RESOURCES: CHILD ABUSE AND NEGLECT

Oral and Dental Aspects of Child Abuse and Neglect:

Clinical Report
CLINICAL REPORT Guidance for the
Clinician in Rendering Pediatric Care
+ How to Cite: Tate AR, Fisher-Owens SA, Spiller L, et al; American
Academy of Pediatrics, Section on Oral Health, Council on Child
Abuse and Neglect Oral and Dental Aspects of Child Abuse and
September 2024 Neglect: Clinical Report. Pediatrics 2024;154(3):e2024068024.

Authors
Anupama Rao Tate, DMD, MPH,a Susan A. Fisher-Owens, MD, MPH, FAAP,b Lora Spiller, MD, FAAP,c Jillian Muhlbauer, DMD,d James L. Lukefahr, MD, FAAP,c
Section on Oral Health, Council on Child Abuse and Neglect

Abstract
In all 50 states, the District of Columbia, and the Commonwealth of Puerto Rico, pediatricians, dental professionals, and other physicians
are mandated to report suspected cases of abuse and neglect to social service or law enforcement agencies. The purpose of this clinical report
is to review the oral aspects of abuse and dental neglect in children and the role of pediatricians, dental professionals, and other physicians
in evaluating such conditions. This clinical report addresses recommendations on the evaluation of bite marks, as well as perioral and intra-
oral injuries, infections, and diseases that may raise suspicion for child abuse or neglect. Some physicians may have received less education
pertaining to oral health, dental injury, and oral disease. These physicians may not detect the mouth and gum findings possibly related
to abuse or neglect as readily as abuse injuries involving other areas of the body. Therefore, pediatricians, dental professionals, and other
physicians are encouraged to collaborate to increase the prevention, detection, and treatment of these conditions in children.

BACKGROUND
Child abuse and neglect affect at least 1 out of 7 children in the United States
each year.1 Maltreatment incidents may have been higher than observed
during and after the global severe acute respiratory syndrome coronavirus
a
Division of Oral Health, Children’s National Hospital, and Department of Pediatrics, George 2 pandemic because of factors such as increased family stressors, isolation
Washington Medical School, Washington, District of Columbia; bDepartments of Pediatrics away from community support systems, and underreporting.2
and Preventive and Restorative Dental Sciences, University of California, San Francisco, Children may be exposed to multiple kinds of maltreatment that mani-
California; cDivision of Child Abuse Pediatrics, Department of Pediatrics, University of Texas fest in the mouth. Abuse can include physical and sexual abuse and may be
Health San Antonio, San Antonio, Texas; and dPrivate practice, Arnold, Maryland.
evidenced by bite marks, dental neglect, and medical child abuse (MCA).
All authors were responsible for reviewing and updating of one or more sections. Drs Tate Bullying and the human trafficking of children also occur and can have
and Lukefahr were responsible for conceptualizing, writing, and revising the manuscript serious long-term effects. Abuse and neglect may be the presenting prob-
and considering input from all reviewers and the board of directors; and all authors
lem, noticed during a physical examination, or children or adolescents may
approved the final manuscript as submitted and agree to be accountable for all aspects
of the work.
disclose information about these experiences. It is important for pediatricians,
dental professionals, and other physicians to be alert to and knowledgeable
This document is copyrighted and is property of the American Academy of Pediatrics about signs and symptoms of child abuse and neglect and to know how to
and its Board of Directors. All authors have filed conflict of interest statements with the
respond. Because of varying resources within different communities, not
American Academy of Pediatrics. Any conflicts have been resolved through a process
approved by the Board of Directors. The American Academy of Pediatrics has neither
all physician or dental professionals of a certain job specification may be
solicited nor accepted any commercial involvement in the development of the content available everywhere, and thus, job roles may sometimes overlap.
of this publication. All pediatricians, dental professionals, and other physicians in the United
Clinical reports from the American Academy of Pediatrics benefit from expertise and
States have a legal requirement to report suspected child abuse and neglect
resources of liaisons and internal (AAP) and external reviewers. However, clinical reports to child protection authorities, although the specific requirements and pro-
from the American Academy of Pediatrics may not reflect the views of the liaisons or the cedures vary among jurisdictions. Racial, ethnic, and economic disparities in
organizations or government agencies that they represent. the reporting of child maltreatment to authorities have long been recog-
The guidance in this report does not indicate an exclusive course of treatment or serve nized3 and have been under closer scrutiny in recent years. Children with
as a standard of medical care. Variations, taking into account individual circumstances, disabilities are a vulnerable population at increased risk of child abuse and
may be appropriate. neglect, and therefore, special attention should be paid to reduce this risk
All clinical reports from the American Academy of Pediatrics automatically expire 5 years in these children and youth.4 The Joint Commission now requires health
after publication unless reaffirmed, revised, or retired at or before that time. care organizations to use written criteria to identify patients who may have
experienced physical assault, sexual assault, sexual molestation, domestic
DOI: https://doi.org/10.1542/peds.2024-068024
abuse, or elder or child abuse and neglect.5 A recognized bias among health
Address correspondence to Anupama Rao Tate, DMD, MPH. E-mail: [email protected] care professionals is the failure to report suspected abuse when the family

