Safeguarding Guide for Dentists

What risk factors make someone more likely to experience abuse?

There is no way to know which children are most vulnerable to abuse, but there are some factors for abuse and neglect risk to be aware of, including but not limited to:

• Very young children
• Children with disabilities and health problems
• Children who have already been, or who are currently being, abused and/or neglected
• Parents who are young when their child is born
• Parents who are poorly informed about parenting
• Parents with mental health issues, especially untreated issues, for example depression, antisocial personality disorder, substance abuse and related disorders
• Single parent households
• Intimate-partner violence
• Parents experiencing emotional and/or financial stress
• Poverty, poor housing and deprivation
• Social isolation
• Violence in the community

Adult abuse and neglect can occur anywhere to anyone; however, there are risk factors that can make a person more vulnerable to abuse.

An adult at risk of abuse may:

• Have an illness affecting their mental or physical health
• Be physically dependent on others
• Have a sensory impairment
• Have a learning disability
• Suffer from drug or alcohol problems
• Have low self-esteem
• Be unable to make their own decisions
• Have a previous history of abuse
• Have negative experiences of disclosing abuse
• Be of increasing age
• Be frail
• Have experienced a lack of access to health and social services or high-quality information

This list is not exhaustive, and other people might also be considered to be adults at risk.

The types of abuse children can encounter

Statutory guidance across the four countries of the UK describes four main categories of child abuse, and these definitions will normally be reflected in local organisations’ policies and procedures.

The four categories are:

These are:

• Physical harm/abuse – this may involve hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating, or otherwise causing physical harm to a child/young person. Physical harm may also be caused when a parent or carer fabricates the symptoms of, or deliberately induces, illness in a child/young person. Harm can also occur due to practices linked to faith and culture, for example, Female Genital Mutilation (FGM).
• Emotional harm/abuse – this is the persistent emotional maltreatment of a child/young person such as to cause severe and persistent adverse effects on the child/young person’s emotional development. It may involve conveying to children that they are worthless or unloved, inadequate, or valued only insofar as they meet the needs of another person. It may include not giving the child the opportunities to express their views, deliberately silencing them or “making fun” of what they say or how they communicate. It may feature age or developmentally inappropriate expectations being imposed on children. These may include interactions that are beyond a child’s developmental capacity, as well as overprotection and limitation of exploration and learning, or preventing the child from participating in normal social interaction. It may involve seeing or hearing the ill treatment of another. It may involve serious bullying, including cyberbullying, causing children/young people frequently to feel frightened or in danger, or the exploitation or corruption of children/young people. Some level of emotional abuse is involved in all types of maltreatment of a child/young person, though it may occur alone.
• Sexual abuse – this involves forcing or enticing a child or young person to take part in sexual activities, not necessarily involving a high level of violence, whether or not the child is aware of what is happening. The activities may involve physical contact, including assault by penetrative acts, for example rape or oral sex, or non-penetrative acts such as masturbation, kissing, rubbing and touching outside of clothing. They may include non-contact activities, such as involving children in looking at, or in the production of, pornographic sexual images, watching sexual activities, encouraging children to behave in sexually inappropriate ways, or grooming a child in preparation for abuse, including via the internet. Sexual abuse is not solely perpetrated by adult males; women can also commit acts of sexual abuse, as can other children.
• Neglect – this is the persistent failure to meet a child/young person’s basic physical and/or psychological needs, likely to result in the serious impairment of the child/young person’s development. Neglect may occur during pregnancy, for example as a result of maternal substance abuse, maternal mental ill health or learning difficulties or a cluster of such issues. Where there is domestic abuse and violence towards a carer, the needs of the child may be neglected. Once a child is born, neglect may involve a parent or carer failing to:
  – Provide adequate food, clothing and shelter, including exclusion from home or abandonment
  – Protect a child/young person from physical and emotional harm or danger
  – Ensure adequate supervision, including the use of inadequate caregivers
  – Ensure access to appropriate medical care including dental care or treatment and also include the neglect of, or unresponsiveness to, a child/young person’s basic emotional needs

The types of abuse adults can encounter

There are ten types of abuse listed in the Care Act (2014).

