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Journal of Forensic and Legal Medicine 43 (2016) 34e41

Contents lists available at ScienceDirect

Journal of Forensic and Legal Medicine

journal homepage: www.elsevier.com/locate/jflm

Review

Domestic violence against children detected and managed in the

routine of dentistry and A systematic review
to b to c
Jose LSA Rodrigues , Anderson PB Lima d , Juliana Y. Nagata , Lilian Rigo ,
c Ademir Franco *
Graziela O. Cericato , , Luiz R. Paranhos a,
to
Department of Dentistry, Federal University of Sergipe, Brazil
b
Private Dental Office, Brazil
c
Department of Dentistry, Meridional Faculty, Brazil
d
Department of Oral Health Sciences, Katholieke Universiteit Leuven, Belgium

article info abstract

Article history: The domestic violence against children (DVAC) interferes in the psychological development leading to
Received 19 February 2016 sequels that manifest and persist up to adulthood. The physical evidences of domestic violence are
Received in revised form more easily observed in the orofacial complex, eventually becoming detected by dentists. The present
24 June 2016 systematic literature review aimed to investigate the perception, knowledge and attitude of dentists
Accepted 10 July 2016
towards the detection and management of DVAC cases. A systematic search was performed in 6
Available online 13 July 2016
databases: PubMed, ScienceDirect, LILACS, SciELO, GoogleScholar, and OpenGrey. Cross-sectional articles
assessing the perception, knowledge, and attitude of dentists facing potential cases of DVAC were
Keywords:
child abuse
selected. No restriction of language, time, and publication status was considered. The search resulted in
Dentistry
1,024 articles, of which 18 fit the eligibility criteria. The knowledge for detecting cases of DVAC obtained
domestic violence during the undergraduation course was classified by the dentists (in 39% of the articles) as “insufficient”.
Forensic dentistry When suspecting of cases involving domestic violence, most of the dentists (in 77.75% of the articles)
considered reporting to the competent authorities. However, the dentists are not sure about who these
authorities are (in 31.25% of the articles). More attention must be given to the Forensic education in
Dentistry. Specifically, proper training is necessary to support the dentists on the detection and management
of pediatric patients under domestic violence.
Systematic Review Registration Number: PROSPERO CRD42015026747 (http://www.crd.york.ac.uk/
PROSPEROUS).
© 2016 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.

1.Introduction demonstrated that the adverse childhood experiences (psycho-logical

The domestic violence against children (DVAC) may be defined
as any attitude (whether by act or omission) that potentially harms
the physical and psychological well-being of a child.1e3 The DVAC
includes physical and psychological violence, sexual abuse, and
neglect.2,4 It may be committed in the domestic environment by
family members, including persons who assumed the paternal
function or any person who has power over the child.3e5 The DVAC
severely impacts in the mental development, leading to consequences
that persists up to adulthood.3,6,7 Felitti et al.,8 1998,
* Corresponding author. Federal University of Sergipe, Pe Alvares Pitangueira St.,
248, centro, Lagarto, SE, 49400000, Brazil.
E-mail address: paranhos@ortodontista.com.br (LR Paranhos).
and physical), such as child sexual abuse, considerably increase the
risk for developing behavioral disorders (eg drug abuse,
depression, and suicide attempt).
The anatomic region most affected in DVAC cases involving
physical manifestations is the face,9 with an estimated prevalence
rate of 58e85%.10 Coincidentally, the orofacial complex comprehends
the region of interest in Dentistry,1 being constantly examined in
the clinical routine. Unknowingly, the dentists may face clinical
sings of DVAC on a daily basis. Unfortunately, many dentists
complain about the lack of capacity for interpreting suspicious
cases and reporting them to the authorities.11e13 consequently, the
DVAC expands as an underreported social problem.
The present systematic review aims to screen from the scientific
literature the current status of the perception, knowledge and
attitude of dentists in relation to the DVAC. In parallel, it also

http://dx.doi.org/10.1016/j.jflm.2016.07.006
1752-928X/© 2016 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
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JLSA Rodrigues et al. / Journal of Forensic and Legal Medicine 43 (2016) 34e41
encourages the participation of dentists in public policies against this
important social problem.
2. Materials and methods
2.1. Protocol and registration
This systematic literature review was performed following the
Preferred Reporting Items for Systematic Reviews and Meta-
Analyses PRISMA14 checklist (www.prisma-statement.org). The
research protocol was registered at the International Prospective
Register of Systematic Reviews (PROSPERO) (http://
www.crd.york.ac.uk/PROSPERO ) under the registration code: CRD42015026747.
2.2. Eligibility criteria
Focused Question: Does the dentist know how to detect and
properly manage cases of DVAC? The research question was based
on the PVO strategy for Systematic Exploratory Review, where P
stands for population, context, and/or problem-situation; V stands for
variables; and O stands for desirable or undesirable outcomes.
Inclusion criteria: Cross-sectional articles assessing the perception,
knowledge, and attitude of dentists facing cases of DVAC. No
restriction of language, time, and status of publication was applied.
Exclusion criteria: Studies exclusively qualitative; studies sam-
pling exclusively undergraduate dentistry students; literature re-
views; letters to the editor and/or publishers; case reports; books;
and book chapters.
23. Information sources
A systematic review was performed in the following electronic
databases: PubMed, ScienceDirect, LILACS, SciELO, GoogleScholar,
and OpenGrey. In order to avoid any selection bias, the “Grey
Literature” was verified through GoogleScholar and OpenGrey
searches. Only the first 200 GoogleScholar results were assessed,
excluding patents and citations.
2.4. Search
The MeSH (Medical Subject Headings) terms used were “atti-
tude”, “domestic violence”, “dentistry”, “child”, “knowledge”,
“diagnosis”, and “perception”. Entry Terms were also used in order to
retrieve all the studies using synonyms for “children”. The Boolean
operators (AND and OR) were used to combine the de-scriptors
(Table 1). This research was performed on April 15th, 2015.
The articles retrieved were imported in Mendeley Desktop 1.13.3
(Mendeley™ Ltd, London, UK) software packages to search for
duplicates.
2.5. Study selection
The selection process was completed in 2 phases. Titles and
abstracts were systematically assessed for eligibility by two ex-
aminers, which were not blind for the name of authors and jour-nals.
Whenever the title and abstract of the studies did not present enough
information, full texts were obtained and assessed. The studies were
analyzed completely also in case of presenting eligible title but no
abstract.
The full texts of the studies considered eligible in this phase were
downloaded and read to verify the presence of every inclusion criteria.
In specific cases, the authors of potentially eligible studies were
contacted by email and asked about the missing information.
The rejected studies were registered separately, displaying the
35
reasons for exclusion.
2.6. Risk of bias and study quality in each study
The quality of the methodology used in the studies included was
evaluated by independent reviewers (authors), according to the
PRISMA14 recommendation. The evaluation was founded on the
description of the information provided in each study. At this point,
the review was performed blindly, masking the names of authors and
journals. It avoided any potential bias and conflicts of interests during
the analysis. The risk of bias and study quality was assessed for
each article using an adapted checklist.15 This checklist was based
on 9 criteria expressed as questions (Q) made to each study, namely:
Q1) Were the objectives, methodology, results, and conclusion
described clearly in the abstract? Q2) Were the objectives mentioned
clearly in the full-text version? Q3) Were the ethical criteria mentioned
in the text? Q4) Was the study type mentioned in the text? Q5) Was
the sample size reported in the text? Q6) Was the sample selected
randomly? Q7) Were the in-clusion and exclusion criteria mentioned
in the text? Q8) Were the results presented clearly and objectively?
Q9) Were the study limitations discussed in the text? Based on the
answers for these
questions, each study received a score translated in quality: low
quality (0e4 points), moderate quality (5e7 points), and high quality
(8e10 points).
2.7. Data extraction of the included articles
The full-texts of the pre-selected studies were revisited and their
data were extracted standardly. The information extracted and
recorded from the studies were: the authorship; the year of publication;
the country in which the study was developed; the sample size, age,
and gender; the experience of the dentists inter-viewed (quantified
in years); the method of interview; the results regarding the perception,
knowledge and attitude of dentists; and the main outcome of the
study.
2.8. Data analysis of the included articles
This step comprised the descriptive analysis of the selected
studies and the verification of homogeneity in the methodology and
outcomes. In case of homogeneity, a meta-analysis was planned.
The final product of the data analysis was presented in the format of
a dissertation.
2.9. Risk of bias across studies
The assessment of the risk of bias across the studies was only
planned if a methodological homogeneity was verified between the
studies, enabling (or not) a meta-analysis.
3. Results
3.1. Study selection
The systematic search resulted in 1,024 studies in the first
selection phase. Eight hundred ninety-nine studies remained after
removing duplicates. Eight hundred and eighty-two were subsequently
excluded for different reasons, remaining 17 studies. Three studies
were added from expert sources. Two studies were excluded for not
distinguishing the dentists from the other pop-ulations sampled. The
final sample consisted of 18 studies (Fig. 1).
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36 JLSA Rodrigues et al. / Journal of Forensic and Legal Medicine 43 (2016) 34e41