Reproduced with permission from Pediatrics, Vol. 154, Issue 3, e2024068024, Copyright © 2024 by the American Academy of Pediatrics.
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is of similar background to the professional.6 Recognition of implicit bias dentist or child abuse pediatrician may be helpful. The clinical report from
and its influence on diagnosing and reporting child maltreatment is also the American Academy of Pediatrics (AAP) titled “The Evaluation of Sus-
an important consideration.7–9 pected Child Physical Abuse” provides additional guidance.11

PHYSICAL ABUSE SEXUAL ABUSE

According to the Fourth National Incidence Study of Child Abuse and Ne- The oral cavity is a frequent site of sexual abuse in children, and acquisition
glect, in 2006 (the most recent year evaluated) at least 323 000 US children of sexually transmitted infections (STIs) via this route can occur.28 Testing
experienced physical abuse.10 Identifying and reporting suspected abuse can for STIs within the oral cavity may be considered when:
be challenging for pediatricians, dental professionals, and other physicians
but has the potential to interrupt the cycle of abuse, secure the child’s safety, • The child gives a history of oral–genital contact;
and in some cases, save the child’s life.11 Missed opportunities to recognize • The child has experienced penetration or has evidence of recent or healed
and report physical abuse remain a significant problem; in one study,12 27.5% penetrative injury to the genitals, anus, or oropharynx;
of abused infants had a previous minor but inflicted injury that had been • The child has been abused by a stranger;
recognized by a parent or physician but usually not reported to authorities. • The child has been abused by an assailant known to be infected with or
The majority of these “sentinel injuries” involved bruising to the face, fore- at high risk for STIs;
head, or ear. The mnemonic TEN-4 (Torso, Ear, or Neck in children less than • The child has a sibling, other relative, or household contact with an STI;
or equal to 4 years of age, and anywhere in an infant under 4 months of • The child lives in an area with a high rate of STIs in the community;
age) has been widely adopted to assist in identifying bruises concerning for • The child has signs or symptoms of an STI (eg, vaginal discharge, genital
abuse.13 An expanded mnemonic with improved sensitivity for identifying itching or odor, urinary symptoms, or genital lesions);
abusive bruise injuries has since been introduced: TEN-4-FACESp (Torso, • The child or the parent of a prepubertal child requests STI testing; and
Ear, Neck, Frenulum, Angle of jaw, Cheeks, Eyelids, Subconjunctivae in • The child is unable to verbalize details of the assault.29
children younger than 4 years, bruising anywhere in infants younger than
5 months, or patterned bruising).14 Culture or nucleic acid amplification tests (NAATs) may be used to test
Craniofacial, head, face, and neck injuries occur in more than half of child for Neisseria gonorrheae and Chlamydia trachomatis infection. NAATs are
abuse cases.12,15–18 All suspected individuals who have experienced abuse or preferred to culture by most clinicians because of their superior sensitivity.
neglect, including children in state custody or foster care, need to be exam- Only Clinical Laboratory Improvement Amendments-approved, US Food and
ined carefully at some point during the evaluation for signs of oral trauma, Drug Administration-cleared NAAT assays should be used.29 Consultation
caries, gingivitis, and other oral health problems. These conditions are with an expert is recommended for positive STI test results in infants and
more prevalent in children who are maltreated than in the general pediatric prepubertal children, because vertical and nonsexual transmission of certain
population.19 pathogens can occur (eg, persistence of perinatally acquired Chlamydia,
Because of their exposed location on the body and anatomic complex- postnatal HIV exposure through infected human milk, and others).30,31
ity, the head and face are more vulnerable to serious injury than are other In one series, STIs were detected in 22.9% of adolescents evaluated
body regions.20 A review of 40 cases of child homicides resulting from family for sexual abuse and in 11.4% of preadolescents.32 Oropharyngeal STIs are
violence noted that 36 (90%) had orofacial injuries.21 Recent research has found detected less frequently than anogenital infections; they commonly do
