A Textual Analysis of Dental Neglect in

the Child Abuse User Manual Series

Arthur Begotti Silva To determine how dental

Division of Pediatric Dentistry
neglect has been historically,
Nemours Children’s Health
and is currently, conceptual-
Stephanie Anne Deutsch ized in the Child Abuse and
Nemours CARE Program
Neglect User Manual Series, a
Nemours Children’s Health
textual analysis was performed
Katheryn Goldman of the new/revised and the
Division of Pediatric Dentistry
1990s versions of the series.
Nemours Children’s Health
The term “dental neglect” was
never specifically mentioned,
and often the concept of dental neglect was grouped within medical
or generalized child neglect.

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C hild neglect is broadly defined as “the failure of a parent or other

person with responsibility for the child to provide needed food,
clothing, shelter, medical care, or supervision to the degree that the
child’s health, safety, and well-being are threatened with harm” (Child
Welfare Information Gateway, 2022, p. 3). This definition is not uni-
versal but rather serves as an overarching guidance as each jurisdiction
within the United States has its own definition of neglect. As a form
of child neglect, dental neglect is defined by the American Academy
of Pediatric Dentistry (AAPD, 2020, p. 16) as “willful failure of parent
or guardian to seek and follow through with treatment necessary to
ensure a level of oral health essential for adequate function and freedom
from pain and infection.” The concept of dental neglect is also vaguely
defined both in the literature and within the law. Khalid and colleagues
(2021) note that the prevalence of dental neglect worldwide ranged
from 34% to 56%; however, estimations reported in the literature may
be inaccurate due to frequent synonymous use of dental neglect and
poor oral health terminology in the literature. Furthermore, caregiver
malintent is rarely parsed out, rendering it difficult to interpret true
estimates of dental neglect.
Burgette and colleagues (2020) conducted an interjurisdictional
comparison of statutes and regulations involving the reporting of child
dental neglect by dentists. The study identified child neglect laws in 51
jurisdictions, including all states and the District of Columbia. However,
it was concluded that only eight jurisdictions mentioned dental in their
definitions of neglect. Furthermore, while eight states mentioned den-
tal in their definitions, none of the jurisdictions adopted the AAPD’s
definition of dental neglect (Burgette et al., 2020). Because of the vari-
ability of the definition of dental neglect within the United States, it
is important to begin to understand how dental neglect is conceptual-
ized within child welfare as child welfare professionals respond to and
investigate cases of child abuse and neglect.
There is a scarcity of research that deals with the intersection of
child welfare and dentistry. While dental neglect is often grouped

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into medical neglect, non-dental professionals do not always have

the training or comfort to identify dental neglect (Whyatt & Barry,
2022). Bradbury-Jones and colleagues (2021) note that while the rela-
tionship between poor oral health and child maltreatment is evidenced,
even with local-level policy and practice development that seek to
improve interprofessional collaboration with dentist and social work
professionals, there is widespread evidence to suggest that the oral
health needs of these children are not consistently met.
Therefore, it is essential that dental professionals collaborate with
child welfare professionals to help better prepare them to appropriately
address cases of dental neglect. One important guide that aids in the
identification of, prevention of, and response to child maltreatment is
the Child Abuse and Neglect User Manual Series. These documents directly
inform child welfare practice and serve as an overarching resource for
child welfare professionals. This study performed a textual analysis of
the Child Abuse and Neglect User Manual Series to help determine how
dental neglect has been historically and is presently conceptualized in
the documents to understand how dental neglect can be better incor-
porated into child welfare practice.

Methods
The study completed a textual analysis of the Child Abuse and Neglect
User Manual Series (see Table 1). The series is published by the U.S.
Department of Health and Human Services’ Administration for
Children and Families and is meant to serve as a foundational tool to
provide both knowledge and practice guidance surrounding child abuse
and neglect to child protective service caseworker and community part-
ners and professionals in law enforcement, the legal system, domestic
violence, health care, mental health care, and substance abuse, as well
as child care and education. The study employed a qualitative approach,
while reporting select quantitative frequencies of terms, through the
theoretical framework of grounded theory, whereby through the data

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Table 1
List of Child Welfare User Manual Series Used in the Analysis

