child abuse

lecture given 8/24/2026

child abuse and neglect

any act or series of acts of comission or omission by a parent, caregiver, or other person in custodial role that results in harm, potential for harm, or threat of harm to a child

a preventable act

occurs across all socioeconomic, racial, ethnic, and cultural groups

may involve an act that harms or threatens a child or a failure to provide necesary care

why does child abuse matter to dentists?

the head, face, neck, and mouth are common sites of inflicted injury (65-75% of cases of physically abused children)

dentists may be among the first healthcare providers to recognize concerning findings

children with special healthcare needs may be particuarly vulnerable

stats on child abuse (not sure if on exam so i’m putting them here just in case)

MA has one of the highest rates of maltreated children

25% increase in incidence of abuse over the past 20 yrs

drop in cases during COVID

79% of perpetrators of child maltreatment are parents, 20.1% are non-parents or have an unknown relationship

pretty much evenly affects boys and girls

highest victim rate is among infants less than 1 yo

what is the etiology of child abuse?

can occur in any family and across all socioeconomic groups

approx 80% of abusers are family, 20% are non-parents or unknown

~50/50 boys and girls

what are caregiver and family risk factors?

history of experiencing or witnessing violence

substance use

mental health concerns

high caregiver stress

limited social support

unrealistic expectations of child development

what factors increase a child’s vulnerability to child abuse?

young age, esp infancy

developmental or physical disabilities

increased dependence on caregivers

communication limitations

family stressors and limited support

however abuse can affect any child

what factors contribute to child abuse?

lack of parenting skills, financial/family stress, history of child abuse, addicition or substance abuse, unrealistic expectations of caregivers, mental health problems

physical abuse definition

intentional bodily harm (kicking, slapping, pinching, biting, choking, shoving, or using physical restraint)

sexual abuse definition

any sexual behavior or activity with a child or exploitation of a minor

emotional abuse definition

a pattern of caregiver behavior that harms a child’s emotional development, well-being, or sense of self worth

dental neglect definition

the willful failure of a parent or guardian, despite adequate access to care, to seek and follow through with treatment necessary to ensure a level of oral health essential for adequate function and freedom from pain and infection

medical child abuse definition

formerly munchausen by proxy

fabrication, exaggeration, or induction of illness in a child by a caregiver

ex: inducing illness or symptoms, withholding food to prevent appropriate weight gain, adding blood to urine or stool to simulate illness

physical abuse as it relates to dentistry

oral injuries may be inflicted with instruments such as eating utensils or a bottle during forced feedings, hands, fingers, scalding liquids, or caustic substances

may result in contusions; burns or lacerations of the tongue, lips, buccal mucosa, palate (soft and hard), gingiva, alveolar mucosa, or frenum; fracture, displaced, or avulsed teeth, or facial bone and jaw fractures

some studies cited lips as the most common site for inflicted oral injuries (54%), followed by the oral mucosa, teeth, gingiva, and tongue

what are signs and symptoms of physical abuse?

unexplained injuries (bruises, broken bones, burns)

patterned or multiple injuries

injury inconsistent with the reported history

injury inconsistent with the child’s developmental ability

unexplained delay in seeking care

biting, ear pulling, hitting, slapping, choking/strangulation, hair pull

*animal bites tend to…

tear flesh

*human bites tend to…

compress flesh and can cause abrasions, contusions, and lacerations

*an inter-canine distance measuring more than ____cm is suspicious for an adult human bite

3.0

adult average is ~3.4cm

analyzing bite marks

can be difficult to interpret due to time elapsed and distortion presented

ideally they should be evaluated by a forensic odontologist or forensic pathologist, but if none are available a dentist may examine

how should you (as a dentist) document bite marks?

photograph- angle the camera directly over the bite, place a ruler/scale marker next to the bute

double swab technique- swab the area with a sterile cotton swab moistened with distilled water, followed by swabbing the same area with a second, dry cotton swab, thus absorbing any excess liquid- DNA present in epithelial cells from the mouth may be deposited in bites even if saliva and cells have dried

PVS impression- will help to provide a 3D model of the bite mark

what should you do with bite mark evidence?

collect, document, label, and maintain chain of custody

can be difficult to interpret, refer to a forensic odontologist/trained specialist when available

comparison with a suspected abuser’s dentition is handled by law enforcement/forensic specialist, not the healthcare provider

sock or glove burns

immersion of feet or hands in scalding liquid

have very distinct, sharply defined marks

burns with a distinct pattern tend to be deliberate

cigarette burns

even brief contact can cause severe burns

the lit end of cigarette can reach temps over 500F, 260C

bruises

bruise color is not a reliable method for determining the age of an injury

evaluate the location, pattern, developmental ability of the child, and whether the injury is consistent with the reported history