that children younger than 4 years with orofacial (especially cheek, ear, jaw, not present with pain, discharge, erythema, or other visible signs of injury
and frenum) and torso bruising are at risk for having been physically abused or infection.33,34 When an STI is confirmed in a child or adolescent being
and are at risk for future, more serious abuse.14 Of children up to age 5 years evaluated for sexual abuse, testing of other sites, including the oropharynx,
with oral injury who underwent skeletal imaging, 25% had occult fractures; is indicated regardless of what contact the child disclosed may be indi-
30% of 37 infants with oral injury who underwent neuroimaging had central cated. In one study, NAATs for oropharyngeal Chlamydia and gonorrhea
nervous system injuries.22 Oral injuries may be inflicted with instruments were positive in 6% of adolescent patients, despite more than half of these
such as eating utensils or a bottle during forced feedings, hands, fingers, patients providing no history of genital–oral contact.34 Oral infection with
scalding liquids, or caustic substances. Physical abuse may result in contu- Trichomonas vaginalis has never been described. Anogenital and oropharyn-
sions; burns or lacerations of the tongue, lips, buccal mucosa, palate (soft and geal human papillomavirus infections may be transmitted sexually, vertically
hard), gingiva, alveolar mucosa, or frenum; fractured, displaced, or avulsed from birthing parent to infant during delivery, or horizontally through non-
teeth; or facial bone and jaw fractures. Naidoo23 cited the lips as the most sexual contact from a child or caregiver’s hand to the genitals or mouth.35,36
common site for inflicted oral injuries (54%) followed by the oral mucosa, In the setting of sexual abuse, national practice guidelines from the AAP
teeth, gingiva, and tongue. Lacerations to the oral frena in premobile infants and Centers for Disease Control and Prevention support postexposure vacci-
are often the result of physical abuse and are frequently associated with nation against human papillomavirus for children 9 years and older if they
other findings of serious physical abuse.22,24 Trauma to the teeth may result have not already started the vaccine series.33,37
in pulpal necrosis, leaving the teeth gray and discolored.25 Gags applied to Children who present acutely with a recent history of sexual abuse need
the mouth may result in bruises, lichenification, or scarring at the corners to receive specialized forensic evidence collection for semen and other
of the mouth.26 In some cases, serious injuries of the oral cavity, including foreign materials resulting from the assault. Specialized hospitals and child
posterior pharyngeal injuries and retropharyngeal abscesses, have been protection clinics equipped with protocols and experienced personnel are
inflicted by caregivers who fabricate illness in a child27 to simulate hemopty- best suited for collecting such specimens and maintaining a chain of evi-
sis or other symptoms requiring medical care. All findings in cases in which dence necessary for investigations. In many cases, oral swab specimens are
there is reasonable suspicion of abuse or neglect, regardless of mechanism, collected irrespective of whether the child specifically discloses oral–genital
need to be reported for further investigation. Unintentional or accidental contact. Typically, the buccal mucosa and tongue are swabbed with a
injuries to the mouth are common and may be distinguished from abuse sterile, cotton-tipped applicator; the swab can be air dried and packaged
by judging whether the history (including the timing and mechanism of appropriately for laboratory analysis.
the injury) is consistent with the characteristics of the injury and the child’s
developmental capabilities. Multiple injuries, injuries in different stages MEDICAL CHILD ABUSE
of healing, or a discrepant history ought to arouse suspicion for abuse. In MCA, also known as “Munchausen syndrome by proxy” and “caregiver
conjunction with reporting, consultation with or referral to a knowledgeable fabricated-illness,” is a form of child maltreatment in which a caregiver

Reproduced with permission from Pediatrics, Vol. 154, Issue 3, e2024068024, Copyright © 2024 by the American Academy of Pediatrics.
Available at: “https://doi.org/10.1542/peds.2024-068024”.

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subjects a child to unnecessary and potentially harmful medical care be- BULLYING
cause of the caregiver’s exaggeration, falsification, or induction of an illness Because children with dental abnormalities are at increased risk for bullying,
or medical condition.38 These children are subjected to unnecessary medical advocating for antibullying prevention programs in schools and other com-
interventions, diagnostic tests, repeated examinations, surgeries, and medi- munity settings by pediatricians, dental professionals, and other physi-
cations. There is no typical presentation of MCA, although commonly, the cians may be beneficial. Thirty percent of children in the sixth through 10th
fabricated illness involves multiple organ systems. Apnea, seizures, feeding grades report having been bullied and/or having bullied others.47 Investiga-
problems, bleeding, and rashes are frequently reported symptoms. One tors from numerous countries and cultures have found that children with
recent study found that gastrointestinal complaints in children who had orofacial or dental abnormalities (including malocclusion) are frequently
experienced MCA led to 6 times more types of feeding complications com- subjected to bullying,48–50 and as a result, may suffer serious psychological
pared with controls who were also being evaluated for gastrostomy tube consequences, including depression and suicidal ideation.51–53 Children who
placement. In this study, the majority of patients experienced resolution reported physical abuse, intimate partner violence, forced sex, and bullying
of their nonoral feeding issues after MCA intervention (ie, removal from were found to also report poor oral health.54 Some children and adolescents
potential offender).39 are at high risk for being bullied for reasons besides orofacial abnormali-
MCA can also present with oral manifestations. One review described ties but are likely to have interactions with pediatricians or dentists. These
4 cases of MCA involving the oral cavity in children ranging from 9 months include LGBTQ+ youth,55 overweight children and adolescents,56 children
to 6 years of age.40 In one case, recurrent mucosal bleeding and ulcerations from racially minoritized groups,57 and children with special health care
were initially treated as Stevens Johnson syndrome and then cicatricial pem- needs.58 There are antibullying prevention programs in schools and other
phigoid. This child died of poisoning and her oral manifestations were found community settings, as well as AAP resources including HealthyChildren.
to be caused by forced ingestion of toxic cleaning products. Another case org, which offers caregivers educational resources on bullying among many
presented with mucosal desquamation, drooling, and dysphagia and was other topics (https://healthychildren.org/English/safety-prevention/at-play/
eventually discovered to be caused by the caregiver placing an acid-based Pages/Bullying-Its-Not-Ok.aspx).
powder in the infant’s food and toys. In all 4 cases, and in most reports in
the literature, the perpetrator was the mother.41 HUMAN SEX TRAFFICKING
Making a diagnosis of MCA can be difficult because of false information Human trafficking is a major global child health issue with substantial
provided and/or induction of illness by the caregiver. Numerous medical medical, psychological, and dental ramifications. The term “human traffick-
professionals from various specialties and institutions are often involved in ing” is often confused with “human smuggling”; however, human trafficking
treating these patients. Diagnosing MCA may require a thorough review requires exploitation and does not require any physical transportation from
of all available medical records, which is often voluminous and can be time one location to another to meet the definition.59 This clinical report focuses
consuming, but is needed to discover concerning patterns and make the on human sex trafficking, defined by the US Department of State as “a
correct diagnosis.42 commercial sex act that is induced by force, fraud, or coercion, or in which
the person induced to perform such an act has not attained 18 years of
BITE MARKS ON THE SKIN age.”59 Precise numbers of children experiencing human or sex trafficking
