Dental neglect as a marker of broader neglect: a qualitative investigation of public health nurses’ assessments of oral health in preschool children

Child neglect is a significant issue in terms of prevalence and severity – it is the most common reason for a child to be made subject to a child protection plan in the UK - and there is indubitable evidence that it is harmful to children [1–4]. The National Society for the Prevention of Cruelty to Children (NSPCC) study on child maltreatment in the UK found that one in ten young adults had experienced serious neglect during their childhood [5]. Neglect is defined as the persistent failure to meet a child’s basic physical and/ or psychological needs, likely to result in the serious impairment of the child’s health or development [6]. A range of adverse health outcomes causally related to neglect is demonstrated significantly in both prospective and retrospective studies [7]. Disruption in attachment patterns and to neurobiological pathways means that neglected children carry a burden of long term consequences into adulthood; and potentially to subsequent generations. The economic burden to the UK caused by maltreatment is enormous, with particular long-term consequences for health and social services and the criminal justice system [8, 9]. It is not just the UK though: in the United States the annual cost to the taxpayer from neglect is estimated to be more than $100 billion [10]. Child neglect also represents the majority of all maltreatment cases. In 2010/11 almost half (42%) of all registrations on Child Protection Registers in Scotland were for children suffering physical neglect [11] and similar trends are seen in the rest of the UK [12], Canada [13], the United States [14] and Australia [14]. Child neglect receives less attention than sexual or physical abuse (the neglect of neglect). Early intervention is crucial, but both recognition of, and responses to, neglect remain inconsistent.

Both the American Academy and the British Society of Paediatric Dentistry define dental neglect as being the willful or persistent failure to meet a child's basic oral health needs by not seeking or following through with necessary treatment to ensure a level of oral health that allows function and oral health (freedom from pain and infection) [15, 16]. Dental neglect can result in the impairment of the child’s oral or general health or development [17]. Dental neglect may exist in isolation, however, there is increasing acceptance that untreated dental disease may be a useful indicator of broader child neglect [17, 18]. Abused and neglected children have been found to have higher levels of tooth decay than the general population. In one Canadian case control study, five year olds with a history of maltreatment had experienced almost twice the number of caries lesions as children in the control group [19] and a similar US based investigation found the study group of abused/neglected five to 13 year-olds to be almost eight times as likely to have untreated, decayed permanent teeth than their controls [20].

Where there is widely available access to dentistry, such as free National Health Service (NHS) dentistry in the UK, but persistent failure of parents or carers to access dental treatment for their child’s tooth decay, this should be considered an alerting feature for practitioners to consider neglect [21]. Specific indicators include: repeated non-attendance for scheduled oral health assessments (dental checkups); attendance for emergency pain relief more than once; and requirement for dental extractions/care under general anesthetic more than once [17, 22, 23]. There are shared views from countries as far afield as the Czech Republic [24], Hong Kong [25], Philippines [26] and Australia [27], that childhood caries represents a significant public health issue. Perhaps unsurprisingly, this is especially the case in countries where national programs of oral health assessment and access to primary oral health care are absent [28].

Public health nursing was established in the UK in the mid-19^th century. Some countries have similar models of public health nursing to those in the UK, but in other countries the role does not exist. In the UK, all public health nurses are registered nurses with specialist qualifications in community health. Their role is an integral part of primary healthcare services, with a focus on prevention and health promotion. Every family with children under five has a public health nurse to offer support to families through the early years. The UK system of public health nursing assessment is based on a number of complex principles that involve ongoing assessment and prioritization [29]. Integral to this is the assessment and promotion of oral health among children and discussion of oral health with all parents and carers on at least four occasions during a child’s preschool years [30]. Targeted support and intervention is provided for families and children deemed to be in most need.

Because of their extensive contact with children, public health nurses’ role in child protection is widely recognized in terms of prevention; identification; intervention and support. However, it is known that there is variation in health professionals’ perceptions of thresholds of neglect [31]. It is also known that public health nurses use dental neglect as a proxy indicator of broader neglect in children [32]. Their role in the accurate, timely assessment of children for dental neglect means that they are potential catalysts in securing a child’s overall safety and well-being. Understanding how public health nurses assess oral health, particularly in relation to dental neglect, is thus an important part of the wider child protection agenda. However, what is not known is what public health nurses actually do to assess for dental neglect. This study sought to address this gap in knowledge.

Public health nurses’ role in identifying cases of child neglect as they relate to dental disease is an under-researched area. An exploratory research design was deemed to be appropriate because it aligns with the UK Medical Research Council’s (MRC) framework for complex interventions that emphasizes the need for exploratory investigations as a necessary precursor to future intervention studies [33]. In this qualitative study, we investigated the role of public health nurses in assessing oral health in preschool children in relation to dental neglect. Data were collected from a purposive sample of 16 public health nurses through semi-structured interviews. Data were analyzed using Ritchie and Spencer’s framework analysis approach [34].

The study findings are reported with reference – and response - to the research questions.

Until now, the means by which public health nurses make assessments of children’s oral health in the UK has been largely un-investigated. This study has provided valuable insights into the processes involved. Findings show that public health nurses in the study rarely looked directly in a child’s mouth to assess dental health status. Public health nurses did make assessments, but rather than direct observation, they used a spectrum of proxy indicators, such as parental dental decay, poor dietary habits, and dental practices as well as parental attitudes towards oral health, as the basis for assessment.

Primarily, assessment was undertaken through opportunistic scrutiny of a child’s teeth, but we also found that the majority of public health nurses used parental dental health as a proxy indicator of the likely condition of a child’s teeth. Interestingly, a number of public health nurses in our study said they did not know what to look for in a child’s teeth, but nevertheless, they were prepared to base their assessments on what they could see of the parents’ teeth. Although this may appear a little strange, it is known that dental health behaviours in parents reflect the care that they then give to their children [36]. So it is likely that an assessment of poor parental dentition is a reasonable indirect marker for low tooth brushing and oral health habits carried out for young children by their parents.

It is interesting that the public health nurses in our study used front teeth as indicators of dental health. Early Childhood Caries (ECC) (previously called Nursing Bottle Caries) seems to be declining in prevalence but is still seen in children in Scotland [37]. The American Dental Association (http://www.ada.org/2057.aspx) define it as the presence of one or more decayed, missing or filled tooth surfaces in preschool-age children. It commonly presents as the front teeth becoming very decayed, often as a result of a sugary substance being placed in the child’s bottle. However, for the majority of children with dental caries it will be most frequently distributed towards the back of the mouth, in the molar teeth. In addition, most abscesses/ swellings and sinuses present around the molar teeth and because of the padded soft tissues of the cheeks around that area, are difficult to detect without a clinical examination involving looking inside the child’s mouth. Taken together, this means that public health nurses may have a very limited picture of a child’s dental health. An opportunistic look at the child’s front teeth as they are talking or smiling, reduces the chance of the presence of dental caries being detected until it causes cavitation of the front teeth. This is a late stage of presentation.

Observation however, constituted only part of the assessments made by the public health nurses. Most public health nurses questioned parents about current practices around oral hygiene habits and dietary practices. This action is entirely appropriate given that statistically significant correlations have been found between dental caries experience of children and their oral health-related habits [25]. As well as serving as an assessment of knowledge within the family, the public health nurses used this form of assessment as a way of gauging parental knowledge and attitudes towards oral health. Again, such practices are likely to be worthwhile. Parents’ own experiences and dental phobia can be an alerting risk factor for dental decay [3] and parental dental knowledge has a significant correlation with a child’s dental caries experience [25]. For this reason, increasing parents’ knowledge of proper feeding habits and oral health practices is deemed to be important [28].

