Case 36

Skateboarding accident?

History of complaint
The childs mother says that he fell off his skateboard and
banged his teeth. The injury occurred yesterday evening
when he was playing at a friends house.

Dental history
The family attend your practice occasionally. The patient
had some primary molars extracted under general anaesthesia 6 months ago and has since missed two appointments
for review.

Medical history
The patient is otherwise fit and well.

What do you need to know about the accident?

SUMMARY
A 6-year-old boy with a facial injury attends late one
afternoon without an appointment. Assess the child
and decide what treatment he needs.

Further details, including the exact time, whether it

was witnessed by others and who was responsible for
looking after him at the time. Was he knocked out when he
fell?
What type of surface did he fall on? Were the abrasions or
mouth contaminated with soil or other dirty material? Is the
patients antitetanus immunization up-to-date?

Examination
Extraoral examination
The child looks anxious and withdrawn. Abrasions are
present on the tip of the nose and the upper lip, as shown
in Figure 36.1. These have a parallel vertical pattern consistent with scraping on a pavement but are not visibly contaminated with debris. When asked if he has injuries
elsewhere, he does not respond at first then shows abrasions
on his knees and elbows.
On examining his face, you notice faint parallel lines of
petechial bruising running horizontally across the left side
of his neck (Figure 36.2) and bruising on both the outer and
inner surface of the right ear (Figure 36.3). No other injuries
are visible on those parts of his arms and legs which are not
covered by clothing.

Intraoral examination
The patients upper anterior teeth and lip are shown in
Figure 36.4.

What do you see?

Fig. 36.1 The patients face on presentation.

History
Complaint
The child complains of loose front teeth and that his mouth
is sore and it hurts to eat.

He is in the early mixed dentition, has poor oral hygiene and

no obvious caries. There are abrasions on the vermilion
border and inner surface of the upper lip. The upper labial
frenum is torn and bruised. The upper left primary central
incisor has bleeding around the gingival margin and is
displaced palatally.
If you were to examine the patient you would find that both
upper primary central incisors are slightly mobile and
tender to pressure. The displaced incisor is not causing
occlusal interference.

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S k at e b o a r din g accid e n t ?

You should already be suspicious about some aspects of

this history. What further information would you ask?
Whether he has already received any medical attention and
why they did not seek dental care sooner. Who was looking
after the child when he was injured?
You should also ask the child himself about the cause of the
injury, particularly allowing him to talk and volunteer
information without asking leading questions.
When you ask the patient what happened to him, he looks
away and says nothing. When you note the marks on the

neck and ear, his mother looks uncomfortable and says, He

fell off a wall last week. Hes very accident-prone.

Investigations
What radiographs would you take and why?
A periapical view of the primary upper incisors should be
taken to show the extent of physiological root resorption, any
displacement or root fractures and the proximity of the
developing permanent incisors. As well as aiding diagnosis
the radiograph will act as a baseline for future monitoring.
If a periapical film is too uncomfortable to hold, an occlusal
view or occlusal taken with a periapical film or detector may
prove more acceptable.

The radiograph is shown in Figure 36.5.

What do you see?
All permanent incisors are present and appear to be relatively
distant from the primary tooth roots. There is resorption of
the upper primary central incisor roots consistent with the
patients age.
There is increased periodontal ligament space and
displacement of the upper left primary central incisor but no
other abnormalities.

Diagnosis
What is your diagnosis?
Facial abrasions, intraoral soft-tissue injuries, subluxation of
the upper right primary central incisor and lateral luxation of
the upper left primary central incisor.

Fig. 36.2 The left side of the patients neck.

The findings are consistent with the history of an accidental

fall from a skateboard but are accompanied by bruises on the
neck and ear which give cause for concern about possible
physical abuse.

Fig. 36.3 The patients right ear.

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Table 36.1 Risk factors for child abuse and neglect

Parental
Parents needing
additional support to
meet childs needs

Social
Families living in
adverse social
environments

Child
Children in need of
additional help to
safeguard their welfare

Young parents

Poverty

Babies and toddlers are most

vulnerable

Single parents

Social isolation

Children with disabilities

Parents with learning

difficulties

Poor housing

Older children, particularly girls,

are more vulnerable to sexual
abuse

Mental health problems

Family violence

Children with behavioural

problems

Drug and alcohol abuse

Fig. 36.4 The mouth at presentation.

Children looked after in foster or

residential care

How certain can you be that injuries are not accidental?

Care must always be exercised when interpreting injuries. It is
important to realize that there are no specific injuries that are
diagnostic of abuse, even though some patterns of injury are
highly suggestive of it. There will almost always be a degree
of uncertainty, especially with the type of injuries presenting
in a dental setting. In all such cases you are likely to be
weighing evidence from a variety of sources and must come
to a judgement yourself. There are no easy answers.

