Dentist Abuse Knowledge and Awareness Results

 Kaur et al. (2014) focused on the case of India and involved 120 registered general dentists. Considering the statistics for the actual abuse, 69.5% of observed cases involved girls, and low socioeconomic status was associated with 77.1% of abuses. The survey focused on dentists` awareness and studied their understanding of abuse signs. The research reveals that 89.7% of participants reported they could differentiate between an abuse and a common injury, and 60.7% detected at least one case of child abuse. Though, Mathur and Chopra (2013) point out that in general, Indian society lacks a comprehensive understanding of the problem.

Results obtained by researchers in India reveal relatively high knowledge of dental practitioners. The second highest result in dentists` knowledge is reported by the study by Azevedo, Goettems, Brito, et al. (2012) in Brazil with 78.7%. However, in this study, only 14.3% of practitioners faced such cases during their practice, and only 24% of those reported the case to authorities. Then, in Saudi Arabia, 73.3% of researched dentists were aware of the abuse signs in the oral cavity and claimed they can distinguish them from an occasional injury (Al-Dabaan, Newton, & Asimakopoulou, 2014). As in the other studies, out of 71 (59%) dentists who experienced such cases, only 10% made a report. Then, Bankole, Denloye, and Adeyemi (2008) present results of similar research in Nigeria indicating that 61.7% of dentists recognized a case of abuse in children. Researchers also admit that abuse of females is more common than in males (Bankole et al., 2008). In the United Arab Emirates, a quarter of respondents detected such cases, and only 30% of those reported to authorities (Hashim & Al Dallal, 2018).

Relatively low levels of reporting the cases of detected child abuse to authorities characterize all of the studies of dentists` awareness regardless of the country of research. The role of education is proved to be crucial this question by some studies. Continuing education is associated with higher detection levels among dentists (Hashim & Al-Dallal, 2018). Some researchers also emphasize the dentists` eagerness to learn and improve their skills and understanding in this area. For example, according to Al-Dabaan et al. (2014), dentists report the need for continuing education. Hence, such studies reveal the gap in dentists` knowledge and provide implications for education and learning. The research by Thomas, Straffon, and Inglehart (2006), which involved 233 dental students, illustrates a clear lack of relevant knowledge in students. While the dominant majority reported having studied the subject at school, only 5.5% could define child abuse, 32.2 did not know about their responsibility of reporting, and 82.4% were not aware of where actually to report. The following discussion of their attitudes, perceptions and existing barriers to reporting can clarify the presented information.

Practitioners` Perceptions and Attitudes

Having the right perception of and attitudes to child abuse observed in the oral cavity can help dentists to diagnose and report the case. The perceptions identify the preparedness of a dentist to see the problem. The attitude also defines if a practitioner will be ready to report the case of abuse to the relevant authorities. There are different factors that can affect dentists` reporting frequency. According to Azevedo et al. (2012), some factors that are correlated with the higher detection rates are regular (more than once a month) encounters with underage patients and private rather than public practice. The uncertainty of a diagnosis is a commonly cited reason which affects a dentist`s attitude to a case of child abuse and its reporting (Azevedo et al., 2012; Hashim & Al-Dallal, 2018).

Although rates of reporting cases of abuse are not high, research illustrates that dentists, in general, recognize their responsibilities regarding child abuse. According to Hashim and Al-Dallal (2018), the majority of dentists involved in research recognize their legal responsibility to report. Then, Garrocho-Rangel, Márquez-Preciado, Olguín-Vivar, et al. (2015) illustrate a case of collaborative dentists` efforts to provide treatment to a girl who had been sexually abused. While the case had been already revealed, dentists needed to develop an elaborate approach to a reluctant 6-year old female patient, for instance, positive reinforcement, voice modulation, and even gifting. The example underpins the need to address children`s related psychological trauma.

While injuries, like bruises, hematomas, or lesions, are obvious signs of abuse, there is also emphasized the role of behavioral markers in underage patients. Costacurta, Benavoli, Arcudi et al. (2016) point out that some behavioral signs may illustrate the case of sexual abuse experienced by a child. Such examples are defensive behavior and reluctance to oral cavity observations. Azevedo et al. (2012) stress the role of not only a child`s behavior but also the parent-child interaction, which may help a dentist to solidify any suspicions regarding abuse. In addition to these factors, Brattabø, Bjørknes, and Åstrøm (2018) emphasize such factors, which do not relate to injury in particular, like the refusal of treatment and abnormal behavior. At the same time, researchers indicate that the presence of a child`s abnormal behavior mentioned in a report to authorities resulted in a lesser rate of being investigated (Brattabø, et al., 2018).

The attitudes of dentists are also shaped by a general perception of the question in society. For instance, Brattabø et al. (2018) reveal that the occurrence of such cases in media, education, and authorities may be associated with a higher case of reporting as it happens in Sweden. However, it is not the main determinant, because, for example, in Norway, such cases are less frequently highlighted, but this does not undermine the dentists` ability to detect child abuse. Hence, the personal attitudes of dental practitioners are deemed defining.

