAP that offers preventive education, screening or poor quality of care. Dental problems may also come from
for risk, and linkages to community-based counseling and being in the trafficking situation, during which time children
treatment resources (https://patiented.solutions.aap.org/ may have had unattended problems in addition to forgone
Handout-Collection.aspx?categoryid=32034).47 preventive care or, even worse, physical abuse or torture to
the head.54,57
Human trafficking Human trafficking is not a problem exclusive to girls and
Human trafficking is a serious child health issue involving women. As many as 50 percent of victims may be boys
medical and dental ramifications, among others, but it is or men, 58 although they are not discussed as much in the
just beginning to be addressed in the United States. The U.S. literature. For both sexes, a commonality is a history of
Department of State defines human trafficking as “[T]he child abuse.

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Dental neglect Conclusions

Dental neglect, as defined by the American Academy of Pedi- It is important for health care providers (including dental
atric Dentistry, is the “willful failure of parent or guardian, providers) to be aware that physical or sexual abuse may result
despite adequate access to care, to seek and follow through in oral or dental injuries or conditions. Health care providers
with treatment necessary to ensure a level of oral health essential should be aware of when and how to document suspicious
for adequate function and freedom from pain and infection.”59 injuries and how to obtain laboratory evidence, photo docu-
Dental caries, periodontal diseases, and other oral conditions mentation, and/or consultation with experts when appropriate.
can lead to pain, infection, loss of function, and worse if left Furthermore, injuries that are inflicted by a perpetrator’s
untreated. These undesirable outcomes can adversely affect mouth or teeth may leave clues regarding the timing and
learning, communication, nutrition, and other activities neces- nature of the injury as well as his or her identity. Health care
sary for normal growth and development.4,60 Some children providers should be knowledgeable about such findings, their
who first present for dental care have severe early childhood significance, and how to meticulously observe and document
caries (formerly termed infant bottle or nursing caries). Care- them. When questions arise or consultation is needed, a
givers with adequate knowledge and willful failure to seek pediatric dentist or a dentist with formal training in forensic
care must be differentiated from caregivers without knowledge odontology can ensure appropriate testing, diagnosis, and
or awareness of their child’s need for dental care when deter- treatment.
mining the need to report such cases to child protective services. Pediatric dentists and oral and maxillofacial surgeons,
Several factors are considered necessary for the diagnosis of whose advanced education programs include a mandated
neglect61: child abuse curriculum, can provide valuable information and
• a child is harmed or at risk for harm because of lack assistance to other health care providers about oral and dental
of dental health care; aspects of child abuse and neglect. The Prevent Abuse and
• the recommended dental care offers significant net Neglect through Dental Awareness65 coalition (http://www.
benefit to the child; healthy.arkansas.gov/programsServices/oralhealth/Pages/PANDA.
• the anticipated benefit of the dental treatment is signi- aspx), which has trained thousands of physicians, nurses,
ficantly greater than its morbidity, so parents would teachers, child care providers, dentists and other dental pro-
choose treatment over nontreatment; viders, is another resource for physicians seeking information
• access to health care is available but not used; and on this issue. Physician members of multidisciplinary child
• the parent understands the dental advice given. abuse and neglect teams are encouraged to identify such dental
providers in their communities to serve as consultants for
Failure to seek or obtain proper dental care may result these teams. In addition, medical providers with experience
from factors such as family isolation, lack of finances, trans- or expertise in child abuse and neglect can make themselves
portation difficulty, parental ignorance, or lack of perceived available to dentists and dental organizations as consultants
value of oral health. 62-64 The point at which to consider a and educators. Such efforts will strengthen our ability to
parent negligent and begin intervention occurs after the parent prevent and detect child abuse and neglect and enhance our
has been properly alerted by a health care provider about the ability to care for and protect children.
nature and extent of the child’s condition, the specific treat-
ment needed, and the mechanism of accessing that treatment.62 Recommendations
Because many families face challenges in accessing dental 1. Health care providers (including dental providers) are
care or insurance for their children, the health care provider, required to report injuries that are concerning for abuse
including the dental provider, will evaluate whether dental or neglect to child protective services in accordance
services are readily available and accessible to the child when with local or state legal requirements. Abusive injuries
considering whether negligence has occurred. A child’s social, frequently involve the face and oral cavity and, thus,
emotional, and medical ability to undergo treatment also may be first encountered by dental providers.
should be considered when determining dental neglect.64 2. Similarly, sexual abuse may involve the mouth, even
To the best of his or her ability, the health care provider without overt signs, and thus, health care providers (in-
should be certain that the caregiver understands the expla- cluding dental providers) should know how to collect a
nation of the disease and its implications and, when barriers to history to elicit this information as well as how to
the needed care exist, attempt to assist the family in finding appropriately collect laboratory tests to support forensic
financial aid, transportation, or public facilities for needed investigations. The general provider is encouraged to
services. Risks and benefits of dental treatment should be become aware of and consult with appropriate special-
explained, and parents should be told that appropriate anal- ists in his or her area for specialized forensic interviews
gesic and anesthetic procedures will be used to ensure the and specimen collection.
child’s comfort during dental procedures. If, despite these 3. Bite marks found on human skin are challenging to
efforts, the parent fails to obtain therapy, the case should be interpret because of the distortion presented and the
reported to the appropriate child protective services agency.62 time elapsed between the injury and the analysis. Ideally,

246 RECOMMENDATIONS: BEST PRACTICES

 AMERICAN ACADEMY OF PEDIATRIC DENTISTRY

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