Journal of Child & Adolescent Trauma (2020) 13:299–303

https://doi.org/10.1007/s40653-019-0247-y

BRIEF REPORT

Dental Neglect
Lora Spiller 1 & James Lukefahr 1 & Nancy Kellogg 1

Published online: 4 February 2019

# Springer Nature Switzerland AG 2019

Abstract
Dental neglect can be an indicator of general child neglect. Inadequately treated dental disease may have significant long-term
impacts on the physical and psychological well-being of children. Primary care providers play a critical role in the prevention of
dental neglect, and should be aware of the manifestations of dental caries and dental trauma. When diagnosing dental neglect,
health professionals should ensure the child’s caregivers have demonstrated an understanding of the condition, its consequences,
and the recommended treatment and then failed to comply with the treatment. Attempts should be made to eliminate any barriers
preventing caretakers from complying with professional advice. Dental neglect is a form of child maltreatment and, if suspected,
should be reported to the appropriate child protective agencies.

Keywords Child maltreatment . Medical neglect . Physical neglect . Early childhood caries . Untreated dental caries . Untreated
dental trauma . Oral hygiene . Child protective services

Dental neglect is the Bwillful failure of a parent or guardian
to seek or follow through with treatment necessary to en-
sure a level of oral health essential for adequate function
and freedom from pain and infection,^ as defined by the
AAPD (American Academy of Pediatric Dentistry 2010).
Higher levels of tooth decay can be found in abused and
physically neglected children compared to those in the
general population (Valencia-Rojas et al. 2008). Greene
et al. (1994) found that children with a history of abuse
were eight times more likely to have untreated caries in-
volving permanent teeth compared to non-abused children.
Although dental neglect may exist in isolation, inadequate-
ly treated dental disease can be an important indicator of
broader child neglect (Bradbury-Jones et al. 2013).
Dentists and other health professionals are often hesitant to
report suspected cases of dental neglect due to a lack of cer-
tainty about the diagnosis or fear of consequences from
reporting, including potential impact on their practice and
possible litigation (Welbury et al. 2003; Al-Habsi et al.
2009). Other factors affecting clinicians’ decisions to not
* Lora Spiller
spillerl@uthscsa.edu
1 main source of Streptococcus mutans in infants are the
Department of Pediatrics, Division of Child Abuse Pediatrics,
University of Texas Health San Antonio, Center for Miracles, 315 N.
San Saba Street, Suite 201, San Antonio, TX 78207, USA
report suspected cases of maltreatment include concerns for
compromising the patient/family-physician relationship and
doubts regarding the benefits of reporting to child protective
services (Jones et al. 2008). Flaherty et al. (2008) demonstrat-
ed that not all suspicions of child maltreatment are reported,
even when the level of suspicion is high. This, along with the
paucity of studies on dental neglect, raises concern that this
important aspect of child maltreatment is often under-detected
and under-reported (Bhatia et al. 2014). Recognizing and
reporting dental neglect is important as it may be an early sign
of general physical neglect in addition to a potential cause of
significant pain and a loss of oral function (Acs et al. 1992;
Bradbury-Jones et al. 2013).
Types of Dental Neglect
Untreated Dental Caries Caries is considered an infectious
disease, most commonly associated with Streptococcus
mutans. These bacteria adhere to the tooth’s enamel, produce
acid and decrease the pH, causing demineralization (Loesche
1986). Consumption of carbohydrates, especially sucrose,
plays a large role in the development of caries, as the bacteria
ferment these sugars to produce an acidic environment. The
mothers, with vertical transmission (passing the bacteria from
a caregiver through saliva) or horizontal transmission (passing
300
the bacteria between various family members or close con-
tacts) (Douglass et al. 2008; Van Loveren et al. 2000).
Initially, white spot lesions appear on the enamel, followed
by cavitation as the tooth continues to demineralize. There is a
characteristic pattern of decay that can be attributed to the
eruption sequence of primary teeth, and therefore, the amount
of time they are exposed to decay-causing substances. The
upper primary incisor teeth are the most severely affected,
and can lead to amputation of the tooth at the gingival crest
(Fig. 1). The primary first molar teeth are typically the subse-
quent teeth affected, followed by the primary second molars
