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Mandatory CE for our children?

Sept. 1, 2010
The ability to detect child abuse requires in-depth knowledge and skill. Neglect and sexual abuse of children can have insidious manifestations.

Would a required course increase reporting of child abuse?

by Ashley Ann Morin, RDH, BSDH

The ability to detect child abuse requires in-depth knowledge and skill. Neglect and sexual abuse of children can have insidious manifestations. Research shows that health-care providers under-identify the signs and symptoms of child abuse. Only after attending a review course on child abuse did the research participants score higher in their posttesting assessment techniques as compared to the pretesting results.1

Health-care providers, particularly dental personnel, are mandated by law in many states to recognize and report suspected cases of abuse. Many injuries that result from physical abuse occur to the head and mouth.2 Dental health-care providers are the first line of defense when a child is presented for dental care needs. It is imperative that these warning signs are recognized and reported to authorities to stop the vicious cycle to the youngest and most vulnerable members of society.

The purpose of this paper is to explore the weaknesses in recognizing and reporting child abuse, and to recommend possible strategies to address these weaknesses. The data suggests a need for regulatory enforcement of continuing education in child abuse. In addition, health-care providers and social workers are encouraged to be part of a multidisciplinary approach to prevent, investigate, and treat victims of child abuse.2,3,4,5 This collaboration will increase the quality of care for children.

Since 1987, research reports and professional papers addressing child abuse suggest that dentists and dental hygienists need to increase their knowledge and skills in recognizing, documenting, and reporting suspected child abuse.2,6,7,8 The lack of response by the dental community may be due to the passive academic delivery of the information in peer-reviewed journals, which are sanitized for publication. No one likes to think that his or her patient could be a statistic. The topic of child abuse makes most professionals uncomfortable. The subject of sexual abuse is not discussed in most homes or at dinner parties.

If we, as health-care providers, do not make this our issue, we become unknowing accomplices to this hideous crime. Professional skill in child abuse assessment can clearly impact the fate of an innocent child, stop the encouragement of the perpetrator, and put an end to the blind eye of society. Continuing education on the knowledge, assessment, and reporting of child abuse must be a priority to help terminate the cycle of violence.

NDACAN statistics

In all 50 states, certain professionals are required to report suspected physical and/or sexual child abuse to a child protective services (CPS) agency. According to the National Data Archive on Child Abuse and Neglect (NDACAN), more than half (57.7%) of all reports were made by professionals in 2007.These included teachers (17.0%), police officers or lawyers (16.3%), and social services staff (10.2%). Nonprofessionals such as friends, neighbors, coaches, and relatives filed the remaining reports.9 Notice that dentists, dental hygienists, family doctors, emergency doctors, or pediatricians are conspicuously absent.

Also in 2007, male children less than one year of age had the highest rate of victimization (22.2 per 1,000), followed by female children (11.6 per 1,000) in the age 4 to 7 range, and 19.0% of all children were in the 8 to 11 age group.9 An estimated 794,000 children are said to be victims of abuse or neglect, with minorities at the top of the list.9 According to Ruth E. Stagg, former manager of a Newark, N.J. Child Protective Services (CPS) district office, the reason why minorities hold the rank of the highest reported is, "There are those that fall under the radar. Mr. and Mrs. six-figure income has the money and connections to circumvent the public eye and avoid being reported. Those in the public welfare system do not have that 'luxury'; that's why they are reported as a statistic. Therefore the national statistics do not reflect what is really going on."3,10 In many cases, children die from their injuries and maltreatment.11 In 2007, the overall rate was 2.35 deaths per 100,000 children.9

NDACAN reveals that 80% of the perpetrators were parents and another 6.6% were relatives of the victim. Many assume it is the so-called "dirty old man" who victimizes children, but statistics show that women comprise a larger percentage of all perpetrators.9 The sad truth is that recurrence of the violence is a huge problem. According to the Children's Bureau, the current national standard for the absence of maltreatment recurrence was 94.6%. It is not known how many cases were never reported.