These are:

• Physical abuse – this may involve physical violence, misuse of medication, inappropriate restraint or sanctions.
• Sexual abuse – this can include verbal sexual abuse, non-consensual touching, fondling, physical restraint, cornering, tickling, kissing, excessive cleaning of genitals, enemas, intercourse, sodomy, oral sex, invasion of privacy and stalking.
• Psychological abuse – this includes emotional abuse, threats of harm or abandonment, deprivation of contact, humiliation, blaming, controlling, intimidation, harassment and verbal abuse.
• Financial or material abuse – including theft, fraud, exploitation, pressure in connection with wills, property, inheritance or financial transactions, and misuse or misappropriation of property, possessions or benefits.
• Neglect and acts of omission – including ignoring medical or physical care needs, failure to provide access to appropriate health, social care or educational services, withholding medication, and inadequate nutrition and heating.
• Discriminatory abuse – including racist or sexist abuse or abuse based on a person’s disability.
• Domestic abuse – including psychological, physical, sexual, financial or emotional abuse, and so-called honour-based violence.
• Modern slavery – includes slavery, human trafficking, forced labour and domestic servitude.
• Organisational abuse – including neglect and poor care practice within an institution or specific care setting such as a hospital, dental practice or care home.
• Self-neglect – includes a wide range of behaviour neglecting to care for personal hygiene, health or surroundings and includes behaviour such as hoarding.

The safeguarding issues dentists may come across

Dental professionals are likely to observe and identify injuries to the head, eyes, ears, neck, face, mouth and teeth, as well as other welfare concerns. Bruising, burns, bite marks and eye injuries are the types of injury that suggest a concern should be raised. Dental professionals are also well placed to identify the risks to oral and general health associated with poor oral hygiene and dental neglect.

Dentists may identify abuse pertaining to the oral cavity which may manifest as abrasions or lacerations of the tongue, lips, oral mucosa, hard and soft palate, gingiva and frenum. The dentist may also observe dental, maxilla and mandible fractures.

Other potential signs of domestic violence that may present at a dental appointment might include:

• The patient is always accompanied by a partner or family member, who frequently speaks for the patient or cancels the patient’s appointments
• The patient displays high levels of anxiety
• Presentation doesn’t fit the explanation provided
• Repeated cancelling or rescheduling of appointments

Neglect of oral health may also lead to current and/or future harm such as toothache, difficulty eating a balanced diet leading to deficiencies and/or malnutrition, sleep deprivation, and absences from school or work. In addition, the individual may get teased or bullied due to the unusual appearance of their teeth.

Child or adult abuse or neglect may present with the parent and or carer agreeing to make the changes needed to improve the patient’s oral health but then making little or no effort with this. Disguised compliance involves a parent or carer giving the appearance of co-operating with a patient’s dental treatment to avoid raising suspicions of unsafe parenting or caring. The aim is to avoid social care interventions by allaying professional concerns. Concerns may also be raised in respect of how a parent or carer has related to, or behaves towards, a child or adult at risk.

A patient may also disclose abuse or other indicators of it; such safeguarding concerns should always be recorded. Accurate record keeping is an essential part of the accountability for safeguarding.

Missed healthcare appointments are the most common reason for dentists to make child protection referrals.

They cause concern because they:

• May be an alerting feature that a child or young person is being neglected
• Are often found when a child has died or been seriously harmed by maltreatment, when a serious case review is conducted
• Should be followed up rigorously but that isn’t always easy to do

Describing children and young people as “Was not brought” (WNB) instead of “Did not attend” (DNA) encourages dentists to think about the situation from the child’s perspective and potentially take action to safeguard them.