Fig. 36.5 Radiographic image.

What factors in the history make you concerned that this

may be child abuse or neglect?

The history is vague and does not fully explain the

injuries observed.
There was some delay in seeking dental care, without
satisfactory explanation.
There was possibly a lack of adult supervision to ensure
his safety.

Why does the history not explain the injuries?

There are injuries to soft tissues not overlying bony

prominences: in this case the neck and ear.
There are injuries to both sides of the body: the left side
of the neck and right ear.
The pattern of bruising on his neck is suggestive of a slap
mark. There are parallel lines of petechial haemorrhages
between the fingers, where blood was forced out of
capillaries by the force of the slap.
Bruising on both inner and outer aspects of the pinna of
the ear suggests injury from pinching or pulling.
The neck and ear are rarely injured in accidental falls
because they lie in a triangle of safety, protected by the
shoulder and the parietal area of the skull.
You might also have a sense of unease about the boys
behaviour and interaction with his mother. The patient
seems unwilling to talk about the cause of the injury.

A torn labial frenum used to be considered diagnostic of

abuse but it is now recognized that it may also result from an
accident. In this case, accompanied by other intraoral injuries,
it would not, in itself, cause you to suspect abuse. However, if
seen in a young child who is not yet walking, and is therefore
unlikely to have fallen, it is a sign that should always be taken
seriously and discussed with an experienced colleague.

What general risk factors are recognized for child abuse?

Recognized risk factors are shown in Table 36.1. Such features
may be noted during the appointment or identified from
previous knowledge of the family, or be present in your
dental records. They are often very helpful when deciding
how to interpret your findings and in deciding what to do.

Treatment
What dental treatment is necessary?
Advise analgesia as required; the drug of choice in this age
group is paracetamol suspension. Recommend a soft diet.
Give instruction in oral hygiene, including use of
chlorhexidine gel applied twice daily for a week. Advise the
mother to return if there is increasing pain or swelling.
Inform the parent of the possibility of damage to developing
permanent teeth and the need for follow up. Make the first
follow up appointment after 1 week.
Splinting the teeth is unnecessary and would hinder the
recommended oral hygiene procedures.

What else should you do?

The injuries to the mouth were probably caused in a
skateboard accident. They are consistent with this explanation

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S k at e b o a r din g accid e n t ?
You have concerns about a childs welfare

Assess the child:

History
Examination
Talk to the child

Discuss with experienced colleagues

Examples of where to go for help:

Local Safeguarding Children Board/Child Protection
Committee procedures (paper or web-based document)
Safeguarding children advisory service telephone helpline
Consultant paediatrician
Child protection nurse
Childrens services/social services
An experienced dental colleague
Others: the childs health visitor, school nurse or general
medical practitioner

You still have concerns

You no longer have concerns

Action needed immediately

Provide urgent dental care
Talk to the child and parents and explain your concerns
Inform of your intention to refer and seek consent to
sharing information
Refer for medical examination if necessary
Keep full clinical records

No further child protection action

Refer to childrens services,

following up in writing within 48 hours

Other action needed:

Provide necessary dental care
Keep full clinical records
Consider liaison with the childs health visitor or
school nurse
If appropriate, provide information about local support
services for children e.g. playgroups or parenting
courses
Arrange dental follow up

Further action later:

Confirm that referral has been received
Arrange dental follow up
Be prepared to write a report for case conference
Talk your experiences through with a trusted colleague

Fig. 36.6 Flowchart for child protection action. (Adapted with kind permission of Committee of Postgraduate Dental Deans and
Directors (COPDEND) from Harris J, Sidebotham P, Welbury R etal. Child protection and the dental team: an introduction to
safeguarding children in dental practice. COPDEND: Sheffield, 2006. Available online at: www.cpdt.org.uk.)
and accompanied by injury on the elbows and knees.
However, there are unexplained injuries on the neck and ear.
You need to decide what must be done about these
additional injuries.
It is often helpful to discuss the case with a suitably
experienced colleague or advisor, such as a nurse or social
worker from the local safeguarding children advisory service.
Telephone numbers for advice and referral should be
available in the practice. A flowchart to guide your actions is
shown in Figure 36.6.
It is likely that in this case you would be advised to make an
immediate referral to childrens services (alternatively known

as social services). A full assessment of the child is needed to

determine whether the unexplained injuries have occurred as
part of a pattern of sustained and deliberate child abuse or
may be the result of momentary loss of control by a
frustrated parent (or other individual inside or outside the
family). This child may urgently need protection or,
alternatively, the family may need advice and support.

What do you say to the child and parent?

Explain that you are concerned about the marks on his neck
and ear and that you need to arrange for someone else to
look at him. Ask consent to phone childrens services to share

S k at e b o a r din g accid e n t ?
this information. If the parent questions whether this is really
necessary you will need to stand your ground and give
further explanation. You should explain that your
responsibility is not simply to help with the health of the
boys teeth but you also have a responsibility for his general
welfare and safety, and you recognize that his mother will
want that too. Research shows that being open and honest
from the start results in better outcomes for children.