Table 1
Electronic databases and applied search strategy.

Database Search strategy Total

PubMed (“attitude”[MeSH Terms] OR “attitude”[All Fields]) AND (“domestic violence”[MeSH Terms] OR (“domestic”[All Fields] 44
http://www.ncbi.nlm.nih.gov/ AND “violence”[All Fields]) OR “domestic violence”[All Fields]) AND (“dentistry”[MeSH Terms] OR “dentistry”[All Fields])
pubmed AND (“child”[MeSH Terms] OR “child”[All Fields] OR “children”[All Fields])
((“attitude”[MeSH Terms] OR “attitude”[All Fields]) AND (“knowledge”[MeSH Terms] OR “knowledge”[All Fields])) AND 23
(“domestic violence”[MeSH Terms] OR (“domestic”[All Fields] AND “violence”[All Fields]) OR “domestic violence”[All
Fields]) AND (“dentistry”[MeSH Terms] OR “dentistry”[All Fields]) AND (“child”[MeSH Terms] OR “child”[All Fields] OR
“children”[All Fields])
(“perception”[MeSH Terms] OR “perception”[All Fields]) AND (“domestic violence”[MeSH Terms] OR (“domestic”[All 10
Fields] AND “violence”[All Fields]) OR “domestic violence”[All Fields]) AND (“dentistry”[MeSH Terms] OR “dentistry”[All
Fields]) AND (“child”[MeSH Terms] OR “child”[All Fields] OR “children”[All Fields])
(“diagnosis”[Subheading] OR “diagnosis”[All Fields] OR “diagnosis”[MeSH Terms]) AND (“domestic violence”[MeSH 215
Terms] OR (“domestic”[All Fields] AND “violence”[All Fields]) OR “domestic violence”[All Fields]) AND (“dentistry”[MeSH
Terms] OR “dentistry”[All Fields]) AND (“child”[MeSH Terms] OR “child”[All Fields] OR “children”[All Fields])
Sky “Domestic Violence” OR “Violence” AND “Dentistry” AND “Child” 05
http://www.scielo.org
Lilacs domestic violence OR violence AND dentistry AND child AND (instance:“regional”) AND (db:(“LILACS”)) fifteen

http://lilacs.bvsalud.org/
ScienceDirect “attitude” AND “domestic violence” OR “Violence” AND “dentistry” AND “children” “attitude knowledge” 124
http://www.sciencedirect.com AND “domestic violence” OR “Violence” AND “dentistry” AND “children” “diagnosis” AND “domestic violence” OR 108
“Violence” AND “dentistry” AND “children” “perception” AND “domestic violence” OR “Violence” AND 176
“dentistry” AND “children” “diagnosis” AND “domestic violence” OR “Violence” AND “dentistry” AND “children ” 101
Google School 6,840 (200)
https://scholar.google.com.br/
OpenGrey “Domestic Violence” AND “Dentistry” AND “Child” 0
http://www.opengrey.eu/ “Violence” AND “Dentistry” AND “Child” 3
Total 1,024

Fig. 1. Flow chart of the literature search and selection criteria adapted from PRISMA.14

3.2. Characteristics of eligible studies
Eleven studies used questionnaires to assess the perception,
knowledge, and attitudes of dentists. Five studies performed per-sonal
interviews. Two studies interviewed the dentists though
phone calls. Male and female dentists were assessed separately in 9
studies. Only 4 studies revealed the age range of the sample. 6
studies performed association tests between the experience of the
dentists and their level of knowledge and attitudes facing clinical
cases of DVAC (Table 2).
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JLSA Rodrigues et al. / Journal of Forensic and Legal Medicine 43 (2016) 34e41 37

Table 2
Summary of descriptive characteristics of studies included.