A study was conducted at a Texas children's hospital in 1995 to determine the physical manifestations of child abuse. The results of the study showed that 74.8% of the children were under age 3, and of those children, 66.2% had injuries to their head, face, mouth, or neck.12 A subsequent study by the American Academy of Pediatric Dentistry was conducted in 1999 to establish clinical guidelines on oral and dental aspects of child abuse and neglect.8 This collaborative group determined that craniofacial, head, face, and neck injuries occur in more than half of the cases of child abuse. They also indicated that the oral cavity is a frequent site of sexual abuse in children. See Table 1 for signs and symptoms of physical abuse.2,3,8,13

The presence of oral and perioral gonorrhea or syphilis in prepubertal children is indicative of sexual abuse.13

Sexually transmitted diseases2,3,4,8,13
  • Syphilis
  • Gonorrhea
  • Genital warts (condylomata acuminate)
  • HIV infection
  • C trachomatis infection
  • T vaginalis infection
  • Herpes simplex
  • Bacterial vaginosis

In 2005, the American Academy of Pediatric Dentistry revisited their guidelines on oral child abuse and neglect. They reported that the child's caretaker could inflict serious injuries in the mouth, such as posterior pharyngeal injuries and retropharyngeal abscesses that would necessitate medical care.3 Young children are capable of creating unintentional injuries. How many times did you run around the house and then fall with a lollypop in your mouth, and it jammed the palate?14 However, unexplained injury or petechiae of the palate at the junction of the hard and soft palate may be due to the trauma of forced fellatio.8 Bite marks and lacerations found in an elliptical pattern2 and HPV-induced oral or perioral warts are also indicative of sexual abuse. Because mucosal injuries often heal rapidly and completely4, we should keep in mind the other conditions. Thumbprint impressions on the cheeks with accompanying fingertip bruises on the back of the neck are clear indications of forced oral sexual abuse.10 Gags that are applied to the mouth result in bruises or scarring at the corner of the mouth, but these appearances are easily excused by the abuser.8 Researchers strongly suggest that physicians or dentists be aware that physical or sexual abuse results in these signs and symptoms.3

N. Kellogg, in her 2005 Pediatrics document, recommends that a pediatrician evaluate all sexually abused children. It should be noted that pediatricians who fail to report suspected abuse are subjected to the penalties of that state. There are also "medical liability risks who fail to diagnose abuse or who misdiagnose other conditions as abuse."4 Their diagnosis requires a report to law enforcement agencies and CPS. Although this seems to be a logical progression, research suggests that pediatricians and other physicians have failed to interpret the signs of abuse and therefore their documentation is incomplete and reporting does not occur. It has been suggested that their shortcomings are due to their lack of education.2,8,13

Review of the related literature

An early study conducted in 1987 was the forerunner of child abuse research.15 This study used a pre- and posttest to ascertain knowledge and skill in the identification of suspected child abuse in health-care providers. The research participants, 10 physicians, eight nurses, and 22 CPS employees, wanted to increase their education, as some admitted to no prior training in child abuse. Two questionnaires determined their previous experience and training in assessment and their basic knowledge of child sexual abuse. The experience and knowledge questionnaires were administered the same day as the symposium (pretest), two weeks later, and again six months later.

At the conclusion of the study, the researchers reported that the knowledge had improved significantly at the two-week posttest (p=.001), and remained elevated at the six-month posttest (p<.02). The researchers acknowledged the small sample used in their study and deliberated on how representative the sample was. The participants volunteered and had an interest in increasing their awareness, but what of those practicing providers that did not share that interest? In their conclusion, the researchers were of the opinion that there is a strong need for continuing education in order for professionals to improve their skills. Hibbard et al. carried out a subsequent study in 1990 using a survey among the same sample demographics, but they included lawyers, law enforcement officers, and psychologists.16 [Note that the study participants match those in the 2007 NDACAN reporting database, with the exception of physicians.]

The subjects were given a five-point Likert Scale survey to assess their experience, training, and knowledge on child sexual abuse. Of the 902 respondents, almost half (48.9%) had prior formal training and 20% were not knowledgeable about important factors that could lead to identification and reporting. There were no statistical significant findings. The difference by profession was p<0.000. One would expect that physicians would score higher due to the nature of their profession. But again the conclusion was the same – a need for continued education of all professionals in order for abused children to receive proper treatment. These studies established a need for more research on the effects of continuing education in child abuse.

From 1991 to 1992, Socolar et al. conducted a randomized, controlled trial using medical record feedback as the intervention to determine physicians' documentation and knowledge.5 A total of 147 physicians were recruited with the incentive of continuing education credits. The doctors were given written feedback on the documentation of abuse in patients' charts, how to assess genital violation, and the implementation of a new, more structured medical record format. The medical records from each physician were reviewed by blinded researchers, who based their findings on a five-point Likert Scale. There was no statistical significance between the control and the intervention groups. When the physicians were surveyed, 50% said the intervention was helpful, and 50% said very helpful. The researchers concluded that using continuing education credits not only increased their sample size, but forced physicians to engage in a "more interactive process," facilitating an increased motivation to learn.