and canines. Although the primary lower incisor teeth are nor-
mally the first to erupt, they are the teeth least likely to decay
due to their position in the mouth, protected by the tongue
when sucking and by copious salivary secretion from the near-
by submandibular salivary gland ducts (Raphael 1999).
The failure to provide treatment for carious teeth is the most
common type of dental neglect (Christian and Mouden 2009).
Since the 1970s, the prevalence of dental caries in children has
declined; however, it remains the most prevalent chronic dis-
ease of childhood (U.S. Department of Health and Human
Services 2000). Early childhood caries (ECC), previously re-
ferred to as Bnursing bottle caries^ and Bbaby bottle tooth
decay^, is a disease commonly found in neglected children.
The AAPD defines ECC as Bthe presence of one or more
decayed (noncavitated or cavitated lesions), missing (due to
caries), or filled tooth surfaces in any primary tooth in a child
under the age of six^ (AAPD 2014, p. 60). These findings
typically result from habitually placing a child in bed with a
bottle or allowing the child to fall asleep while breast feeding.
Prolonged nocturnal breast-feeding can be harmful to primary
teeth due to the decreased rates of salivation and swallowing
during sleep, prolonging the contact milk has with dental sur-
faces. The development of caries is also associated with
breastfeeding more than seven times daily in toddlers older
than 12 months of age (Feldens et al. 2010).
Untreated Dental Trauma A failure to seek treatment after
trauma to the mouth can also be considered dental neglect.
Fig. 1 Severe early childhood caries with amputation at the gingival
crest. (Courtesy Jeffrey Mabry, DDS)
Journ Child Adol Trauma (2020) 13:299–303
Up to 75% of injuries in physically abused children involve
the head and neck region (daFonseca et al. 1992). Those inju-
ries involving trauma to the oral cavity can be characterized in
three groups: injuries to the teeth, injuries to the soft tissue,
and injuries to the jaw including fractures of the mandible or
maxilla. Approximately 10% of children between the ages of
18 months and 18 years experience significant tooth trauma
(Tinanoff 2011). Children between the ages of one and three
are most likely to sustain injuries to teeth from falls or physical
child abuse. Tooth injuries may involve the hard dental tis-
sues, the dental pulp (nerve), or the periodontal structure
which includes the surrounding bone and attachment appara-
tus. As with cases of ECC, the teeth most commonly affected
in cases of dental trauma are the maxillary incisors. If fractures
of the teeth involve the pulp, they are considered complicated,
as opposed to dental fractures which are confined to the hard
tissues. Bacterial contamination is possible when the pulp is
exposed, leading to infection with a periapical abscess or pulp
necrosis. These teeth may appear to be bleeding or have a
small red spot (Fig. 2). Complicated fractures typically require
root canal therapy. The normal development of the permanent
dentition can be affected by these injuries to the primary den-
tition. Therefore, it is often necessary to extract primary
incisor teeth if they have sustained a significant injury.
Any tooth trauma should be evaluated by a dentist as soon
as possible to assess the probability of any future compli-
cations, which include infection and deleterious effects to
permanent teeth. Fractures involving the pulp require im-
mediate referral to dentistry, with the goal of minimizing
contamination in order to improve the prognosis (Josell
and Abrams 1991; Tinanoff 2011).
Trauma to the teeth may involve the periodontal structures.
These injuries are more common in primary teeth compared to
permanent teeth, and typically manifest as teeth that are mo-
bile or displaced following a traumatic injury. Concussions
result from minor damage to the periodontal ligament, and
cause tenderness but no movement of the tooth. Primary inci-
sors that have sustained a concussion may become discolored
as a result of pulpal degeneration. Subluxations are more
Fig. 2 Complicated fracture of a maxillary central incisor. (Courtesy
Jeffrey Mabry, DDS)
Journ Child Adol Trauma (2020) 13:299–303
significant injuries and typically manifest with hemorrhage
surrounding the neck of the tooth at the gingival margin.
Subluxated teeth demonstrate horizontal and/or vertical mo-
bility without displacement of the tooth. In order to ensure
proper repair of the periodontal ligament, a subluxated tooth
may require immobilization with a splint. Pulp necrosis with
tooth discoloration can develop following a subluxation.
Intrusions result when teeth are impacted into their socket.