Barriers to Reporting Abuse

An important step of dentists, who detected child abuse, is reporting such cases to the relevant authorities. However, the researched literature reveals that there exist various barriers to reporting, which include a lack of knowledge, uncertainty, and perceptions. The rates of reporting among those dentists who detected at least one case range from as low as 10% (Al Dabaan et al., 2014) to 30%, which also is not a high indicator (Hashim & Al Dallal, 2018). There are obviously present some barriers which prevent dentists from fulfilling their legal obligation to report a case of child abuse.

Considering the barriers to reporting, there are identified diverse factors relating to their perceptions, diagnosis uncertainty, reluctance to have complications, or the lack of knowledge and instructions. One barrier on the way to reporting is the lack of education and knowledge about such responsibility or relevant authorities. Kaur et al. (2014) revealed that the lack of relevant knowledge of their role prevented dentists from reporting in 43.9% of cases. In research by Sonbol, Abu-Ghazaleh, Rajab, et al. (2012), this barrier was named by 41% of surveyed dentists. Hashim and Al-Dallal (2018) identify a similar barrier of not knowing the legal procedure and authorities to refer among dentists. Such a barrier exists even in the United States, although the laws of all states mandatory require dentists to report child abuse (Katner & Brown, 2012).

A related barrier reported in the literature is the uncertainty of dentists regarding their diagnosis, which results in a hesitancy to report. In the study by Hashim and Al-Dallal (2018), this barrier was reported by 33% and was the most common. However, in research by Al-Dabaan et al. (2014), this reason was at the second place cited by dentists, and it was reported by 79% of practitioners.

Additionally, in 42.1% of cases, dentists named the absence of relevant history or a precedent as their reason not to report (Kaur et al. 2014). As a result, the lack of social perception and precedents prevent dentists from creating such crucial precedents. Perceptions of dentists also affect the issues, as they often do not believe that the necessary protective measures would be undertaken (Azevedo et al., 2012). Owais, Qudeimat, & Qodceih (2009) even report a position that “it is not the dentist’s responsibility” by 22% of respondents in Jordan (p. 293). The researchers also point out the barrier of not having the relevant history in 76% of cases (Owais et al., 2009).

Another major barrier is associated with the fears of any further complications and problems which may affect a dentist`s career. It is revealed by researchers that being apprehensive about the influence of such a report on the specialist`s further professional practice translated in 14% of non-reporting cases (Kaur et al. 2014). Hashim and Al-Dallal (2018) point out that the fear of violence on behalf of a child`s family was a reporting barrier in 17.7% of cases in Dubai. On the contrary, according to Al-Habsi, Roberts, and Attari (2009), the fear of consequences not for a dentist but for a child was a reason of non-reporting in 79% of cases studied in London. In research by Al-Dabaan et al. (2014), which was conducted in Saudi Arabia, the fear to inflict any negative consequences on a child was cited by 87.7% of dentists as a barrier to report.

It can be seen that there is a wide range of factors that create barriers to reporting the case of child abuse to authorities. However, in researches conducted across the countries, different causes are put at the first place, depending on cultural perceptions and social factors. The impact of precedents on dentists` actions also emphasizes the need to make the cases of reporting publicly known and information more easily accessed and disseminated. Rising general public awareness about the issue is important. Communication between dentists and social care workers is advised (Harris, Elcock, Sidebotham, et al., 2009).

Transmission of Diseases

Child abuse in the oral cavity is associated not only with physical and psychological abuse, but it may also be a cause of serious diseases. The abuse may even lead to the development of sexually transmitted diseases. According to Nilchian, Sadri, Jabbarifar et al. (2012), the oral cavity can become a point of child sexual abuse, but the signs of such abuse are typically not easily detected. However, registering such abuse may become more facilitated for a dentist when there are observed symptoms of some sexually transmitted disease. Signs of such diseases can be detected on a child`s skin of an oral cavity as well as at the mouth (Kos & Shwayder, 2006). Percinoto, Danelon, and Crivelini et al. (2014) discuss a case of a child with symptoms of Condyloma acuminata in the oral cavity and highlight the present challenges. One of them is the reluctance of parents or guardians to report the case because some relatives are most often involved as perpetrators. Understanding the outcomes of child abuse, like diseases and specific signs in the oral cavity, can help to cure the abused children properly (Costacurta, et al., 2016).

Conclusion

To summarize, detection and reporting child abuse in the oral cavity presents a challenging case for dentists. Understanding the routines dentists should use to detect, diagnose, and report child abuse in the oral cavity can be helpful in the prevention of such cases and prosecution of wrongdoers. The reviewed literature contributes to the clearer realization of the knowledge and awareness of dentists across the world. Examples derived from Brazil, India, Iran, Saudi Arabia, Jordan, England, and United Arab Emirates. There are discussed reasons encouraging and preventing practitioners from reporting child abuse cases. The main barriers reported in the literature review are lack of relevant knowledge, hesitancy in diagnosis, and fears regarding the impact on a professional career and on a child. Implications for dentists` education and instruction are provided. 

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