Socolar et al. followed with a 1993 study using a cross-sectional survey and blinded chart review to determine the quality of documentation by physicians in their child sexual abuse evaluations.17 Knowledge scores gained by a survey and five randomly chosen medical records were obtained from 145 physicians. They reviewed the medical records to determine disclosure by the child, the aspects of the incident, the physical examination, and the quality of the documentation. The blinded reviewers used a Likert Scale for the overall assessments. The results are as follows: 30% and 23% had excellent or good documentation, 43% and 45% were adequate, and 27% and 32% were rated as not good or poor. The researchers did not delineate which specialty of medicine had the highest scores; however, 83% of the participants were pediatricians, 12% were family physicians, and 5% were other specialists.

Socolar et al. regretted using only a maximum of five random charts for each physician regardless of their previous experience. They realized that it was a small subsample and therefore would not be representative of all physicians. The conclusions were similar to their previous 1991 study in that structured medical records, lecture attendance, continuing education on sexual abuse of children, and intensive training at medical centers were recommended.

As in the 1991 Socolar study, continuing education credits were used as an incentive during a 2005 education intervention to assess knowledge changes.1 A total of 64 subjects participated in a voluntary completion of a self-study, case-based syllabus that included a workbook and accompanying videotape. There were two groups of participants – 30 practicing physicians, 24 practicing physician assistants, and 10 pediatric residents. The pre- and posttests were forced choice answers based on process, history, physical exam, and legal matters. The pretest scores were significantly lower (p<.001) than the average posttest scores for all participants. Although there were increased scores, more than half (59.4%) did not correctly identify the clinical findings, and 39.1% did not know the legal implications and protocol. This is unfortunate as the majority of the subjects were practicing pediatric providers. As mentioned in the previous studies, the participants were a motivated group with an expected increase in learning. The researchers speculated that if the educational package were given to a larger population, few would have finished the program and the course would not have been as successful.

In a 2009 study, a more positive outlook on pediatricians' training and knowledge was published in Pediatrics.18 A six-point Likert survey was given to 53 program directors and 462 residents to establish demographics, child abuse training, patient experience, and knowledge of child abuse. A 24-question quiz was used to determine knowledge on assessment techniques of child abuse and neglect. Of the 462 residents, there were 55 emergency medicine, 104 family medicine, and 303 pediatric residents.

Unlike the previous study, the pediatricians had the highest scores. The researchers reasoned that the pediatric residents acquired more hours of didactic instruction, clinical teaching, and clinical experiences (P<.001) than the other specialties. Family medicine participants scored lower compared to emergency medicine and pediatric medicine as their programs provided the lowest amount of child abuse training. Emergency medicine programs do not have a required rotation in child abuse. The researchers had doubt about their findings as the participants were recruited from facilities that had better training and knowledge than other residency programs. Therefore there might be some miscalculations in a larger population.

The conclusions are similar to the earlier studies in that training in knowledge and assessment is crucial, and based on this study the researchers believe that the current level of training is inadequate. They also feel "there is a need for a national child abuse curriculum that can be adapted to any training site."

The NDACAN database revealed that dentists, dental hygienists, family doctors, emergency doctors, or pediatricians were absent from the list of reporters. According to L.D. Mouden, DDS, MPH, a noted author on child abuse, only 1% of reported cases of child abuse were made by dentists.11 The possibility exists that there is insufficient education in the dental schools that would contribute to the lack of knowledge and legal responsibility. The Journal of Dental Education published a study in 2006 on educational experiences and knowledge in dental and dental hygiene students to test that theory.19 Two hundred and thirty-three dental students and 74 dental hygiene students were given a questionnaire (see Figure 1) that was divided into two parts – two open-ended questions regarding the students' gender, year of program, and educational experience and knowledge, followed by 16 true/false questions pertaining to signs and symptoms of abuse and legal responsibilities of reporting.

Figure 1. Wording of the knowledge questions concerning child abuse/neglect Journal of Dental Education 2006: Child Abuse and Neglect: Dental and Dental Hygiene Students' Educational Experiences and Knowledge.

The dental students had more classroom instruction (184.48 vs. 112.90) than the dental hygiene students. Despite that educational advantage, they both had the lowest percentage of correct answers concerning the signs of physical abuse. Less than one third knew their legal obligation to report abuse, and most did not know where to report and the consequences thereof. Based on their findings, the researchers suggested that students are ill prepared for the world of child abuse and neglect. They cited previous studies that indicated a need for practicing dentists and dental hygienists to obtain more training in knowledge, assessment, and reporting.