An x-ray is necessary in these cases to differentiate intrusion
from avulsion, as these severely intruded teeth may have a
knocked-out appearance and the tooth may appear to be ab-
sent. Extrusions occur when the tooth is partially displaced
from its socket, typically toward the tongue, involving fracture
of the wall of the alveolar socket. Without immediate treat-
ment, extruded permanent teeth will likely become fixed in
the displaced position. Extruded primary teeth usually require
extraction, as repositioning and splinting of the affected tooth
may negatively affect the development of the permanent teeth
(Tinanoff 2011).
Consequences of Dental Neglect
ECC is an aggressive disease and has the ability to quickly
cause cavitation in demineralized teeth. The dental pulpal tis-
sue can become infected, which can then penetrate the alveo-
lar bone and gingiva, resulting in an abscess (Fig. 3). In more
serious cases, there may be fascial plane involvement which
has the potential to be life-threatening (AAPD 2014). ECC
can also cause developmental defects of enamel in succeeding
permanent teeth (Broadbent et al. 2005).
ECC is associated with dental pain and difficulty eat-
ing with a loss of oral function leading to negative ef-
fects on nutrition and weight (Acs et al. 1992). The
effects of dental neglect also lead to difficulty sleeping
and poor performance in school in addition to disfigure-
ment, resultant low self-esteem, with an overall compro-
mise in quality of life (Ramazani 2014; Blumenshine
et al. 2008). Poor dentition, including untreated maloc-
clusion, has been associated with bullying in school
Fig. 3 A well-circumscribed and fluctuant tooth abscess involving a
maxillary incisor. (Courtesy Jeffrey Mabry, DDS)
301
children, which can result in long-term psychological
consequences (Al-Omari et al. 2014).
Dental extraction is often required when carious teeth be-
come painful or infected, putting victims of dental neglect at
risk for complications associated with general anesthesia,
which is often required for operative procedures in small chil-
dren. The premature loss of primary teeth can result in many
occlusion problems including space loss, rotated or misplaced
adjacent teeth and the need for antagonist tooth extrusion
(Lourenço et al. 2013).
Diagnosis of Dental Neglect
Differentiating dental caries from dental neglect is difficult.
There is no evidence to support a threshold number of caries
in order to diagnose dental neglect. Common features of den-
tal neglect include a failure to provide basic oral care (oral
hygiene, proper diet, and establishment of a dental home),
failure to seek treatment for oral pain, and untreated infection
(Noble et al. 2014). Once dental pathology is identified, a
history of missed appointments indicating a lack of continuity
of care supports dental neglect (Raphael 1999). The presence
of untreated, rampant caries should cause a medical provider
to consider the possibility of dental neglect, taking into con-
sideration that the presence of caries may reflect a lack of
caregivers’ knowledge or resources rather than a neglectful
attitude (Souster and Innes 2014). The lack of perceived value
of oral health can explain a caregiver’s failure to seek appro-
priate dental care, as many individuals do not acknowledge
the importance of primary teeth and may even consider dental
decay as an unavoidable natural phenomenon (Lourenço et al.
2013; Stevens 2011).
Screening questions for children when assessing for dental
neglect should include the following:
& Do you have any problems eating certain foods, like hard,
cold, hot, or chewy foods?
& When do you brush your teeth?
& Does anyone help you brush your teeth?
& Do you ever get teased or bullied at school?
& What do they tease you about?
& Have you ever hurt any of your teeth?
Screening questions for parents when assessing for dental
neglect should include the following:
& Does anyone in your family have a history of dental
problems?
& When was the last time anyone in your family went to the
dentist?
& Has your child ever been to a dentist?
& What have you noticed about your child’s teeth?
302
& Do you brush your child’s teeth?
& Does your child ever have a bottle or sippy cup in bed?
& Have you ever noticed bleeding from anywhere in your
child’s mouth?
A thorough oral examination is an essential component of a
child’s physical exam. When examining an apprehensive
younger child, a useful technique is to place the child in the
caregiver’s lap facing the caregiver, and the child’s head is
reclined into the examiner’s lap while the caregiver holds the
child’s hands. A systematic approach should assess the fol-
lowing: integrity of the enamel, presence of caries, appearance
