Patient Presentation
A 4-year-old female came to clinic for an initial health screening as she had been placed into foster care the day previously after the children had been removed from their home. The very experienced foster mother had been given little information, but said the reason for removal was parental substance abuse and neglect. Her school age sister was coming to a later appointment that day as well. The foster mother said when both arrived, the children and their clothing were dirty but she did not see any infestations. The child had said little since placement and seemed quite wary. The foster mother had been able to bathe her but she would not allow someone to brush her teeth, and she noted that she had bad breath. She also would not eat until the foster parents and other household children retreated away from her. Then she ate quickly and would keep her eyes averted. The foster mother said the older sibling was acting similarly but would answer direct questions for both of them.

The pertinent physical exam showed a very quiet child who would sit next to the foster mother with eyes averted. Over the interview and physical examination she would answer simple questions and would assist the pediatrician. Her vital signs were normal. She appeared thin and her weight was 3rd percentile, height was 25%. Skin examination had some bruises on her shins and dorsal surfaces of arms. She had a couple of healing cuts on her shins but no abnormal skin lesions. Her eyes were normal but she was unwilling or unable to complete the visual acuity examination. Her mouth had intact frenula, obvious brown spots on multiple dental surfaces and her gingiva appeared red and swollen in multiple places. She had obvious halitosis. Her nose was patent without obvious rhinorrhea. Her ears had thick cerumen. Her neck had multiple shotty anterior cervical nodes without other adenopathy. She did allow an inspection of her genitourinary area which appeared normal. The rest of her examination was normal.

The diagnosis of a neglected child who had been placed into foster care and who had dental caries and gingivitis was made. The Department of Health Services was working on providing additional medical information including immunization. The foster mother said that she felt she had the supports she needed to help the child at this point, but that she could use some help with her mouth. Quietly she remarked that this was the worse halitosis she had encountered with a newly placed child. The pediatrician suggested to get a very soft toothbrush and start to brush her teeth regularly with fluoride toothpaste. “I also have some toothettes which I can give you. They are small sponges on a stick that are softer. If the toothbrush is too much for her you can use these the same way. I also can talk with a dentist friend of mine to get her in to see someone relatively quickly,” the pediatrician offered. The mother said she was going to call her dentist when they got home and when she brought the older sibling in the afternoon she hoped to have more health information, both of their immunization records and she would let the doctor know if she needed the dental referral too. “I hope we can make a better plan this afternoon once we both have more information,” she said.

Discussion
Neglect is a form of child maltreatment. It is the chronic failure by the child’s caretaker to meet the child’s basic needs such as food, clothing, shelter and adequate safe-guarding. Failure to also meet medical/dental, emotional and educational needs are also included as neglect. Neglect can be one of the most difficult forms of child maltreatment to identify and/or prove. Presentations for child neglect include:

• No physical or sexual abuse signs
• Abnormal growth pattern or non-organic failure to thrive
• Chronic infections such as diaper dermatitis
• Cold injuries
• Delayed puberty
• Dirty clothes and/or body
• Dental caries
• Infestation such as lice
• Developmental delay or immaturity
• Behavior that is listless, distractable, attention-seeking
• Poor concentration
• Lack of self-esteem or confidence
• Truancy, problems with the law
• Alcohol or substance abuse
• Self-harm

A review of presentations for child maltreatment can be found here.

Learning Point
Oral health is important to overall health. Basic oral health including daily tooth brushing and flossing can prevent many dental problems. Regular, preventative, dental care for cleaning and examination is valuable. Many children may also receive dental sealants to help prevent caries.

Dental plaque is the sticky biofilm that coats the teeth. It is usually colorless and contains bacteria. It is the “fuzzy” feeling on the teeth. It is removed by regular daily dental care. This film is normal (is symbiotic) but can become dysbiotic causing dental disease.

Tartar or dental calculus is calcified dental plaque and is a more serious problem as it can extend under the gingival line. This requires professional dental treatment to remove.

Dental caries are one of the most common infections. They occur when the normal biofilm becomes more acidic and demineralizes the tooth structure. Caries are usually caused by Streptococcus viridans.

Dental abscesses are usually caused by poor oral hygiene but others are at risk because of malformations and deformation of the dental structure or underlying medical conditions. Dental abscess often contain poly-organisms with combinations of anaerobic and fastidious organisms. A review of caries and abscess can be found here

Gingivitis is the infection and swelling of the gingival tissues. Periodontitis is the infection and destruction of the gingival and other supporting tissues of the teeth (especially the periodontal ligament) including potentially bony erosion. Periodontitis also has various definitions depending on the extent, severity and age of patient, although these definitions are used less consistently. There are several different infections that are associated with severe periodontitis including Aggregatibacter actinomycetemcomitans, Polyromanas gingivalis, Tannerella forsythia and Selomonads.

Gingivitis and periodontitis are a continuum of the same inflammatory, infectious process. Depending on the patient “[m]icrobial dysbiosis, overgrowth of pathogenic bacteria, herpesvirus reactivation, immune-system disruption and acquired and/or genetic susceptibility factors are probably involved in disease progression from gingivitis to periodontitis.”

Gingivitis and periodontitis can be prevented and treated if needed. Limited access to professional care is partially associated with the prevalence of periodontal disease.

Treatment needs ongoing professional care including professional cleaning which may be extensive and require anesthetic (local and/or operative), treating active infections, and may need dental surgery for treatment of pocket disease and even bone grafting. Treatment of this gingivitis/periodontitis continuum not only treats the local disease, but also has been shown to have systemic health improvements especially in reduction of processes associated with systemic inflammation, cardiovascular disease and even premature births.

Symptoms of gingival/periodontal disease include:

• Guns that are red, swollen, and sore
• Easy bleeding while brushing or flossing
• Halitosis
• Receding gums (pulling away from the teeth
• Teeth that are loose or have changes in the tooth space (teeth may be separating)
• Loose or separating teeth that show greater than normal spacing
• Bite or tooth alignment changes
• Obvious purulence

Questions for Further Discussion
1. What problems should be considered and screened for in children entering foster care or being internationally adopted? A review can be found here
2. When can children brush their teeth unsupervised?
3. What are indications for dental referral?

Related Cases

Disease: Gum Disease | Child Dental Health | Child Abuse

Symptom/Presentation: Dental Problems | Child Abuse and Neglect and Sexual Abuse

Specialty: Dentistry / Orthodontia | Child Abuse and Neglect

Age: Preschooler

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Gum Disease, Tooth Decay and Child Abuse

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Fine DH, Patil AG, Loos BG. Classification and Diagnosis of Aggressive Periodontitis. J Periodontology. 2018;89(Suppl 1: S103-119.

Botero JE, Rösing CK, Duque A, Jaramillo A, Contreras A. Periodontal disease in children and adolescents of Latin America. Periodontology 2000. 2015;67(1):34-57. doi:10.1111/prd.12072

Orlandi M, Muñoz Aguilera E, Marletta D, Petrie A, Suvan J, D’Aiuto F. Impact of the treatment of periodontitis on systemic health and quality of life: A systematic review. Journal of Clinical Periodontology. 2022;49(S24):314-327. doi:10.1111/jcpe.13554

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa