In 2014, over 50,000 children were identified as needing protection from abuse in the UK. The NSPCC believes that for every one child on a child protection register or plan, another eight are suffering abuse.
Child Protection and the Dental Team1 is the definitive guide to how dental professionals can play their part in safeguarding children. Martyn Green was a member of the expert team that produced the guidance in 2006 and his NHS practice in Devon was used as a testing ground for the advice and training material.
'We wanted to keep the advice grounded and intelligible to all members of the dental team because child protection should be a team effort,' he explains. 'All members of the dental team are in a position to spot warning signs. Receptionists witness how a child behaves in the waiting room, for example, while nurses observe what happens while the dentist is focusing on the mouth.'
Martyn believes that dental practices are well-placed to help young patients at risk. As well as offering the opportunity to closely examine patients for signs of orofacial trauma and observe their interactions with others, he points out that disclosures are often made to someone the child knows and trusts. 'I'm now retired, but in my 30 years as a practitioner I might have seen three generations of the same family many times over many years and got to know them well. That isn't necessarily the case for a GP.'
Until January 2015 Martyn gave lectures about child protection to dentists and Dental Care Professionals in the south west. While he is in no doubt there is a greater awareness of child protection because of tragic cases such as Victoria Climbie and Baby P, he worries that some dental professionals are still reluctant get involved.
One complex aspect of child protection that causes particular difficulty is dental neglect. It was recognised by NICE in 2009 that 'when parents persistently fail to obtain NHS treatment for their child's tooth decay' it should prompt healthcare professionals to consider whether the child is being neglected.2 Dental neglect is defined by the British Society of Paediatric Dentistry 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'.3 It's often hard, at least initially, to determine whether advanced dental disease in children has been caused by ignorance, poor parenting, being unable to cope, or something more sinister. Dental professionals should consider each case in the context of factors like access to dental treatment and the impact on the patient.
'The term dental neglect should be reserved for the failure to respond to a known significant dental problem or persistently and deliberately ignoring advice,' explains Martyn. 'For example, if a child has an abscess and you refer them to local hospital but they don't attend - it's up to you to follow up and find out why. If the family say they didn't receive the appointment or the car broke down, that is unfortunate. But if they clearly couldn't be bothered, you should consider dental neglect.
'We should be alert to signs that the parents are struggling to cope,' he adds. 'A common failing among all dental professionals is that we only look at the teeth but child protection shows the importance of a more holistic approach.'
Besides dental neglect, dental professionals might also encounter victims of physical, emotional and sexual abuse during their career. Martyn warns against preconceptions about the types of families where abuse takes place. 'There are risk factors for child abuse such as alcoholism, domestic violence and mental illness, but it's wrong to think that abuse is confined to any particular socioeconomic group. It's also much more common than you'd think. I have raised concerns a couple of times during my career but there may have been other children who were victims and I didn't know.'
Child Protection and the Dental Team gives examples of possible non-accidental injuries that are suggestive of abuse, such as frenum tears in non-ambulant babies and blunt trauma resulting in damage to the permanent or primary teeth. It also sets out three stages in the assessment of any physical injury - evaluating the injury itself, taking a history and exploring the broader picture (for example, the child's behaviour or the parent-child interaction).
Bear in mind also that abusers are often adept at covering their tracks and may delay bringing children for an appointment. Any delay in attendance following an accident should therefore be regarded as a warning sign.
If a child presents with an injury, Martyn recommends asking open questions rather than interrogating the child or parent. 'For example, say to a young child, 'that's an interesting bruise, how did you do that?', not, 'did daddy hit you'? Does the explanation fit the injury? Why was there a delay in coming for treatment?
Dr Martyn Green
Your notes are also a vital tool as Martyn explains. 'A minor injury should be recorded because you or a colleague might notice something similar six months later and you can build up a long-term picture. It is also possible you may be asked to provide copies to assist a police investigation.'
He advises dental professionals to record all they can, including diagrams showing size, shape and colour of injuries (photographs are more complicated due to the precise forensic requirements and the need to obtain explicit consent). Document the facts and differentiate between fact and opinion - for example, 'there were four parallel bruises 3cm x 1cm on the right cheek (fact)' rather than, 'it was a slap (opinion)'. It is also important to know and record who accompanied the child, their explanation for the injury and the child's demeanour during the appointment.
If a child confides that they're being abused, take this seriously. Martyn advises against asking leading questions in this situation. Instead, listen to what they say and tell them that you will take the matter further. He warns that you must not promise them that you will keep the abuse a secret and that you have to pass the information on to others who can help.
Acting on concerns
If you believe a young patient is a victim of abuse or neglect, you have an ethical duty to raise concerns as soon as possible. The Government guidance Working Together to Safeguard Children4 says, 'Early sharing of information is the key to providing effective early help where there are emerging problems.'
You're unlikely to be criticised for acting in good faith. Doing nothing is a far greater risk.
Referrals to children's services are usually done by telephone and followed up in writing within 48 hours. The GDC expects dental professionals to find out about local child protection procedures, including who to contact for further advice and how to refer concerns to an appropriate authority. Child Protection and the Dental Team includes a useful flowchart which sets out the action you should take. Many dental professionals worry about getting this wrong but you're unlikely to be criticised for acting in good faith. Doing nothing is a far greater risk.
'Many people imagine that a child protection referral is going to lead to a 3am police raid and the removal of a child,' says Martyn, 'but this is a misconception. It is much more likely that social services will work with the family to help them make arrangements for the safety and protection of the child. You have to remember that diagnosing abuse is not your decision. Your obligation is to share your concerns. Decisions will be made by an experienced team of child protection professionals working together. Your referral may well be part of a jigsaw which might also include pieces from the GP, school or relatives.'
Even if turns out that a child isn't at risk of abuse, your concerns may point to other welfare or educational needs that aren't being met. The decision to share information can help ensure they receive extra support through the Common Assessment Framework (CAF), a coordinated multi-agency approach to supporting children, young people and families.
If you're in any doubt about the right course, Martyn suggests you speak to a colleague or the child protection lead (you can also contact the DDU advice line). You can also ask social services for advice on a 'no name' basis, although if the matter is judged serious enough they might ask you to make a formal referral there and then. Dental professionals can't refer children anonymously and you should record your referral in the patient's notes.
Before making a referral, you would usually be expected to talk to the child's parent or guardian about your concerns and explain what you're going to do, unless this would put the child at greater risk. 'People at my lectures often looked horrified when I told them that part of their responsibility to take concerns further was informing parents,' recalls Martyn. 'But difficult and sensitive conversations are part of dental practice, such as telling a patient you have found a lesion on their tongue. As dental professionals, we should have the communication skills to talk openly and honestly with patients and maintain their trust.'
Child protection in practice
To make it easier to meet child protection obligations, Martyn recommends that practices provide support in the form of clear practice procedures, a child protection lead and regular training for all members of the team. The Royal College of Paediatrics and Child Health has published guidance5 describing roles and competencies for staff by seniority. Organisations that advise on or provide training include Local Safeguarding Children Boards (LSCBs), Local Area Teams/Health Boards and Local Education and Training Boards (LETBs). He notes that safeguarding children features in the essential standards set out by the GDC and Care Quality Commission.
'In the aftermath of the Victoria Climbie case, it was noted that doing the simple things well can save lives', Martyn concludes. 'Dental professionals may not be as closely involved with child protection as social services or other healthcare professionals, but everyone in the practice team must be attuned to the risk and fully aware of their responsibilities when it comes to raising concerns. Child protection is too important to be left to someone else.'
Interview by Susan Field