Author Country of study Sample Age Gender Time of professional work Method PKA

Australia 347
* ÿ PI ÿÿÿ
John et al.16 4
Australia 122 * ÿ
Kilpatrick et al.27 4 TQ ÿ e ÿ
Love et al.24 USES 321 39 years old (28%) between 40 and 91% _ 9%\ Graduated: 1969 PQ ÿÿÿ
49 (36%) between 50 and 59 or prior (24%)
(25%) 60 yrs old (12%) 70's (33%)
80's (32%)
1990 or later (11%)
Andrade Lima et al.17 Brazil 70
* ÿ
4 TQ ÿÿÿ
Thomas et USES 220 4 81% _ 19% \ ÿ PI ÿ ÿ e
127
* ÿ
al.25 Chaim and Gonçalves20 4 PQ ÿÿÿ
Brazil Manea et al.21 Italy 95 Average 37 years old 63% _ 37% \ ÿ PI ÿÿÿ
Bankole et al.28 Nigeria Al-Habsi 175 *
4 ÿ PQ ÿ and ÿ
et al.29 United Kingdom 105 Harris et al.19 United * ÿ
4 PQ ÿÿÿ
Kingdom 490 4 26% _ 74% \ 10 years (17%) PI ÿÿÿ
10 to 19 years
(42%)
20 to 29 years
(24%)
30 years (16%)
Tornavoi et al.5 Brazil 180
* ÿ PI ÿÿÿ
4
Fracon et al.26 Brazil 19
* ÿ
4 PQ ÿÿÿ
Owais et al.22 Jordan 342 4 66%_ 5 years (54%) PQ ÿÿÿ
3. 4%\ <5 years (46%)
Azevedo et al.23 Brazil 187 4 47.6%_ 52.4%\ 10 years (45.4%) PQ ÿ and ÿ
11 to 20 years (23.2%)
21 to 30 years (15.1%)
>30 years (16.2%)
Sonbol et al.12 Jordan 280 4 62.5% _ 37.5%\ >5 years (62%) PQ ÿÿÿ
<5 years (38%)
Laud et al.13 Greece 368 Average 43 years old 54% _ 46% \ ÿ PI ÿÿÿ
Harris et al.18 *
United Kingdom 628 4 ÿ PQ ÿÿe
Al-Dabaan et al.30 Saudi Arabia 122 40 yrs old (73.8%) fifty%_ <20 years (88.5%) PQ ÿÿÿ
>40 years old (26.2%) fifty%\ >20 years (11.5%)
Q: articles that observed the perception of dentists; K: articles that observed the knowledge of dentists; A: articles that observed the attitudes of dentists; –: articles that did not
observe the items P, K or A; ÿ: articles that observed the items P, K or A; 4: articles that did not reveal the age of the dentists interviewed; _: male gender; \: femalegender; *:
articles that did not reveal the gender of the dentists interviewed; ÿ: articles that did not reveal the level of professional experience. Methods for the application of
questionnaires: PQ: Postal Questionnaire; PI: Interview; TQ: Telephone Questionnaire.

