Pediatric Dental Health

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Dental And Orofacial Aspects Of Child Abuse
Children are our most valuable national resource. Nevertheless, child abuse continues to be a serious cause of injury and death for many young children. In 1997, just under one million children were victims of child abuse or neglect. In 65% of physical abuse cases, there were head, neck, or facial injuries. Physicians and dentists therefore play a key role in the detection, treatment, and reporting of child abuse.

Child abuse is defined as any act that endangers or impairs a child's physical or emotional health or development. Neglect occurs in 55% of child abuse cases. Dental neglect is the willful failure by a parent or guardian to seek and obtain treatment for dental problems which cause pain, infection, or interfere with adequate function.

Child abuse was first brought to national attention in 1962 with Dr. Kempe's landmark article in JAMA: "The Battered Child Syndrome." By 1974, the national Child Abuse and Treatment Act was signed into law. Currently, each of the 50 states requires physicians, dentists, and healthcare workers to report cases of suspected child abuse to authorities, such as police and Child Protective Services.

The various types of child abuse include: physical, emotional, sexual, Munchausen Syndrome by proxy, and neglect. Factors contributing to abuse include: stress, family crisis, lack of support network, substance/alcohol abuse, and learned behavior. The role of physicians and dentists is: detection, documentation, treatment, and notification of authorities. The role of Child Protective Services or Social Services is: determining whether abuse has occurred.

The detection protocol used by physicians and dentist takes into account: child behavioral indicators, child history indicators, caretaker indicators, and physical indicators.

Behavioral indicators of the abused child may include:

Lack of eye contact.
Wary of parent or guardian.
Fear of touch.
Inappropriate language.
Overly anxious to please.
Inappropriate clothing for the time of year.
Dramatic mood changes.
History of suicide attempts.
History of running away.

Medical and social history of the abused child may include:
Low family income.
Unexplained or inconsistent injuries.
Delay in seeking care.
Specific accusation by a child.
Child with a chronic illness.
Premature child (seven times more likely than than a term-birth child to be abused).
Child living in an extremely isolated area.
Child who is viewed as "different."
Child with special needs.
Child with very strict or overly critical parents.
Abused children 8 times more likely to have untreated dental caries than other children.

Caretaker indicators may include:
Giving an explanation of the injury which is inconsistent with the facts.
Providing a vague story of the injury, lacking details.
Caretaker plays down the "incident."
Delays seeking care.
Caretaker is a substance/alcohol abuser.
Hostile or aggressive attitude.
Live-in boyfriend or cohabitator.
Compulsive behavior.
Inflexible attitude.
Has unreasonable expectations of the child.
Has previously abused a child.
Blames a third party.
Passive and dependent.
Hospital shopper.

Physical and dental indicators of abuse include:
Retinal hemorrhage - diagnostic of shaken baby syndrome.
Fractured incisors - may be due to repeated trauma.
Burns on lips - due to forced feeding of hot food.
Bruises on lips - due to forced pacifier use.
Frenum bruise - due to forced feeding of a non-ambulatory child.
Oral or perioral syphilis or gonorrhea (pathognomonic of sexual abuse).
Veneral warts (condylomata acuminata) - highly indicative of sexual abuse.
Palatal petechiae or erythema - probable sexual abuse.
Bite marks - 65% of them are visible while child is clothed.
Bruises in various stages of healing - indicative of multiple episodes of abuse.

Determining the age of multiple bruises by color.
0 - 2 days: swollen and tender
2 - 5 days: red and blue
5 - 7 days: green
7 - 9 days: yellow
9+ days: brown, then clearing

Recording and preserving bite mark evidence:
Bite marks by an adult: intercuspal distance is greater than or equal to 3 cm.
Bite marks by a small adult/large child: intercuspal distance is 2.5 - 3 cm.
Cotton swab moistened with distilled water is used to sample saliva or DNA remaining in the bite mark areas.
Color film, ASA 100 or slower, for photographs.
Photographs taken perpendicular to the bite marks.
Scale ruler in every photograph.
Identification tag in at least one close-up photograph.
Impression of bite marks are best done on a sedated child.
Impression of bite marks done using a polyether impression material, with an outer plaster matrix for rigidity.
Buccal mucosa and tongue swabbed for evidence of semen.
Strict chain of custody must be maintained for all evidence samples submitted for forensic analysis.