Untreated dental disease has been noted to be a useful indicator of broader child neglect [17, 18] and public health nurses have previously been found to use dental neglect as a proxy indicator of general neglect in children [32]. This is supported by the findings from our study where the public health nurses indicated that they perceived poor dental health in children to be a marker of broader neglect. For the public health nurses in this study, there were two key indicators that a child protection intervention may need to be considered: a child suffering from untreated dental caries or a child with significant dental pain where parents had failed to take them for dental care having been advised. This is in line with the markers recommended for acting upon in current guidance [21–23, 38]. Whilst our findings support those of others and show that public health nurses would act in line with recommendations, there is a communication pathway break as they are not routinely made aware, by dental authorities, as to when a child has active dental disease. This has implications for public health nurses’ opportunity to engage in appropriate, timely follow-up.

The public health nurses in our study indicated that dental neglect is rarely an isolated issue that leads on its own to child protection referral. From this it may appear that there is disconnect between the acknowledgement of dental neglect as a marker of broader neglect and lack of initiation of child protection intervention. Dental neglect is considered to be part of a mosaic of issues associated with a neglected child and it tends to be other presenting issues that initiate a response in the first instance. There is perhaps confidence among public health nurses that neglect will be picked up through mechanisms other than through oral health assessment; and once recognized then it might be assumed that dental neglect could also be an issue. This reflects the apparent understandings of public health nurses, that dental neglect is part of a much broader picture of neglect. However, it appears that opportunity to look for decayed teeth in a young child and use this as a clinical marker for general neglect is currently not being maximised.

Consistent with other studies on neglect, concerns about neglected children were often perceived by public health nurses to be difficult to grapple with, as the chronic nature, coupled with the difficulty in demonstrating the potential harm of neglect, are significant and intangible [31, 39, 40]. Severe dental neglect constitutes actual harm and may be confirmatory of the more general concerns that tend to be intractable in neglect. There is more research to be undertaken to ascertain whether dental neglect is recognized by public health nurses prior to more general concerns about a child; and if it is, how they respond.

Findings from this study indicate that dental neglect can remain ‘unseen’ and ‘unspoken’. The former may be attributable in part to the oral health/disease indicators used by public health nurses being too blunt to detect dental neglect. It may also be because the mouth is rarely inspected directly making it not possible for insidious intra-oral disease to be detected. This group of public health nurses did not consider it appropriate to carry out a clinical examination of a child’s mouth and felt that they were not qualified to diagnose dental problems. Dental neglect may be ‘unspoken’ in the sense that public health nurses in our study expressed frustration and concern about communication deficits between professional groups, particularly regarding a child’s (non-) attendance at dental services. They felt this had an impact on their assessments of need, planning and follow-up of proportionate interventions. The unseen and unspoken aspects of our findings are important because when public health nurses become aware of dental neglect, they take a number of decisive actions to protect a child such as assessing for broader neglect, referral to dental services, and initiation of child protection intervention where appropriate. Public health nurse interventions in response to child protection concerns consisted of referral to dental services and sharing information with relevant partner agencies. The response to these issues – that they identified as child protection concerns - therefore largely consisted of making a referral to dental health services and not as a specific child protection response. This may be appropriate, but it conflicts with their separate reports of using untreated decay and failure to take a child for treatment when they are in pain, as triggers for child protection interventions. This has implications for education and awareness raising among public health nurses, in terms of dental neglect being considered as a marker for broader issues and potential child protection concerns.

Direct communication with dental services did not seem to be routinely used as a part of the assessment process when there was no particular concern about a dental problem involving pain or infection that needed to be managed. Powell and Appleton [41] emphasize the importance of public health nurses’ recognition of a child’s attendance at routine health appointments. They called for a re-conceptualisation of the phrase ‘did not attend’ to one of ‘was not brought’. What is clear from our study is that lack of any clear pathway for feedback on this does not allow public health nurses to know if a child ‘was not brought’ to dental health services, nor if they did attend and whether it was a serious case of dental neglect. This communication issue might be a common problem as oral health is often seen as separate to children’s general health [42]. Identification and instigation of local solutions would overcome this problem and could comprise, for example, salaried dental services, public health dentists and public health nurses working together to identify possible strategies.