TEN-4-FACESp

bruising in these locations in children <4 may be concerning for abuse and warrents further evaluation

torso, ears, neck, any bruise on an infant under 4 mo, frenulum, angle of jaw, cheeks, eyelids, subjunctiva, patterned bruising

sexual abuse as it relates to dentistry

although the oral cavity is a common site of sexual abuse in children, visible oral injuries or infections are rare

when oral-genital contact is suspected, referral to a specialized clinical setting for a comprehensive examination is strongly recommended

findings that may require further eval: oral/perioral gonorrhea in a prepubertal child, unexplained palatal petechiae or trauma, unexplained oral or perioral lesions like warts

HPV lesions

differential diagnosis- condyloma acuminatum

can be transferred vertically or horizontally

oral gonorrhea

*primary herpetic gingivostomatitis (HSV)

very common viral infection of the mouth

often caused by herpes simplex virus type I

frequently affects children aged 6mo to 5 yr

transient and self-limiting condition, NOT associated with sexual abuse

fever 2-3 days is common precursor

bullying

children with orofacial or dental differences may be targets of bullying

dental providers can ask about bullying when appropriate and help connect pts with support

what factors are necessary for the diagnosis of neglect?

a child is harmed or at risk for harm because of lack of dental care

the recommended dental care provides significant net benefit to the child

the anticipated benefit of the dental treatment outweighs potential risks, making treatment clearly preferable

access to dental care is available but not utilized

the parent or caregiver understands the dental advice and recommendations given

what do you need to keep in mind when considering whether to report a case of dental neglect to CPS?

it is important to distinguish between caregivers who have adequate knowledge and knowingly fail to seek care vs those who are unaware of their child’s dental needs

severe dental disease alone does not establish dental neglect

when should you report dental neglect?

caregiver understands the explanation of the disease and its implications

any barriers to care are identified and the family is assisted to overcoming them

risks and benefits of the proposed treatment are clearly explained

risk of no treatment are also clearly explained

if the parent/caregiver fails to seek or follow through with treatment despite these efforts, the case should be reported to the appropriate CPS agency

*what are 3 conditions that may mimic symptoms of abuse?

epidermolysis bullosa, hemophilia, staphylococcal scalded skin syndrome (SSSS)

*epidermolysis bullosa

a rare genetic skin disorder characterized by fragile, blistering skin

blisters appear in response to minor trauma such as rubbing, scratching, or heat

blisters and skin erosions may mimic burns

*hemophilia

an inherited bleeding disorder where the blood does not clot properly due to a deficiency in clotting factors (commonly factor VIII or IX)

this can result in spontaneous bleeding as well as excessive bleeding following surgery or an injury

children with bleeding disorders may develop spontaneous or disproportionate bruising

*staphylococcal scalded skin syndrome (SSSS)

a rare but serious skin infection that causes peeling skin over large areas of the body

may appear as though the skin has been burned by a hot liquid

triggered by exotoxin release from specific strains of staphylococcus aureus bacteria

most common in infants and young children bc of immature kidneys that cannot clear s. aureus

dentists are mandated reporters, what does this mean?

mandated to report suspected cases of abuse or neglect

must be familiar with the perioral signs of child abuse and neglect

record all findings that may be helpful in the case including physical evidence and any statements made by the child or caregiver during the dental visit

report all suspected cases to appropriate state or local authorities in accordance with mandated reporting laws

t/f in MA, mandated reporters are proctected from any criminal, civil liability or retaliation by employers from reporting in good faith

true

what are the penalties for failing to report abuse in MA?

$1000 fine for failure to make required oral and written reports of suspected abuse

willful failure to report child abuse and/or neglect that resulted in serious bodily injury or death: fine up to $5000, up to 2.5 years in jail, can be reported to the board of registration in dentistry

how can you report child abuse in MA?

DCF for all suspected abuse/neglect of children under the age of 18

when you have resonable cause to believe that a child is being abused or neglected, immediately contact DCF

a written 51A report must follow in 48 hrs

proof is not required to make a report

what must be included in an 51A report?

your name, address, and phone number

all identifying info about the child and the parent/caregiver

nature and extent of the suspected abuse and/or neglect including evidence and photographs

circumstances under which you first became aware of the child’s maltreatment

detail any immediate steps (if any) taken to assist or protect the child (referral, treatment, hospitalization)

any other information you believe may be helpful

include a copy of the pts dental/med chart (considered a legal document) as supporting evidence

what services are rendered by DCF?

provide mental health and substance abuse services for families and children

recommend parenting skill classes, or alcohol and drug rehab courses as needed

provide prevention services

provide reunification services

provide foster care

what findings should raise concern when considering abuse?

delay in seeking care without a resonable explanation

history inconsistent with the childs injury

injury inconsistent with the child’s developmental abilities

unexplained or multiple injuries

signs of neglect

caregiver history that changes or conflicts with other accounts

what are some behavioral indicators of possible child abuse or neglect?

wary or fearful behavior around parents or caregivers

lack of eye contact

flinching or being fearful to physical touch

feelings or attempts to run away

dramatic mood changes including sudden shifts from calm to agitated

overly aggressive behavior towards others

withdrawn, or emotionally unresponsive demeanor

history of depression, anxiety, or attempted suicide

how should you take action?

evaluate, ask, document, report