Acute or healed bite marks on the skin may indicate abuse. Dentists trained are difficult to obtain because of the complicated nature of these definitions,
as forensic odontologists can assist pediatricians, other dental profession- as well as underreporting and failure to recognize trafficking. The average
als, and physicians in the detection and evaluation of bite marks related to age of children who are exploited for sex is 12 years, and children as young
physical and sexual abuse.43 Bite marks on the skin need to be suspected as 6 years are targeted.60 Children who are or have been in foster care,61 are
when ecchymoses, abrasions, or lacerations are found in an elliptical, horse- experiencing homelessness, identify as LGBTQ+,62 run away from home,63 or
shoe-shaped, or ovoid pattern.43 Frequently, bite marks are found on the are incarcerated in juvenile detention facilities64 are more likely to be tra-
cheeks, back, sides, arms, buttocks, and genitalia.44 Bites produced by dogs ficked. Advances in technology, with the Internet and mobile devices, have
and other carnivorous animals tend to tear flesh, whereas human bites facilitated perpetrators’ ability to traffic children, often without requirement
compress flesh and can cause abrasions, contusions, and lacerations, but of the child to leave their own home.
rarely avulsions of tissue.45 An intercanine distance (ie, the linear distance Trafficking survivors often experience significant physical and sexual
between the central point of the cuspid tips) measuring more than 3.0 cm violence and may have observable injuries that are poorly explained. Survi-
is suspicious for an adult human bite.45 vors also are at higher risk for STIs, unsafe abortions, malnutrition, and
The pattern, size, contour, color, and evolution of a bite mark ideally can untreated medical conditions. Posttraumatic stress disorder, anxiety, depres-
be evaluated by a forensic odontologist. If a specialist is unavailable, a child sion, suicidal ideation, self-harm, and substance use concerns are common
abuse pediatrician or pediatric dental professional experienced in identi- to people who have experienced human trafficking.64 Dental problems also
fying the patterns of child abuse injuries may examine and document the rank high in this list: For women and adolescents who were trafficked in
bite mark characteristics photographically with an identification tag and Europe, 58% reported tooth pain.65 In the United States, more than half
scale marker (eg, ruler) in the photograph. Further information is available (54.3%) of women and adolescents who were trafficked reported dental
on the American Board of Forensic Odontology (ABFO) Website to locate problems, most commonly tooth loss (42.9%).66 Children who have experi-
an expert and review the standards and guidelines for evaluating bite marks enced trafficking may present to dental offices for care. It has been reported
(www.abfo.org). that child trafficking survivors have twice the risk for dental problems, be-
Bite marks found on human skin are challenging to interpret and differ- cause they “often suffer from inadequate nutrition leading to retarded
entiate because of similarities in dentition, distortion on skin, and time growth and poorly formed teeth, as well as dental caries, infections, and
elapsed between the injury and the analysis.43 Recent investigations have tooth loss.”67 For older children, dental problems may trace back to their si-
led to questions about the scientific validity and overapplication of forensic tuation of origin, with limited access to or poor quality of care.
patterned evidence (bite mark analysis in particular) and its role in legal Trafficked children experience unique challenges in accessing medical and
proceedings.46 In response, the ABFO has adopted more conservative guide- dental care. However, studies have shown that a large percentage of these
lines and no longer endorses positive identification of a suspect dentition youth do present for health care during the time they are being trafficked.68
to a bitemark.46 More high-quality research is needed regarding bite mark One study found that 26.5% of trafficked individuals were seen by a dentist
analysis and its use in identifying potential perpetrators. during the time they were being trafficked, despite the fact that few were
identified by clinicians.69 Validated screening tools exist for health care set-
tings but are still underutilized.70