Capacity Building Center for States. (2018a). Child protection in families

experiencing domestic violence (2nd ed.). U.S. Department of Health
and Human Services, Administration for Children and Families,
Children’s Bureau.
Capacity Building Center for States. (2018b). Child protective services: A guide
for caseworkers. U.S. Department of Health and Human Services,
Administration for Children and Families, Children’s Bureau.
Child Welfare Information Gateway. (2003a). Child protection in families
experiencing domestic violence. U.S. Department of Health and
Human Services, Children’s Bureau.
Child Welfare Information Gateway. (2003b). A coordinated response to child
abuse and neglect: The foundation for practice. U.S. Department of
Health and Human Services, Children’s Bureau.
Child Welfare Information Gateway. (2003c). The role of educators in
preventing and responding to child abuse and neglect. U.S.
Department of Health and Human Services, Children’s Bureau.
Child Welfare Information Gateway. (2006a). Child neglect: A guide for
prevention, assessment and intervention. U.S. Department of Health
and Human Services, Children’s Bureau.
Child Welfare Information Gateway. (2006b). The importance of fathers in the
healthy development of children. U.S. Department of Health and
Human Services, Children’s Bureau.
Child Welfare Information Gateway. (2006c). Working with the courts in
child protection. U.S. Department of Health and Human Services,
Children’s Bureau.
Child Welfare Information Gateway. (2008). The role of professional child
care professionals in preventing and responding to child abuse and
neglect. U.S. Department of Health and Human Services, Children’s
Bureau.
Child Welfare Information Gateway. (2009). Protecting children in families
affected by substance use disorders. U.S. Department of Health and
Human Services, Children’s Bureau.
Child Welfare Information Gateway. (2010a). Community partnerships:
Improving the response to child maltreatment. U.S. Department of
Health and Human Services, Children’s Bureau.

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Table 1 (Continued)

Child Welfare Information Gateway. (2010b). The role of first responders in

child maltreatment cases: Disaster and nondisaster situations. U.S.
Department of Health and Human Services, Children’s Bureau.
Gaudin, J. M., Jr., & U.S. Department of Health and Human Services. (1993).
Child neglect: A guide for intervention. U.S. Department of Health and
Human Services, Children’s Bureau.
Gentry, C. E., & U.S. Department of Health and Human Services. (1994).
Crisis intervention in child abuse and neglect. U.S. Department of
Health and Human Services, Children’s Bureau.
Kropenske, V., Howard, J., Breitenbach, C., Dembo, R., & U.S. Department
of Health and Human Services. (1994). Protecting children in
substance-abusing families. U.S. Department of Health and Human
Services, Children’s Bureau.
Pence, D., Wilson, C., & U.S. Department of Health and Human Services.
(1992). The role of law enforcement in the response to child abuse
and neglect. U.S. Department of Health and Human Services,
Children’s Bureau.
Peterson, M.S., Urquiza, A.J., & U.S. Department of Health and Human
Services. (1993). The role of mental health professionals in
the prevention and treatment of child abuse and neglect. U.S.
Department of Health and Human Services, Children’s Bureau.

obtained, the researchers generated a theory on the way dental neglect is

conceptualized in the user manuals through the context in which dental
neglect is presented (Creswell & Poth, 2016). The study evaluated both
the New and Revised versions as well as the 1990s versions. The man-
uals in this temporal frame consisted of a total of 17 publicly available
documents (see Table 1). The 1990s versions include five documents
and the revised versions include 12 documents. All documents were
manually reviewed by the researchers. Each document was searched
twice by both coding researchers to ensure all textual references were
identified. Eleven search terms were initially utilized to locate areas in
the text where dental health was mentioned: “dental,” “oral,” “mouth,”
“tooth,” “teeth,” “dentist,” “dentistry,” “toothbrush,” “cavity,” “decay,”

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and “caries.” These codes were determined by preliminary searches of

the documents and agreed upon by the coding researchers, who are
practicing dentists, to be common terms associated with oral health.
Search terms related specifically to dental trauma secondary to phys-
ical or sexual abuse were excluded as the research question aimed to
understand dental neglect and not oral manifestations of child abuse.
The codes were categorized based upon the context in which each of
these terms was utilized. The categories were manually clustered into
themes, allowing for the development of common themes across the
documents. The medical researcher then reviewed the themes to ensure
accuracy, and all three researchers determined the findings.

Results
1990s Child Welfare User Manuals
The term “dental neglect” specifically was not found in any of the docu-
ments in this temporal frame. The following describes the themes that
were noted where dental neglect was alluded to or indirectly mentioned.
As noted in Table 2, the term “dental neglect” was not specifi-
cally utilized although it was alluded to in the article series. When
dental neglect was indirectly referenced, it was mentioned in the con-
text of physical neglect including refusal or delay in dental care. The
term “dental” is also mentioned under childhood deprivation, where
it is stated that this deprivation will lead to oral health problems that
will require attention in the future into adulthood. Dental neglect was
likely assumed to be grouped together with medical neglect as a sub-
set of physical neglect, although they are separate fields and involve
different training.

