Navigating dental neglect

Dental professionals are often the first line of defense in identifying neglect. Neglect can take on many forms: supervised neglect, self-neglect, child neglect, and elder neglect. Dental professionals have the responsibility to act as mandatory reporters when abuse or neglect is suspected, but dental neglect can be more ambiguous. Dental professionals often encounter patients who have experienced dental neglect, specifically supervised neglect, dental neglect in children, or self-neglect.

Dental neglect is defined as “a failure to take precautions to maintain oral health; failure to obtain needed dental care; and physical neglect of the oral cavity, teeth, and mouth.”¹ This definition was revised in 2013 to include, “the absence of valuing oral health.”²

But how are supervised neglect and self-neglect defined? These definitions are more ambiguous due to the established standards of care within independent offices and professional and individual state laws. The term “standard of care” is a legal term, not a medical term; therefore, this standard can vary from state to state.³ Dental neglect has been clearly defined as it pertains to children and their caregivers, but do these same guidelines apply to the adult and geriatric populations? This is where the lines begin to blur, as there is substantially less general guidance and fewer studies on dental neglect in adults and geriatric patients.

Dental neglect can be broken down further into the following categories:

• Dental neglect in children is the “willful failure of a parent or health-care guardian to seek or follow through with medically necessary care that would ensure a level of oral health essential for adequate function and freedom from pain and infection.”⁴ This impacts the child’s ability to eat, speak, learn, and attend school.
• Self-neglect in adults is the refusal of medical or dental treatment and attending to their basic needs, which can include water, food, clothes, and personal hygiene. Self-neglect is a threat to one’s own health and safety.⁵
• Supervised neglect is defined as a patient who is receiving routine dental care and continually refuses the recommended standard of care.⁶

Factors that contribute to dental neglect include:

• Limited access to care
• Gender
• Cost of dental care or finances
• Lack of dental insurance
• Dental health education
• Cultural beliefs

Solutions to help address dental neglect

Once dental neglect has been identified, what is the best way to address it? What resources are available to patients, and how should dental providers encourage and support patients who may not have the ability or desire to prioritize their oral health care? Just as it is important to present patients with treatment options, it is also important to provide them with viable resources if the need is verbalized or suspected.

The Emergency Department Referral Program

Between 2020 and 2022, approximately 2 million people visited the emergency department due to dental pain from caries and abscesses, a substantial increase from 2019.⁷ This is often the first place people experiencing dental pain visit, but most emergency rooms are not equipped to diagnose and treat dental problems. Frequently, patients are dismissed in pain with a prescription and referral to a dentist for evaluation. Unfortunately, this is not a feasible solution for dental emergencies due to dental neglect.

The dental neglect scale (DNS), which is used to assess neglect in children, has been found to be applicable for adults and other at-risk populations. This rating scale includes six self-reporting statements that include maintaining home dental care, receiving dental care, avoiding dental care, oral hygiene, diet, and prioritizing oral health.² The goal is to identify patients prior to their seeking hospital care for dental pain and provide resources for dental treatment.

In 2014, the American Dental Association (ADA) introduced an initiative to address dental self-neglect and the burden placed on emergency departments. The Emergency Department Referral Program (EDRP) works with local partners, including community resources, local dentists, and hospitals. This volunteer-based model reinforces the importance of oral health care and provides qualifying patients with ownership and autonomy in their own health-care journey. If there is not an EDRP locally, the ADA website provides guidance and resources on how to establish local programs for underserved areas.

Reduced cost or free dental care clinics

Dental care is the least utilized health service in the United States because the cost can be prohibitive. A recent Health Policy Institute report published by the ADA indicated that “13% of the population reported cost barriers to dental care, compared to 4%–5% for other health-care services.”⁸ Even those with private insurance policies face cost restrictions. Unlike medical insurance, dental insurance has significantly lower coverage limits and higher co-payment amounts. The American Association of Retired Persons (AARP) reported in 2023 that cost and limited coverage benefits factored into the decision to opt out of Medicare dental coverage, leading to either a delay in care or no care at all for poll participants.⁹

National organizations can provide resources for patients experiencing dental neglect. These services are often free dental clinics or ones at reduced costs. For example, the Dental Lifeline Network, established in 1974, partners with dental providers across the United States to provide donated dental services to vulnerable adults.¹⁰ Other options may include dental schools or dental hygiene programs that provide reduced fee schedules for patients. While this route may be more time-consuming, the fee structure is more reasonable. Patients often receive exemplary care because their dental work is reviewed at each step by both dental students and faculty. State and local dental organizations and health departments may also offer free dental clinics to patients who demonstrate financial need.