The public health nurses alerted us to a post-referral gap in the care pathway and lack of feedback from dental care services regarding a child’s attendance or non-attendance. Typically they are not made aware of (missed) appointments and as a consequence are unable to plan further intervention, such as facilitating future attendance. One particular break in the pathway of care was identified for children where a significant dental problem was identified and the public health nurse initiated a dental referral. Although they could do so, there was no established pathway for the public health nurse to receive information back from dental care professionals as to whether the child had attended for treatment or not. As a result, a child whose medical/dental needs are not being met might never be picked up because the public health nurse was unaware that the child had not attended a dental appointment which was likely to be for management of infection and pain. It was quite possible that the public health nurse might not even have been made aware that the dental professional had arranged for general anesthetic for the child. This is a key finding and clear pathways are needed between public health nurses and dental health professionals.

Overall, findings show a range of assessments made by public health nurses and also some of the actual or potential barriers to assessment. Public health nurses made decisions about targeted support based on two broad indicators: social issues and concerns about dental health. Social determinants such as homelessness, poor housing, domestic abuse and parental substance misuse were alerting issues. Interventions regarding targeted support consist of two main strategies: provision of additional resources to promote dental health and referral to dental services.

This study has provided new insight into public health nurses’ role in the assessment of oral health in preschool children in relation to dental neglect. It has highlighted that dental neglect, whilst taken seriously by public health nurses, is not easily assessed or well defined in terms of thresholds. Public health nurses use three mechanisms to assess oral health: 1) a range of proxy measures; 2) opportunistic observation; 3) discussion with parents. Dental neglect may be ‘unseen’ (unidentified) and ‘unspoken’ (not communicated). The unseen and unspoken aspects of our findings are important because when public health nurses are aware of dental neglect they take a number of decisive actions to protect a child such as assessing for broader neglect, referral to dental services; and initiation of child protection intervention where appropriate. In the area of the UK in which the study was conducted, our findings have highlighted a gap in the care pathway for children where a significant dental problem is identified, particularly regarding interdisciplinary communication.

Dental neglect is rarely an isolated issue that leads on its own to child protection referral. It is considered to be part of a mosaic of issues associated with a neglected child and it tends to be other presenting issues that initiate a response in the first instance. This reflects the apparent understandings of the public health nurses who took part in our study, that dental neglect is part of a much broader picture of neglect. Although they take their child protection role seriously, a prospective link is rarely made between dental caries and child neglect. Clear guidance for public health nurses as to what to look for - and how - is required. Improved two-way communication between child dental care providers and public health nurses is necessary to close any gaps in care pathways. Despite the local nature of this study and the associated limitations, the findings and the issues that have been highlighted are translatable to other settings. This is irrespective of country or context.

In preparing this manuscript we have adhered to the RATS guidelines on qualitative research (http://www.biomedcentral.com/ifora/rats).

The study was undertaken as part of a programme of research being undertaken in Scotland as a collaborative venture between the University of Dundee (Schools of Dentistry and Nursing & Midwifery), NHS Fife; and the National Society for the Prevention of Cruelty to Children (NSPCC). CB-J has a clinical background as a public health nurse and is an experienced qualitative researcher. She has undertaken research involving vulnerable populations and has a specific interest in the issue of child abuse and neglect. NI has extensive research experience in paediatric dentistry, including studies involving children in primary care environments. She has played a key role in developing national guidelines in Scotland for childhood dental caries, which included guidance on managing children with dental neglect. DE is a Consultant in Paediatric Dentistry with extensive research expertise with children in the area of children’s dentistry – both for dental trauma and dental decay. He has chaired two national guideline development groups on management of dental caries in children. FB has six years’ experience of public health nursing and seven years previous experience as a School Nurse. She was a founder member of the School and Public Health Association (SAPHNA) in the UK. She currently holds the Child Protection Trainer role within NHS Fife, Scotland. Her clinical expertise in child protection adds a crucial practice dimension to this clinical – academic research collaboration. JT holds a position as the inaugural Chair in Child Protection at the University of Edinburgh/NSPCC Child Protection Research Centre. She is an internationally recognized expert in the area of child protection, with a wide range of publications in the fields of child and public health, child abuse and protection, social work and health services research.