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Table 2
Thematic Coding of Terms Found in the 1990s User Manual Series

Themes in 1990s Manuals

Dental Medical Neglect Substance

Abuse
Oral Reporting Sexual Feeding Substance
Practices Abuse Concerns Abuse
Mouth Sexual Abuse Substance Prenatal Drug
Abuse Exposure
Teeth Physical Abuse

Cavity Abdominal Cavity

As demonstrated in Table 2, the search term “oral” was only found

to be associated with issues in feeding, sexual abuse, and ways to report
child maltreatment and in the context of physical abuse. Other terms
such as “mouth,” “teeth,” and “tooth” are mentioned in the articles but
only in relation to physical and sexual abuse, illicit drug usage, and
issues with feeding.

New Revisions Articles

As seen in the 1990s Child Welfare User manuals, the term “dental
neglect” was not specifically mentioned and was grouped with medical
neglect as a subsection of physical neglect. The article Child Protective
Services: A Guide for Caseworkers (Capacity Building Center for
States, 2018) states that the possibility of generalized child neglect
would be when a child lacks or has unattended proper dental care that
is not obtained. When dental problems were mentioned, none of the
articles descriptively defined what should specifically be identified as
potential clinical markers of dental neglect. The terms “dirty teeth” and
“decaying teeth” were mentioned with no specific remarks as to what
this might look like in clinical practice. The term “decay” was men-
tioned along with the term “abscess,” but there were no descriptions

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of what the terms “decay” or “abscess” mean, how these conditions may
appear to a non-dental professional, or the possible harm to the child
these conditions may cause. Dental care was also mentioned under
health and physical development, stating that the child not getting
dental care now might suffer from tooth decay in the future. When
physical abuse is mentioned, one of the signs cited was unexplained or
repeated dental injuries. The articles also utilized “poor oral health” and
“neglect” interchangeably.
As demonstrated in Table 3, the term “mouth” is mentioned in the
articles but never in the context of dental neglect. The term “mouth”
was utilized when discussing drug usage, sexual abuse, chemical burns,
and injuries due to physical abuse, which can include tooth injuries.
When tooth injury was mentioned, it included both the possibility of
accidental cause and the steps needed to differentiate whether it con-
stituted child maltreatment—such as checking for discrepancies in the
injury and the history provided.
The terms “tooth” or “teeth” were rarely used throughout the articles
and when mentioned were not in the context of dental neglect. In the
article Child Protective Services: A Guide for Caseworkers (Capacity
Building Center for States, 2018), it is mentioned that unclean teeth
could be a sign of caretakers not meeting the emotional or medical
needs of the child.

Comparing 1990s Manuals with New Revisions

Figure 1 demonstrates a comparison between the 1990s and New
Revisions Child Abuse and Neglect User Manual Series. The select terms
chosen were most closely associated with the context of dental neglect
within the documents. Figure 1 demonstrates that while dental neglect
is not mentioned in either set of documents, there is an increased men-
tion of the concept of dental neglect in the New Revisions version as
compared with the 1990s documents.

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 Table 3
Thematic Coding of Terms Found in New Revisions of the User Manual Series

Themes in New Revisions Manuals

Begotti Silva et al.

Dental Generalized Child Medical Neglect Unattended Physical Abuse

Neglect Dental Issues
Oral Reporting Sexual Abuse Oral Hygiene
Practices
Mouth Sexual Abuse Drug Usage Physical Abuse Witnessing
Domestic Violence
Tooth Physical Abuse Unattended Dental
Issues
Teeth Generalized Child Physical Abuse Medical Unattended Dental Drug Oral
Neglect Neglect Issues Usage Hygiene
Dentist Barriers to Care Mandate Reporting
Toothbrush Oral Hygiene
Decay Oral Hygiene Unattended Dental General Physical Neglect
Issues Neglect
Child Welfare

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Figure 1
Comparison of Select Oral Health Search Terms in the 1990s versus
New Revisions of the Child Abuse and Neglect User Manual Series