Documenting informed refusal

The standard of care refers to “the degree of care a prudent and reasonable person would exercise under the circumstances. State legislatures, administrative agencies, and courts define the legal degree of care required, so the exact legal standard varies by state.”³ Due to legal standards and liability, it is imperative that dentists and dental hygienists continue to educate themselves on both national and local protocols for neglect, as well as emerging dental trends and standards of care. The ADA identifies the standard of care as “multi-pillar” to include evidence-based dentistry—patient based with legal and ethical considerations.¹ Dental providers do have the authority to dismiss a patient from a practice if they consistently decline treatment and the current course of care no longer meets local or state standards.

Continued documentation of patient education and informed refusal of treatment provides evidence of treatment recommendation discussions. Open lines of communication between providers and the patient will allow for a transparent discussion on health impacts of continuing subpar treatment and whether dismissal is needed. By signing an informed refusal, the patient is acknowledging the recommended treatment and the associated risks.

Continued patient education and treatment plan presentations

Often in cases of dental neglect, providers have presented treatment recommendations at multiple appointments for an extended period of time. It is important to continue to present the patient with all the treatment options, including doing nothing and the repercussions of doing so. However, to fully understand the ramifications of “doing nothing,” it is important that dental providers take the time to fully educate patients on their oral health, the impact on their general health, as well as the etiology of oral diseases. Patients may benefit from receiving this information through a multidisciplinary approach. Studies show that the “Rule of 7” can be applied to making health changes.¹² When a patient has heard oral hygiene instructions or treatment recommendations seven times, they are more likely to make a change and take action.

Conclusion

Dental neglect can be tricky to navigate when there are many factors that need to be considered. The standard of care is constantly evolving and changing, and the bar is pushed higher and higher with advancements in dentistry, technology, and techniques. Quality dental care can take different forms for patients experiencing dental neglect, including resource referrals, patient dismissal, or persistent yet rewarding patient education. 

Editor's note: This article appeared in the June 2026 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.

References

1. What is patient neglect? A legal definition and examples. LegalClarity. July 16, 2025. Accessed January 30, 2026. https://legalclarity.org/what-is-patient-neglect-a-legal-definition-and-examples/
2. Dahl SH, Søndenbroe R, Jensen SS, Øzhayat EB, Markvart M. High degree of dental neglect characterizes adult patients hospitalized with severe odontogenic infections: a retrospective cross-sectional study. BMC Oral Health. 2025;25(1):1545. doi:10.1186/s12903-025-06711-x
3. Vanderpool D. The standard of care. Innov Clin Neurosci. 2021;18(7-9):50-51.
4. Definition of dental neglect. American Academy of Pediatric Dentistry. Revised 2025. Accessed February 12, 2026. https://www.aapd.org/research/oral-health-policies--recommendations/dental-neglect/
5. Dong XQ. Elder self-neglect: research and practice. Clin Interv Aging. 2017;12(12):949-954. doi:10.2147/CIA.S103359
6. Machado K. Refusing refusals: why dental professionals need to defend the standard of care. Today’s RDH. February 4, 2024. Accessed February 10, 2026. https://www.todaysrdh.com/refusing-refusals-why-dental-professionals-need-to-defend-the-standard-of-care
7. Emergency department referrals. American Dental Association. Accessed February 26, 2026. https://www.ada.org/resources/community-initiatives/action-for-dental-health/emergency-department-referrals
8. National trends in dental care use, dental insurance coverage, and cost barriers. American Dental Association Health Policy Institute. September 2024. Accessed February 26, 2026. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/hpi/national_trends_dental_use_benefits_barriers_2024.pdf
9. Lankford K. 5 things you should know about dental coverage and Medicare. AARP. April 19, 2023. Accessed February 26, 2026. https://www.aarp.org/medicare/dental-coverage
10. Dental Lifeline Network. Accessed March 1, 2026. https://dentallifeline.org
11. Informed consent/refusal. American Dental Association. Accessed March 1, 2026. https://www.ada.org/resources/practice/practice-management/managing-patients-informed-consent-refusal
12. Dodier S. The rule of 7: how many times do we need to see something before it sticks? CompetencED. October 16, 2025. Accessed March 1, 2026. https://www.competenced.com/post/the-rule-of-7-how-many-times-do-we-need-to-see-something-before-it-sticks