3.3. Risk of bias among results 4. Discussion

Heterogeneous methodology was observed between studies.
None of the studies met all the methodological criteria for the
classification of quality.15 Two studies had high methodological
quality (from 8 to 10 points). Twelve studies had moderate meth-
odological quality (from 5 to 7 points). Four studies had low
methodological quality (from 0 to 4 points) (Table 3).
3.4. Results synthesis
Thirteen studies investigated the three topics addressed in the
present systematic review: the perception, the knowledge, and the
attitude of dentists. Two studies exclusively investigated the
perception and attitudes. Two studies exclusively investigated the
perception and knowledge. The most prevalent attitudes consisted
of contacting the competent authorities (n ¼ 12 studies) and con-
tacting the Police department (n ¼ 13 studies) (Table 4). In the
investigation of the perception, suspicious cases involving DVAC
were experienced by 13e81% of the dentists (Table 5). Yet
considering the investigation of knowledge, most of the dentists were
aware of the legal importance of suspecting cases of DVAC.
However, these dentists revealed not being familiar with the
detection and management of these cases (Table 5).
3.5. Risk of bias across studies
The studies selected for this analysis were considered hetero-
geneous, and they did not have compatible data to enable a meta-
analysis.
Nearly 10 million cases of domestic violence are expected every
year in the United States.9 Specific data on the prevalence of cases
involving children are hardly obtained in a reliable manner, once
Domestic violence remains an underreported social problem. Yet
the prevalence of physical signs of DVAC may be assessed more
accurately. It is estimated that these signs involve the orofacial
region in 58e85% of the cases.10 This region is examined routinely
by dentists. In specific countries, such as United States8 and Brazil,1
The dentists are required by the Law to report the suspicious cases
of DVAC observed the dental practice. In the context of the present
investigation, child abuse was the term used to describe the physical
and psychological violence against children, including neglect
conditions. Despite that, the literature does not always combine
violence, abuse and neglect in association with a single term
(DVAC). Consequently, the studies that investigated the DVA using a
different definition may not have been detected during the sys-
thematic search. In order to minimize this bias, the present study
used the definition that is more often referred to in the literature and
which includes in DVAC the physical and psychological violence,
sexual abuse, and neglect.2,4 Using this definition, the present study
aimed to assess the perception, knowledge, and attitude of dentists
facing clinical cases of DVAC.
The first topic of interest in the present research was the
perception of the dentists regarding the clinical cases of DVAC. The
evidences extracted from the scientific literature12,16e19 revealed a
discrepancy between the number of professionals who notice signs
of DVAC and the number of professionals who report to the
competent authorities. John et al.,16 indicate that only 8% out 28% of
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38 JLSA Rodrigues et al. / Journal of Forensic and Legal Medicine 43 (2016) 34e41

Table 3

Analysis of the potential risk of bias and individual quality of the eligible articles.

Author Q1 (1 point) Q2 (1 point) Q3 (1 point) Q4 (1 point) Q5 (1 point) Q6 (1 point) Q7 (2 points) Q8 (1 point) Q9 (1 point) Total Overall quality

John et al.16 Kilpatrick ÿ ÿ eeee ÿ (2 points) e ÿ ÿ 5 Points þþ

ÿ ÿ
and and

et al.27 ÿÿÿ e Love et al.24 Andrade Lima et al.17 ÿÿÿ eee ÿ (2 points) ÿ Thomas et al.25 ÿÿÿ e 6 Points þþ

ÿ ÿ eee ÿ ÿ
and and

4 Points þ
and

6 Points þþ

ÿ ÿ ÿ
and and

6 Points þþ
and

Chaim and Gonçalves20 ÿÿÿ eee ÿ (1 point) ÿ Manea et al.21 Bankole et al.28 Al-Habsi et al.29 ÿÿÿ e Harris et al.19 Tornavoi et al.5 ÿÿÿ e ÿ ÿ (1 point) ÿ Fracon et al.26 ÿÿÿ eeee ÿ Owais et al.22 ÿÿÿ e ÿ Azevedo et al.23 ÿÿÿÿ e ÿ (1 point) 5 Points þþ

ÿ Sonbol et al.12 ÿ (1 point ) ÿ ÿ eee ÿ e ee 3 Points þ

ÿ Laud et al.13 ÿÿÿÿÿÿÿ (1 ÿ ÿ eee ÿ

and

ÿ (1 point) ÿ ÿ (1 point) ÿ ÿ eee 5 Points þþ

point) ÿ Harris et al.18 ÿ (1 point) ÿ Al-Dabaan et al.30 ÿÿÿÿ e ÿ (2 points) ÿ ÿ

and and

ÿ 6 Points þþ

ÿ ÿ
and and

4 Points þ
and and

6 Points þþ
and

4 Points þ

ÿ ÿ
and and

6 Points þþ
and and

6 Points þþ

ÿ ÿ ÿ ÿ ÿ
and and

7 Points þþ
and

8 Points þþþ

ÿ ÿ ÿ ÿ
and and and

6 Points þþ

ÿ
and

8 Points þþþ

Q1) Were the objectives, methodology, results, and conclusion clearly described in the abstract? Q2) Were the objectives mentioned clearly in the full-text version? Q3) Were

the ethical criteria mentioned in the text? Q4) Was the study type mentioned in the text? Q5) Was the sample size reported in the text? Q6) Was the sample randomly

selected? Q7) Were the inclusion and exclusion criteria mentioned in the text? Q8) Were the results presented clearly and objectively? Q9) Were the study limitations

discussed in the text? Answers: ÿ, yes; -, No. Overall quality: þ (low); þþ (moderate); þþþ (high).