Discussion and Conclusions

As can be seen from all the articles searched in both temporal frames,
there is not a single time where the term “dental neglect” is specifically
mentioned. Often, dental neglect is alluded to as part of medical or
physical neglect but is not clinically defined. In the article, “The Role of
Educators in Preventing and Responding to Child Abuse and Neglect”
(Child Welfare Information Gateway, 2003), the term “decay” is uti-
lized in one sentence to describe poor hygiene. Two sentences later, the
authors go on to describe decay in the context of unmet medical needs
leading to an abscess. Using the term “decay” dually in this manner
confuses the idea that “dental decay” and “poor oral hygiene” are equiv-
alent terms. It also diminishes the severity of untreated dental decay, or
rather, it does not make it clear that dental decay is not just a matter

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of having “dirty” teeth but can have significant associated morbidity

and in extreme cases, mortality. Symptoms of untreated dental decay
and descriptions of dental infection should be added in more detail to
help guide social work practitioners to identify children who may need
dental intervention.
The user manual series often grouped dental neglect as a part
of generalized child neglect or medical neglect. In congruence with
these findings, the National Child Abuse and Neglect Data System
(NCANDS)/Child Maltreatment report for the FFY 2021 (U.S.
Department of Health and Human Services, 2023) does not differen-
tiate dental neglect from medical neglect. The data indicate that dental
neglect is not distinguished from medical neglect when compiling fed-
eral statistics on national abuse victimization patterns (U.S. Department
of Health and Human Services, 2023). The issue with encompassing
dental neglect within medical neglect is that this notion assumes that
dental care is provided within the same health care delivery modality as
general medical care. In actuality, for the most part dentistry is provided
in private offices outside of the purview of traditional interdisciplinary
health care centers such as hospitals where referrals and social work
intervention could be readily accessible. While the American Academy
of Pediatrics notes that collaborating with professionals and resources
within the community to help optimize the health of a child who has
been medically neglected is important, as dentistry is often practiced
in isolation, this principle is less readily translated into dental practice
( Jenny & Committee on Child Abuse and Neglect, 2007). Thus, child
welfare professionals should strongly consider dental neglect as dis-
tinct from medical neglect and that gathering national data about den-
tal neglect cases specifically may help guide future interventions and
collaboration with dentistry. Currently data compiled by the National
Child Abuse and Neglect Data System (NCANDS) categorizes child
maltreatment types as medical neglect, neglect, physical abuse, psycho-
logical maltreatment, sexual abuse, and sex trafficking (U.S. Department
of Health and Human Services, Administration for Children, 2023).

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Similarly, the Child Welfare Information Gateway (2018) identifies

five main types of neglect: physical, inadequate supervision, emotional,
educational, and medical. Presumably dental falls into the category of
medical neglect even though dental and medical care are disparate enti-
ties within the United States that are typically practiced in vastly dif-
ferent settings. Subcategorizing dental neglect within medical neglect
will help inform specified intervention and provide evidence to support
greater oral health resource allocation for families.
When the oral cavity was mentioned, it was mostly in the context
of injuries and findings associated with instances of physical and sexual
abuse. These types of injuries and findings are more easily identifiable
as a form of child maltreatment and can be more readily associated
with a rationale of caregiver malicious intent. The difficulty in identi-
fying cases of child neglect, including dental neglect, is that the cause
may not be caregiver malicious intent but rather social factors that limit
a caregiver’s resources to be able to adequately provide for a child. As
many families face challenges accessing dental care as well as obtaining
coverage and financial resources to afford care, it must be ascertained
if these factors are the source of failure to follow through with care
(Fisher-Owens et al., 2017). It is also important to note that the act
of taking a child to the dentist is not necessarily adequate in provid-
ing dental care for a child. Episodic pain relief is not considered to be
appropriate dental treatment when sufficient resources exist to allow
for comprehensive care (Laskey & Sirotnak, 2020). Thus, a careful his-
torical context must be obtained to identify if dental care is being with-
held as an informed parental decision, or if the family does not have
means for providing care for the child. Both instances are appropriate
for social work intervention, albeit with different pathways.
The findings of the analysis of these user manuals highlight the
importance of dental and social work interprofessional collaboration.
It may be challenging for social workers to identify clinical signs of
dental neglect without collaboration with a dental professional. One
study conducted by Negro and colleagues (2019) sought to evaluate