Figure 2. Journal of Dental Hygiene, Vol. 79, No. 1, Winter 2005. Survey Instrument
Discussion of results/findings

A common theme appears in pediatric journals regarding child abuse and neglect. "Physicians receive minimal training in oral health and dental injury and disease and usually do not detect dental aspects of abuse and neglect as readily as they do child abuse and neglect involving other areas of the body."8 Studies have shown that education brings an increased knowledge as measured by the pretest and posttest scores. Researchers have repeatedly advocated for postgraduation courses, including the use of continuing education credits as an incentive.

Although dental and dental hygiene schools have a curriculum devoted to child abuse and neglect, graduating students need field experience before they can rely on their academics. As mentioned previously in the pediatric studies, even field experience did not prepare the doctors for adequate assessment. The American Dental Association is well aware of the problem as they have adopted principles of ethics that address our legal responsibilities: "Dentists shall be obliged to become familiar with the perioral signs of child abuse and to report suspected cases to the proper authorities consistent with state laws. If dentists' failure to report suspected cases of abuse and neglect can be considered an indicator of awareness, then dentistry's level of awareness of child maltreatment is abysmal, because the most important factor in recognizing child abuse is to be aware of its existence."11

L.D. Mouden addressed these grave concerns in his article, "Dentistry Preventing Family Violence."6 He admonished dentists for "not living up to their legal and ethical obligation to report suspected child victims." Dental hygienists are often the first health professionals to come in contact with patients. We perform the first prophylaxis on children going into kindergarten or preschool. We can help create an atmosphere of trust for suspected child abuse victims, as we are able to spend more time with patients than the dentist. Yet we have failed to live up to our obligations.

A 2005 study was administered to registered dental hygienists (see Figure 2) to assess their training and experience in reporting abuse, signs and symptoms of abuse, and the likelihood of making a report.20 Prior to the training program only 20% of dental hygienists knew all aspects of abuse. After the training, 100% reported that they would make a report, and 96% knew how to make a report. There is an obvious need for increased awareness and more training for dental personnel.

Approximately 65% of child abuse injuries involve the head, neck, or mouth areas.11 If a child presents with multiple injuries or injuries at different stages of healing, this warrants an investigation. Sadly, if that child presents with injuries above the neck such as on the face, ears, neck, top of shoulder, and forearm, you can imagine what lurks below that we cannot see.21

A recent conversation with a dentist confirmed my suspicions that our profession is not aware of the possibility of abuse. He explained, "I notice these things (sic) when they come in, but in all honesty, I've never observed any oral symptoms that I have equated with child abuse. Torn frenums come in every so often, but these are usually accompanied by one or both parents after a serious accident."22 As per NDACAN, 80% of perpetrators are parents.9 Is it possible that this dentist misses the opportunity to protect children? Had he participated in a review course, the signs would be more apparent to him and he would not accept the parents' explanation at face value.

Fortunately, the Prevent Abuse and Neglect Through Dental Awareness (PANDA) coalition has trained dental personnel through continuing education. According to the PANDA program, "The extremely low reporting rate by dentists seems to be related to the lack of training dentists receive in how to recognize and report abuse and neglect, and concerns about the ramifications of becoming legally involved in such cases."23 Because of the disturbing nature of the material, many offices do not take advantage of this valuable program and do not schedule a presentation.23

According to New Jersey statute, law enforcement officers undergo mandatory continuing education on domestic violence every six months for recertification.24 Under this umbrella of domestic violence lies child abuse and neglect. One strategy may be to follow their initiative and have child abuse and neglect continuing education mandatory for relicensure for dental health professionals. Repeated sexual and physical abuse in children has two outcomes: those that survive and try to get on with their lives, and those that do not. These strategies may help increase earlier recognition of child abuse and possibly save lives.

Ashley Ann Morin, RDH, is a practicing dental hygienist for 33 years and recently graduated from the Dental Hygiene Bachelor's Degree Completion Program at Massachusetts College of Pharmacy and Health Sciences in Boston.


1. Botash A, Galloway A, Booth T, et al. Continuing medical education in child sexual abuse. Archives of Pediatrics & Adolescent Medicine [Internet]. 2005[cited 2010 Jan 16]; 159:e561-566. Available from Registration required for access.