Reproduced with permission from Pediatrics, Vol. 154, Issue 3, e2024068024, Copyright © 2024 by the American Academy of Pediatrics.
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DENTAL NEGLECT nonconforming, children who are overweight or obese, youth who are
The American Academy of Pediatric Dentistry recognizes the influence of subjected to human trafficking, and children with special health care
social factors on children’s oral health including access to care, dental disease, needs.55–57
behaviors, and oral health inequalities.71 Dental neglect, as defined by the Medical and dental collaboration to prevent child maltreatment is im-
American Academy of Pediatric Dentistry, is the “willful failure of parent or portant. The National Maternal and Child Oral Health Resource Center
guardian, despite adequate access to care, to seek and follow through with (Special Care | Module 3: Oral Health Supervision [mchoralhealth.org]) has
treatment necessary to ensure a level of oral health essential for adequate resources for health care providers seeking information on this issue.81
function and freedom from pain and infection.”72 Dental caries, periodontal Pediatric dentists and oral and maxillofacial surgeons, whose advanced edu-
diseases, and other oral conditions can lead to pain, infection, loss of func- cation programs include a mandated child abuse curriculum, can provide
tion, and systemic infection if left untreated.72 These undesirable outcomes valuable information and assistance to other health care providers about
can adversely affect learning, communication, nutrition, and other activi- oral and dental aspects of child abuse and neglect. Physician members of
ties necessary for normal growth and development.18,73 Dental neglect is the multidisciplinary child abuse and neglect teams are encouraged to identify
most frequent type of abuse seen by dentists and can be challenging to such dental providers in their communities to serve as consultants for
identify because it is chronic and insidious in nature.74,75 Some children who these teams. In addition, physicians with experience or expertise in child
present for dental care have severe early childhood caries (formerly termed abuse and tpdel neglect can make themselves available to dentists and
“infant bottle” or “nursing” caries). It is important to differentiate caregiv- dental organizations as consultants and educators. Such collaborative
ers with adequate knowledge but willful failure to seek care from caregivers efforts will strengthen the ability to prevent and detect child abuse and
with barriers to care or those without knowledge or awareness of their child’s neglect and enhance the ability to care for and protect children.
need for dental care when determining the need to report such cases to child
protective services. Pediatricians can play an important role in encouraging RECOMMENDATIONS
families to seek dental care and explaining benefits of completing needed 1. Pediatricians, dental professionals, and other physicians must report
dental treatment.76 Several factors are considered necessary for the diag- injuries that are concerning for abuse or neglect to child protective serv-
nosis of neglect77 : ices in accordance with local or state legal requirements. For more in-
formation about requirements in your state, contact the AAP state
• a child is harmed or at risk for harm because of lack of dental health care; advocacy team (e-mail: [email protected]).
• the recommended dental care offers significant net benefit to the child; 2. In cases of sexual abuse that may involve the mouth, even without overt
• the anticipated benefit of the dental treatment is significantly greater than signs, pediatricians, dental professionals, and other physicians should
its morbidity, so parents would likely choose treatment over nontreatment; know how to collect a history to elicit this information and to perform
• access to health/dental care is available but not used; and oral STI testing using appropriate tests to support forensic investigations.
• the parent understands the dental advice given. When sexual abuse is suspected or diagnosed in a child, the case needs
to be reported to child protective services and/or law enforcement agen-
Failure to seek or obtain proper dental care may result from factors cies for investigation.82–85 A multidisciplinary child abuse evaluation for
such as family isolation (physical or cultural), lack of finances, transportation the child and family is preferred when available.
difficulty, ignorance, or lack of perceived value of oral health.78–80 The point 3. Consultation with a child abuse pediatrician may be helpful when a
at which to consider a parent negligent and begin intervention occurs after pediatrician, dental professional, or other physician suspects MCA.
the parent has been properly alerted by a pediatrician, dental professional, 4. Because ABFO guidelines no longer endorse positive identification of a
or other physician about the nature and extent of the child’s condition, the suspect dentition to a bitemark, pediatricians, dental professionals, and
specific treatment needed, and the mechanism of accessing that treatment.78 other physicians should consult with a forensic odontologist, pediatric
Many families face challenges in accessing dental care or insurance for their dentist experienced in forensic issues, or child abuse pediatrician for help
children, and dental services may not be readily available. A child’s social, in evaluating bite marks. To locate an expert and review the standards
emotional, and medical ability to undergo treatment, as well as cultural and and guidelines for evaluating bite marks, go to www.abfo.org.
religious differences, are important to consider.80 5. Because children with dental abnormalities are at increased risk for bully-
Pediatricians, dental professionals, and other physicians can make a ing, pediatricians, dental professionals, and other physicians should ask
reasonable effort to help caregivers understand the explanation of the dental their patients about bullying and advocate for antibullying prevention
disease and its implications, the risks and benefits of dental treatment, programs in schools and other community settings.
and the use of the appropriate analgesic and anesthetic during the proce- 6. Because children who have experienced human trafficking may visit the
dure to ensure the child’s comfort. Assistance can be provided to the family health care setting (dental and medical), pediatricians, dental profession-
in finding financial aid, transportation, or public facilities for needed services. als, and other physicians are encouraged to be aware of human traffick-
If, despite these efforts, the parent fails to obtain therapy, the case war- ing screening tools and the risk factors for human trafficking to identify
rants reporting to the appropriate child protective services agency.78 children at risk (of all genders) and to safely report and connect patients
to resources. They can also advocate for antitrafficking efforts.
CONCLUSIONS 7. If parents fail to obtain necessary treatment of a child’s oral or dental
Physical or sexual abuse may also result in oral or dental injuries or condi- disease after barriers to care have been addressed, the case must be re-
tions. Pediatricians, dental professionals, and other physicians can document ported to the appropriate child protective services agency as concerning
suspicious injuries, obtain laboratory evidence, photo documentation, and/ for dental neglect.
or consult with experts when appropriate. The role of forensic bite mark 8. Pediatricians, dental professionals, and other physicians are encouraged
analysis in legal proceedings has been brought into question because of to consult with colleagues on challenging cases and collaborate with
lack of scientific validity, and as a result, the ABFO no longer endorses them to provide education and support toward improved identification
positive identification of a suspect dentition to a bitemark. of child maltreatment.
Dental neglect has been recognized for years to be a significant child 9. Pediatricians, dental professionals, and other physicians should recognize
health issue. Pediatricians, dental professionals, and other physicians can be and acknowledge implicit bias and reduce its influence on diagnosing
alert to children and youth at particular risk for orofacial and dental neglect and reporting child maltreatment.
and its psychosocial consequences, such as LGBTQ+ youth who are gender