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the feasibility of social worker-delivered oral health interventions for

preschoolers in foster care. Participants were knowledgeable about
the consequences of untreated tooth decay; however, despite their
understanding of the issue, most respondents lacked confidence in
their ability to identify tooth decay (Negro et al., 2019). It was noted
that before entering foster care, most children did not have a history
of visiting the dentist due to financial barriers and a lack of pro-
viders who accept Medicaid (Negro et al., 2019). Creating strong
interprofessional collaboration between child welfare professionals
and dental professionals would allow for dental professionals to help
train child welfare professionals to identify signs of dental disease
as well as create a referral network for identified children in need of
oral health intervention. Enhanced education and training for child
welfare professionals related to issues surrounding oral health would
also help assist families in overcoming social barriers that prevent
access to oral health care. Barriers can include economic hardship,
lack of access to care, lack of knowledge, and lack of trust in health
care providers, which all can contribute to a child not receiving ade-
quate health care services ( Jenny & Committee on Child Abuse and
Neglect, 2007).
Additionally, there is potential concern for biases in referrals
regarding dental neglect that parallel concerns around over-report-
ing/over-substantiation of certain racial/ethnic groups experiencing
other forms of abuse who may also be more readily affected by the
factors listed above. Interconnection between dental professionals
and social workers would help bridge access-to-care issues that pre-
vent families from obtaining dental care, such as inability to access
transportation or difficulty navigating the health care systems. Social
work intervention that provides links to community-based supports
addressing these factors can help to empower families to appropri-
ately seek and follow through with dental care. In addition, greater
dental professional involvement in child welfare assessments would
help to provide clinical and historical context to situations of dental

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neglect, both in isolation and as a part of greater child neglect, which

could provide clarity and insight into potential cases of child mal-
treatment. Finally, future research should further evaluate how den-
tal neglect is conceptualized through state and child welfare agency
training materials and policies.

References
American Academy of Pediatric Dentistry. (2020). Dental neglect [definition]. The
Reference Manual of Pediatric Dentistry. Author.

Bradbury-Jones C, Isham L, Morris AJ, Taylor J. (2019). The “neglected” relationship

between child maltreatment and oral health? An international scoping review of
research. Trauma, Violence & Abuse, 22(2), 265-276.

Burgette, J. M., Safdari-Sadaloo, S. M., & Van Nostrand, E. (2020). Child dental
neglect laws: Specifications and repercussions for dentists in 51 jurisdictions. The
Journal of the American Dental Association, 151(2), 98-107. https://doi.org/10.1016/j.
adaj.2019.09.010

Capacity Building Center for States. (2018). Child protective services: A guide for caseworkers.
U.S. Department of Health and Human Services, Administration for Children and
Families, Children’s Bureau.

Child Welfare Information Gateway. (2018). U.S. Department of Health and Human
Services, Children’s Bureau.

Child Welfare Information Gateway. (2003). The role of educators in preventing and
responding to child abuse and neglect. U.S. Department of Health and Human Services,
Children’s Bureau.

Child Welfare Information Gateway. (2022). Definitions of child abuse and neglect. U.S.
Department of Health and Human Services, Administration for Children and Families,
Children’s Bureau. https://www.childwelfare.gov/topics/systemwide/laws-policies/
statutes/define/

Creswell, J. W., & Poth, C. N. (2016). Qualitative inquiry and research design: Choosing
among five approaches. Sage Publications.

Fisher-Owens, S. A., Lukefahr, J. L., & Tate, A. R. (2017). Oral and dental aspects of child
abuse and neglect. Pediatric Dentistry, 39(4), 278-283.

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Jenny, C., & Committee on Child Abuse and Neglect. (2007). Recognizing and respond-
ing to medical neglect. Pediatrics, 120(6), 1385-1389. https://doi.org/10.1542/
peds.2007-2903

Khalid, G., Metzner, F., & Pawils, S. (2021). Prevalence of dental neglect and associated
risk factors in children and adolescents: A systematic review. International Journal of
Paediatric Dentistry, 32(3), 436-446.

Laskey, A., & Sirotnak, A. (2019). Child abuse: Medical diagnosis and management. American
Academy of Pediatrics.

Negro, K. S., Scott, J. M., Marcenko, M., & Chi, D. L. (2019). Assessing the feasibility of
oral health interventions delivered by social workers to children and families in the
foster care system. Pediatric Dentistry, 41(1), 48–51.

U.S. Department of Health and Human Services, Administration for Children and Families,
Administration on Children, Youth and Families, Children’s Bureau. (2023). Child mal-
treatment 2021. https://www.acf.hhs.gov/cb/data-research/child-maltreatment

Whyatt, L., & Barry, S. (2022). An exploratory study investigating the barriers to
reporting child dental neglect concerns among general medical practitioners in
Greater Manchester. The British Dental Journal, 1-5. https://doi.org/10.1038/
s41415-022-5221-7

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