Table 4

Summary of the main attitudes mentioned in the eligible articles.

Author A1 (%) A2 (%) A3 (%) A4 (%) A5 (%) A6 (%) A7 (%) A8 (%)

ÿ x ¥ 4 ÿ
q

John et al.16 75# Kilpatrick et al.27 eeeeee 72; 41 Love et96

al.24 10 Andrade Lima51 75# 86 81 26 18
and and and and and

et al.17 7.14 Thomas et al.25 Chaim and Gonçalves20 Manea et al.21

and

Bankole et al.28 Al-Habsi et al.29 Harris et al.19 29# Tornavoi et al. 5 eee 45 Fracon et al.26 15 Owais et al.22 eee 33 Azevedo et al.23 Sonbol et al.12 eeeeeee 41 Laud et al.13 Harris et al.18 Al-Dabaan et 43; 38 75; 80 ee e

al.30 64
and and

29 54
and and and e ee e

and

3.92 15.69 54.9 and

11.77 55.55 ee 5.56 67.86

and and and and and and and and and e ee e

and and

23.62 44.88 5.75

and e ee e and

1.58
and

and

38# 17 38# 38# 20 52# eee 92 63 86.5 84 29# 78 53 37 15.8

and and and e ee e

74.9 21.1
and

52# 22
e ee e

and

44 and and and and and

35 and

86.5

82 87 and and

32 35 29 and

32
and and and and e ee e

35 5
and and and and and e ee e

and and and and e ee e

and and and and and and and and and e ee e

43 e ee 41

18 33 13 4 35
and e ee e and and

twenty-one

and and and and and and and and and e ee e

39.4 55.7 7 2.82 19.7

and and e ee e and and

Attitudes: A1 e Write down observations on the medical record; A2 e Talk about the case with another professional; A3 e Talk to the caretakers responsible for the child; A4 e

Contact the Competent Authorities; A5 e Contact the Police Department; A6 e Talk to the child; A7 e Did not know how to act; A8 e Did not report (ÿ: Uncertainty about the

diagnosis; §: Fear of potential consequences to the child; ¥: Patient confidentiality; 4: Fear of litigation; ÿ: Did not wish to get involved; q: Did not know who to report to); #:

grouped rates of different attitudes; –: data not shown in the article.

the dentists who noticed signs of DVAC reported to the authorities. knowledge of dentists about clinical cases of DVAC. Love et al.,24
Similarly, Andrade Lima et al.,17 Sonbol et al.12 and Harris et al.19 Thomas et al.25 and Harris et al.19 observed that 43%, 73%, and
observed the same situation in 5% out of 27.1%; 12% out of 49.6%; 84% of the dentists, respectively, received education about violence
and 11% out of 37% of the dentists, respectively. These outcomes during the undergraduation or graduation in dentistry. On the
represent an alarming panorama and indicate that dentists may other hand, Manea et al.21 and Fracon et al.26 noticed that the great
detect signs of violence against children, but they do not know how majority of the dentists (91% and 73.7%, respectively) had never
to proceed in this situation. In accordance, Chaim and Gonçalves20 attended classes for child abuse or neglect. Clearly, these different
and Tornavoi et al.4 showed that nearly 62% of dentists do not findings reflect a potential interaction of the type of dental edu-cation
consider themselves able to diagnose cases of DVAC. Oppositely, the provided in different countries. Specifically, a higher number
researches performed by Manea et al.,21 Owais et al.22 and Azevedo of dentists familiar with their role towards the detection of signs of
et al.23 revealed a higher amount of dentists that judged themselves violence against children was observed in the United States24,25 and
able to detect cases of child abuse in the clinical routine (58%, 70%, in the United Kingdom.19 In the United States, the knowledge on
78.7%, respectively). The contradictory scenarios reveal that the domestic violence is remarkably more advanced due to educational
proper management of pediatric patients under domestic violence programs, such as PANDA (Prevent Abuse and Neglect through
remains uncertain. Dental Awareness, Delta Dental, Kansas, USA)9 and an organization
The second topic of interest in the present research was the that empowers professionals for the protection of the children.31
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JLSA Rodrigues et al. / Journal of Forensic and Legal Medicine 43 (2016) 34e41 39