of the gingivae, and the appearance of the frenula. A tongue
depressor, light source, and a gloved hand may be used to
ensure adequate visual access to all of the intraoral areas. If
a lack of appropriate weight gain is noted in association with
poor dentition, the physician should consider oral pain as a
factor.
Caregivers should be considered negligent when they
have been properly informed of the extent of the child’s
condition by a health care professional, demonstrated un-
derstanding of important dental instructions and treat-
ment, and failed to comply with important medical/
dental advice. This information should also include the
specific treatment needed and clear instructions on how
to access that treatment (Berger and California Society of
Pediatric Dentistry 1989). If bullying is identified, the
framework presented by Lyznicki et al. (2004) for ap-
proaching bullying with patients and parents can be help-
ful. If socioeconomic barriers exist, efforts should be
made to assist families in finding financial aid and trans-
portation for the recommended healthcare services. If
caregivers fail to follow through with treatment despite
these efforts, and after healthcare providers have made
reasonable effort to ensure that caregivers fully under-
stand the disease and the possible consequences, the
caregivers should be reported to the appropriate child
protective services agency (Berger and California
Society of Pediatric Dentistry 1989).
Prevention
Children should be referred to a dentist to establish a dental
home within 6 months after the first tooth eruption, but no
later than 1 year of age. Eighty percent of 3 to 4 year old
children have met the number of well-child visits recommend-
ed by the American Academy of Pediatrics, compared to the
26% who have met the number of dental visits recommended
by the American Academy of Pediatric Dentistry (Yu et al.
2002). Primary care providers, therefore, have the opportunity
to play a critical role in the promotion of oral health and the
prevention of dental neglect. The 20% of 3 to 4 year old
Journ Child Adol Trauma (2020) 13:299–303
children who do not receive regular medical care are at an
increased risk for dental neglect.
New parents should be instructed to avoid: the use of a
bottle as a pacifier, allowing an infant or toddler to fall
asleep with a bottle containing decay-causing substances
such as milk or juice, and frequent consumption of sugar-
containing drinks and snacks. Teeth should be cleaned
regularly as soon as they erupt, typically around 6 months
of age. This can be accomplished by wiping a child’s
teeth and gums with a damp cloth, followed by the intro-
duction of a soft toothbrush around 12 months of age.
Twice-daily brushing with fluoridated toothpaste reduces
the risk for development and progression of caries. An
adult’s supervision is necessary up to the age of seven,
as children in this age group lack the manual ability to
effectively brush their teeth alone (Lourenço et al. 2013).
Children less than 3 years of age should receive a Brice-
size^ amount of fluoridated toothpaste, which is approxi-
mately 0.1 mg fluoride. Children between the ages of 3
and 6 years of age should receive a Bpea-size^ amount of
fluoridated toothpaste, which is approximately 0.25 mg
fluoride. In order to maximize the beneficial effect of
the fluoride, rinsing the mouth after brushing is not en-
couraged. Early preventive interventions are critical, as
caries-conducive dietary practices are established by
12 months of age (AAPD 2014). In addition to health
professionals, other child professionals, such as those in-
volved in child welfare and school counselors, may also
contribute to the prevention and identification of dental
neglect by using the recommended screening questions.
Conclusion
Dental neglect is a common but under-recognized condi-
tion of childhood. Clinical presentations include untreat-
ed caries and untreated dental trauma, which can signif-
icantly impact a child’s function, appearance, comfort,
and quality of life. Clinicians have the opportunity to
prevent these common and deleterious outcomes by im-
proving detection and optimizing treatment of childhood
dental diseases and injuries.
Acknowledgments The authors thank Dr. Jeffrey Mabry, DDS for pro-
viding the included photographs.
Compliance with Ethical Standards
Disclosure of Interest On behalf of all authors, the corresponding author
states that there is no conflict of interest.
Publisher’s Note Springer Nature remains neutral with regard to jurisdic-
tional claims in published maps and institutional affiliations.
Journ Child Adol Trauma (2020) 13:299–303
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