Are there any circumstances in which you would not discuss

child protection concerns with the parents?
Whilst it is generally considered good practice to explain your
concerns to the child and parents, there are certain
exceptions:

Where discussion might put the child at greater risk

Where discussion would impede a police investigation or
social work inquiry
Where sexual abuse by a family member, or organized or
multiple abuse is suspected
Where fabricated or induced illness (formerly known as
Munchausen syndrome by proxy) is suspected
Where parents or carers are being violent or abusive, and
discussion would place you or your staff at risk
When parents or carers are not present and it is not
possible to contact them without causing undue delay in
making the referral.
In these circumstances, first seek advice from your dental
defence organization or from senior child protection
professionals. Reasonable judgement must be made in each
case.

What do you do next?

Phone childrens services to make a child protection referral.
You will be asked to give the full name of the child, date of
birth, address, gender, school and the name of the person(s)
with parental responsibility. Discuss your concerns and agree
what will happen next. Agree with the social worker what you
will tell the parent and child and what will happen next.

Anything else to remember?

You need to keep comprehensive contemporaneous clinical
records including any explanation given by the parent and
child in their own words. You should include both a written
description and a diagram of the injuries. Differences
between fact and your opinion should be clearly stated. You
should include a summary of the discussions with the child
and parent.
If other members of the dental team have been involved,
they also should record their observations.

What action is required later?

The telephone referral must be followed up in writing within
48 hours. Childrens services should confirm receipt of the
referral, decide on the next course of action and give
feedback to you.
If you hear nothing, you should telephone again to confirm
that your referral has been received and acted upon. You
should be prepared to write a report for a child protection
case conference if requested to do so. You will also need to

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ensure that the child receives a follow up dental

appointment.
It is important to acknowledge that involvement in child
protection cases can be distressing. If necessary, take time
to talk through your experiences with a trusted colleague
or seek further advice from the safeguarding advisory
service.
Research shows that dentists do not always respond
effectively when they recognize signs of child abuse and
neglect. This is a serious matter: it may be some years before
another opportunity arises for someone to take action to
protect the child from the misery of ongoing maltreatment.
Furthermore, to ignore suspicions about abuse could result
in a complaint against you and may put your registration
at risk or lead to a professional negligence claim. The
General Dental Councils ethical standards guidance makes
it clear that all members of the dental team must follow
local child protection procedures if you suspect that a child
might be at risk because of abuse or neglect.
When dentists are asked why they do not follow child
protection procedures correctly, they often say that they
want to be really certain before taking action. You can be
reassured that the responsibility for making a diagnosis of
abuse is not something you have to shoulder alone but is
always shared by a multi-agency team. Discuss your concerns with the experts and refer early.
Do not fear that the family will suffer drastic action.
Children are only removed from their families when there
is no safe alternative. Emphasis is given to supporting the
family to protect their own children.
You may be concerned about possible litigation if you
get it wrong, yet the law places the childs welfare as paramount and protects health professionals who make child
protection referrals in good faith. This is a challenging area
of practice but expert help is available.

Is dental neglect abuse?

Child abuse is defined in four categories: physical abuse,
emotional abuse, sexual abuse and neglect. Abuse or neglect
may be by inflicting harm or by failing to prevent harm.
Recently there has been increased interest in whether severe
untreated dental disease indicates neglect and should
prompt a child protection referral.
Under the United Nations Convention on the Rights of the
Child 1989, children have a right to the enjoyment of the
highest attainable standard of health and to facilities for the
treatment of illness and rehabilitation of health. To enjoy
optimal oral health, children need their parents to provide a
suitable diet, facilities for and help with oral hygiene, and
access to dental treatment when needed. There is no doubt
that oral disease can have a significant impact on a childs
general health and can cause pain, loss of sleep, and even
poor growth and quality of life. Once dental problems have
been explained to parents or carers, and appropriate and
acceptable dental treatment has been offered to restore oral
health, the following would be of concern:

Repeated missed appointments

Failure to complete planned treatment
Repeatedly returning in pain

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Requiring repeated general anaesthesia for dental

extractions.
Preschool children are particularly vulnerable and, in such
cases, it is recommended that you should contact the childs
health visitor to discuss how you might work together to
support the family to ensure that the childs needs are met.
This contributes to safeguarding children, namely, not only
protecting children from abuse and neglect, but taking a

wider range of measures to promote their health and

development and minimize risks of harm. In the vast majority
of cases, lack of knowledge and difficulty accessing care
account for the apparent neglect. However, if a child is
already suffering significant harm from untreated dental
disease, it will be necessary to make a child protection referral
without delay.