Table 5
Summary of the main results and outcomes found in the eligible studies.

Authorship, Perception Knowledge Outcome

(year)

John et al.16 28% of the respondents suspected of Only 24% of the respondents knew that they are not This study showed a high level of interest by the
(1999) child abuse in one or more of their legally required to report child abuse in Victoria respondents and a strong desire to obtain more
patients. (Australia). However, 74% of them knew that they could information about their legal responsibilities. A clear need
be called to testify in Juvenile Court. for the inclusion of a formal training during the
undergraduate, graduate, and extended education
levels was observed.
Kilpatrick Two groups of respondents were and

Professionals who treated a higher number of pediatric

et al.27 investigated. In the first group, 58% of the patients had more knowledge than general dentists did.
(1999) respondents suspected of child abuse. However, several of the dentists interviewed were
In the second group, 24% of the unwilling to report suspected cases, which is probably
respondents suspected of child abuse. because of the lack of knowledge on child protection
protocols.
Love et al.24 81% of the respondents suspected 43% of the respondents received some type of Oral health professionals could play a vital role to help
(2001) some type of violence against their education regarding violence, either during the individuals exposed to any type of violence by their
pediatric patients. undergraduate education and related courses. relatives.
Andrade Lima 27.1% of the respondents suspected of 97.71% of the respondents considered the topic of Most of the respondents considered the topic of 'child
et al.17 child abuse. 'child abuse' important for clinical practice. abuse' important for clinical practice. However, most of them
(2005) However, he emphasized that the information had never suspected child abuse. From the respondents
obtained in their academic education were who suspected of child abuse, only one reported the case
insufficient. to the Court.
Thomas et al.25 20% of the respondents suspected one 85% of the respondents answered correctly about Approximately one out of five professionals who
(2006) or two cases of child abuse. 1% when to report child abuse and 27% answered participated in this study suspected of child abuse. This may
suspected of three or more cases. correctly about where the report should be made. 40% be emphasized because dentists were not
of the respondents received information on the topic of sufficiently informed about their legal responsibilities and
child abuse during educational programs, 56% obtained especially regarding the reporting of suspicious cases.
information through professional journals, and 33%
had extended education on the topic. 38.58% of the

Chaim and respondents considered 18.90% of the respondents were oriented, either themselves able to Most of the professionals seem to be unprepared to
Gonçalves20 diagnose children during the undergraduate or graduate education and adolescents affected by detect cases of child abuse, and it is possibly related to the
(2006) child abuse. about child abuse. 16% suspected of cases of child lack of training and education in the field.
Manea et al.21 abuse. 91% of the respondents had never attended classes Most of the professionals are unable to manage
(2007) on the topic of 'child abuse or neglect'. 83% of suspicious cases. Education is highlighted as essential to
professionals admitted the need for improving their improve the ability of professionals in recognizing and
knowledge on child abuse. reporting domestic violence against children.
Bankole et al.28 39.4% of the respondents suspected one and