2. Committee on Early Childhood, Adoption, and Dependent Care. Oral and dental aspects of child abuse and neglect. Pediatrics [Internet]. September 1986 [cited 2010 Jan 18]; vol.78 no.3; e537-539. Available from:

3. American Academy of Pediatric Dentistry (AAPD). Guideline on oral and dental aspects of child abuse and neglect. American Academy of Pediatric Dentistry [Internet]. 2005 [cited 2010 Jan 20]; e4 p. Available from

4. Kellogg N. The evaluation of sexual abuse in children. Pediatrics [Internet]. Aug 2005; [cited 2010 Jan 20]; 116(2); e506-12. Available from

5. Socolar R, Raines B, Chen-Mok M, et al. Intervention to improve physician documentation and knowledge of child sexual abuse: a randomized, controlled trial. Pediatrics [Internet]. May 1998[cited 2010 Jan 16]; vol.101, no.5, e817-824. Available from

6. Mouden LD. Dentistry preventing family violence. Mo Dent J.[Internet]. 1996 [cited 2010 Feb 20]; Nov-Dec;76(6):e 21-2,24,27. Available from Registration required for access.

7. Spencer D. Child abuse: dentists' recognition and involvement. CDA. Journal [Internet]. April 2004[cited 2010 Jan 18]; vol. 32, no.: e299-301. Available from

8. Joint statement of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry. Clinical guideline of oral and dental aspects of child abuse and neglect. Pediatrics [Internet]. August 1999 [cited 2010 Feb 20]; vol. 104 no.2: e348-350. Available from:;1044/2/348.

9. The National Data Archive on Child Abuse and Neglect (NDACAN). Child maltreatment 2007 report. Washington, DC: U.S. Department of Health and Human Services, 2007 [cited 2010 Feb 20]; e180 p. Available from:

10. Stagg R. LCSW, MSW (telephone conversation February 1, 2010) gave interview on child sexual abuse.

11. Mouden LD, Bross D. Legal issues affecting dentistry's role in preventing child abuse and neglect. J Am Dent Assoc [Internet]. 1995 [cited 2010 Feb 20]; 126: e1173-1180.

12. Jessee SA. Physical manifestations of child abuse to the head, face, and mouth: a hospital survey. ASDC J Dent Child. 1995 [cited 2010 Feb 20]; Jul-Aug; 62(4): e245-9. Available from:

13. Kellogg N. Oral and dental aspects of child abuse and neglect. Pediatrics [Internet]. December 2005 [cited 2010 Jan 17]; vol 116 no. 6; e1565-1568. Available from; 116/6/1565.

14. Shanel-Hogan K. What is this red mark? CDA Journal [Internet]. April 2004 [cited 2010 Jan 17]; vol.32 no. 4. E304-305. Available from law/issues_&_policies/abuse_detection_and reporting.

15. Hibbard R, Serwint J. Educational program on evaluation of alleged sexual abuse victims. Child Abuse & Neglect [Internet]. 1987[cited 2010 Jan 18]; vol.11, e513-519. Available from ScienceDirect. Registration required for access.

16. Hibbard R, Zollinger T. Patterns of child sexual abuse knowledge among professionals. Child Abuse & Neglect [Internet]. 1990[cited 2010 Jan 16]; vol. 14, e347-355. Available from ScienceDirect. Registration required for access.

17. Socolar R, Champion M, Green C. Physicians' documentation of sexual abuse of children. Archives of Pediatrics & Adolescent Medicine [Internet]. February 1996 [cited 2010 Jan 18];150(2):e191-196. Available from Registration required for access.

18. Starling S, Heisler K, Paulson J, Youmans E. Child abuse training and knowledge: a national survey of emergency medicine, family medicine, and pediatric residents and program directors. Pediatrics [Internet]. April 2009[cited 2010 Jan 18]; 123(4):e595-602. Available from

19. Thomas J, Straffon L, Inglehart M, Habil P. Child abuse and neglect: dental and dental hygiene students' educational experiences and knowledge. Journal of Dental Education [Internet]. 2006[cited 2010 Jan 18]; 70(5):e558-565. Available from

20. Harmer-Beem M. The perceived likelihood of dental hygienists to report abuse before and after a training program. Journal of Dental Hygiene.[Internet]. Winter 2005[cited 2010 Jan 25]; 79(1): e7. Available from Registration required for access.

21. Nuzzolese E, Lepore M, Montagna F, et al. Child abuse and dental neglect: the dental team's role in identification and prevention. International Journal of Dental Hygiene [Internet]. April 2009[cited 2010 Jan 18]; 7(2)e96-101. Available from Registration required for access.

22. Spiller, Martin DMD. (e-mail conversation Feb. 11, 2010) gave interiew on suspected child abuse. Available from [email protected].

23. The PANDA Program Delta Dental of NJ. Available at Accessed January 10, 2010.

24. Manning, D. Chief of Police Somerville, NJ Police Department (personal conversation Feb. 1, 2010). Discussed department mandatory certification requirements in domestic violence.

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