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LEAD AUTHORS Nancy Heavilin, MD, FAAP

Anupama Rao Tate, DMD, MPH Amanda Bird Hoffert Gilmartin, MD, FAAP
Susan A. Fisher-Owens, MD, MPH, FAAP Lora Spiller, MD, FAAP Natalie Kissoon, MD, FAAP
Jillian Muhlbauer, DMD Bethany Anne Mohr, MD, FAAP
James L. Lukefahr, MD, FAAP Patricia Morgan, MD, FAAP
Shalon Marie Nienow, MD, FAAP
SECTION ON ORAL HEALTH EXECUTIVE COMMITTEE, 2022–2023 Norell Rosado, MD, FAAP
Jeffrey M. Karp, DMD, MS, Chairperson Eric L. Beyer, MD, IBCLC, FABM, FAAP
Chevon Brooks, MD, FAAP COUNCIL ON CHILD ABUSE AND NEGLECT LIAISONS
Lauren M. Feldman, DMD Rachael Keefe, MD, MPH, FAAP, Council on Foster Care, Adoption, and Kinship
C. Eve Kimball, MD, FAAP Anupama Rao Tate, DMD, MPH Care
Brooks Keeshin, MD, FAAP, American Academy of Child and Adolescent
PAST SECTION ON ORAL HEALTH EXECUTIVE COMMITTEE MEMBERS Psychiatry
Karen Sokal-Gutierrez, MD, MPH, FAAP Jennifer Matjasko, PhD, Centers for Disease Control and Prevention
John H. Unkel, DDS, MD, MPA, FAAP Serena Wagoner, DO, Section on Pediatric Trainees
Elaine Stedt, MSW, ACSW, Administration for Children, Youth and Families,
SECTION ON ORAL HEALTH LIAISONS Office on Child Abuse and Neglect
Matt Zaborowski, MPH, CPH, American Dental Association
Matt Crespin, MPH, RDH, American Dental Hygienists’ Association STAFF
Amr Moursi, DDS, PhD, American Academy of Pediatric Dentistry Tammy Piazza Hurley
Jeff Hudson, MA
SECTION ON ORAL HEALTH STAFF
Kera Beskin, MPH, MBA
ABBREVIATIONS
COUNCIL ON CHILD ABUSE AND NEGLECT, 2022–2023 AAP: American Academy of Pediatrics.
Suzanne Breen Haney, MD, MS, FAAP, Chairperson ABFO: American Board of Forensic Odontology.
Antoinette Laskey, MD, MPH, MBA, FAAP, Chairperson-elect MCA: medical child abuse.
Andrea Asnes, MD, MSW, FAAP NAAT: nucleic acid amplification test.
Verena Brown, MD, FAAP STI: sexually transmitted infection.
Rebecca G. Girardet, MD, FAAP

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2024 by the American Academy of Pediatrics.
FUNDING: No external funding.
FINANCIAL/CONFLICT OF INTEREST DISCLOSURES: Dr Fischer-Owens has disclosed a financial relationship with Colgate, as a DSMB member. Disclosures are
reviewed and mitigated through a Conflict of Interest process approved by the AAP Board of Directors.

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