Improvement of education is necessary in the

(2008) or more cases of child abuse. undergraduate, graduate or extended education
programs.
Al-Habsi et al.29 15% of the respondents suspected of at 80% of the respondents revealed that this topic is Professionals need to be more informed about their role in
(2009) least one or more cases of child abuse. extremely important for their work. 79% of the child protection.
sample would like to learn more about the issue. 26%
Harris et al.18 About two in every three respondents had of the respondents reported that child protection A great difference was found between the number of
(2009) already seen a suspected case of abuse. had been included as a class during the undergraduate professionals who suspected of abuse and the ones who
education. 80% of the respondents pointed out the reacted towards child protection. Most of the
need for improved training on child protection. 39% respondents indicated the need for additional
of the education.
Tornavoi et al.5 62% of the respondents considered respondents claimed that they had never received any The knowledge of professionals on the topic of
(2010) themselves unable to diagnose cases of guidance about domestic violence against children. 'domestic violence' is still insufficient. A broader
child abuse. approach of the topic is necessary during the
undergraduate education.
Fracon et al.26 68.43% of the respondents reported the 73.7% of the respondents reported that they never had The respondents considered themselves able to identify
(2010) ability to distinguish an injury derived any orientation on the topic. cases of child and adolescent abuse. However, more
from violence. information and training is still necessary in the field.
Owais et al.22 20% of the respondents suspected at least 97% of the respondents identified sexual abuse The main reasons for the low prevalence of reports on child
(2009) 1 case of child abuse. (92%), neglect and emotional harm (both 84%) as abuse were the uncertainty of the respondents regarding
indicators of domestic violence against children. the detection of suspicious cases and the related
consequences for the children.
Azevedo et al.23 14.3% of the respondents suspected of and

Even with several respondents considered by

(2011) child abuse cases. themselves as able to recognize child abuse, only a small
part of them referred the cases to legal authorities. More
knowledge on the field was pointed out as necessary.
Sonbol et al.12 49.6% of the respondents suspected of 34% of respondents reported having formal training to There is a discrepancy between recognizing signs of
(2011) child abuse. recognize and report child abuse, and 42% abuse in children and correctly reacting to it. Furthermore,
presented qualification on the topic. the knowledge of professionals on the indicators of child
abuse is poor and needs to be improved. The
improvement in education on the field is necessary.
Laud et al.13 48% of the respondents suspected of 21% of the participants were formally trained on the The professionals do not feel properly informed for the
(2013) violence against their patients (13% topic during the undergraduate education and 12% recognition of child abuse cases. There is a great need for
mentioned child abuse and 35% during the graduate education. education on this topic, both during the
mentioned neglect). undergraduate and graduate programs, as well as in
extended education courses.
(continued on next page)
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40 JLSA Rodrigues et al. / Journal of Forensic and Legal Medicine 43 (2016) 34e41

Table 5 (continued)

Authorship, Perception Knowledge Outcome

(year)

Harris et al.19 37% of the respondents suspected of child 29% of respondents received formal training on child The professionals seem to recognize more cases of
(2013) abuse/neglect in one or more of their protection during the undergraduate education. violence compared to remaining literature. However, there
pediatric patients. 55% received information during the graduate are still limitations that indicate the need for improved
education. 15% of the Scottish dentists never had any training.
type of training on child abuse. 3.3% of the
Al-Dabaan 59% of the respondents reported respondents attended classes about child protection The dentists presented proper knowledge regarding the main
et al.30 assisting at least one child with against violence. 94.7% of the respondents signs of child abuse. However, more information is necessary
(2014) suspicion of abuse in the last 5 years. agreed that information on the topic is essential for their on the topic during the undergraduate and graduate education.
education.

Due to the educational approach, it is estimated a growth of 60% in
the prevalence rate of child abuse cases reported by the dentists.9
Oppositely, in Brazil26 and Italy21 most of the dentists revealed that
they never had education in child abuse and neglect. However, these
findings must be interpreted carefully, once even in a single country
(eg: Brazil with nearly 200 million inhabitants) there are strong
discrepancies in the undergraduation programs in Dentistry offered
by the different universities. In most of the cases, dentists may seek
for advanced education in child abuse and neglect in specializations/
master courses in Forensic Dentistry.
From an overview, the difference in the level of education high-lights
the need for a multidisciplinary dental training designed typically at
the interface of public health and Law. Sonbol et al.12 confirmed the
essential role of the multidisciplinary education, showing that dentists
with formal training on child abuse during undergraduation were 3.2
times more likely to report suspicious cases to the competent
of clinical cases of DVAC. Apparently, the limitation is justified by the
lack of a formal multidisciplinary education on Law and social health
during the undergraduation course.
The present research provides scientific evidence to encourage
the implementation of the related training and education for dentists,
highlighting the important role that it may have supporting the justice
and society.
Conflicts of interest
None.
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