A recent medical journal article discusses child abuse:
DiScala C, Sege R, Li G, Reece RM. Child abuse and unintentional injuries. Arch Pediatr Adolesc Med. 154:16-22, 2000.

Dental Care For Children With Cleft Lip And Palate
Cleft lip, with or without cleft palate, affects approximately one in every 1,000 newborn infants. It is a craniofacial, oral, and dental birth defect in which there is an opening in a structure around the mouth and face. The causes of this problem are both environmental and genetic.

A cleft lip can range in severity from a simple notch in the upper lip to a complete opening in the lip, extending into the floor of the nostril. The upper gums may be involved. Clefts can occur on one or both sides, and with or without involvement of the palate. Orofacial clefts occur during the fourth to tenth week of fetal development. They are caused by a failure of elements of primary and/or secondary palate to develop normally.

Children born with cleft lip and palate have special health care needs due to early feeding concerns, middle ear disease, problems with speech, dentofacial abnormalities, and orthodontic problems. Children are treated by a multi-disciplinary cleft-palate team, which usually consists of a plastic surgeon, oral and maxillofacial surgeon, dentist, orthodontist, speech therapist, ENT specialist, audiologist, psychologist, and geneticist.

Important milestones for care are:
Lip closure at 3 months.
Dental exam at 6 months.
Palate closure at 18 months.
Speech therapy from 6 to 11 years.
Early orthodontic treatment from 7 to 8 years.
Intraoral alveolar bone grafting from 8 to 10 years.
Comprehensive orthodontic treatment from 11 to 14 years.

As soon as a baby's first teeth erupt, which occurs between six and twelve months of age, parents need to clean the teeth with a new, damp cloth twice a day. It is better to use a baby tooth cleanser, not tooth paste, until the baby is about two years old. Using a baby tooth cleanser will prevent excessive fluoride ingestion during infancy. At eighteen months of age, the first primary molars begin to erupt. and it will be time to brush all of the teeth with an infant toothbrush, twice a day. Parents may be reluctant to brush in the cleft area, but this is precisely where good oral hygiene is most critical. Plaque can easily accumulate on the teeth in the cleft area. During brushing of the front teeth, the lip should be carefully lifted away so that the front teeth will be visible and accessible for cleaning.

Some infants and toddlers may refuse to let parents brush their teeth. To help with this problem, parents can experiment with various rewards for good behavior during brushing. The initial tooth brushing attempts need to last only 5 seconds or so - and some little reward should be provided immediately thereafter. The time spent brushing the teeth can be gradually increased. Using this "rewards technique," parents should follow the first successful attempt at tooth brushing with letting their baby "play with a favorite toy" or "play a favorite game."

It is absolutely essential to give a baby only water in its bottle when it is sleeping or taking a nap. Do not put fruit juice, soft drinks, sweet tea, formula, or milk in a baby's bottle or sipper cup during bedtime or nap time. Do not dip pacifiers in sweet liquids. All of this is important, because there is almost no saliva flow during sleep. Consequently, any food or drink which is in a baby's mouth at this time stays there many hours and promotes the caries disease process.

Parents of children with cleft lip and palate should ask their dentist to:
Provide the first dental examination no later than 6 months of age.
Show the area of the cleft inside the mouth using a mirror.
Point out any extra or missing teeth in the cleft area.
Identify any teeth which may be poorly formed or hypoplastic.
Provide advice on dentally-safe food and drinks.
Explain the relationship between sugar and tooth decay.
Demonstrate tooth brushing, especially in the cleft area.
Show how to carefully lift the lip away from the front teeth during brushing.
Review the need for fluoride supplements.
Periodically apply topical fluoride varnish to teeth which are at risk for dental caries.
Schedule periodic recall exams so that dental health and orofacial growth can be evaluated.

A recent dental journal article reviews cleft lip and palate treatment:
Rivikin CJ, Keith O, Crawford PJM, Hathorn IS. Dental care for the patient with cleft lip and palate. Part 2: The mixed dentition stage through to adolescence and young adulthood. British Dental Journal 188:131-134, 2000.

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