German Dentists’ Knowledge About How to Proceed in Cases of Suspected Child Abuse and Neglect

Introduction: Studies from several countries have shown that there is a lack of knowledge related to child protection among dentists and their teams. So far, there are no data available about the situation in Germany. Aim of this study is to describe the perception of the role of German dentists in terms of child abuse and neglect.

Material and Methods: A questionnaire previously used by other studies regarding the role of dentists in child protection was adapted to German terminology and provided online. The internet address has been shown in different German dentists’ association journals addressing dentists only. The participation was voluntary.

Results: A total of 251 (79.68%) dentists completed the questionnaire with valid data, 62.5% reported to have had a sus- picion of child abuse or neglect. Of these, 21,7% had reported their suspicion to the social services. Dentists specialized in pediatric dentistry reported their suspicion more often. Most frequently reported barriers towards contacting social services were uncertainty about diagnosis, fear of violence towards the child and the lack of knowledge in terms of referral procedures. Most of the participants expressed a need for further education.

Conclusion: Dentists in Germany are not able to fill their role in child protection matters sufficiently and show a need for undergraduate and continuing postgraduate training.

Keywords: Domestic Violence, Pediatric, German Dentistry, Education

Child well-being risks can have many facets. They range from neglect and bullying to sexual violence and physical abuse of children and adolescents. Since recent time, these issues have increasingly gained public and political attention. A whole series of recent surveys on abuse, neglect and maltreatment refer to very specific groups, such as children in protectories or in other institutions, but also in families themselves (for an overview in Germany see the web page of the Independent Commissioner for Child Sexual Abuse Issues) [1].

Dentists are in a particularly exposed position when it comes to identifying abused and neglected children, especially since a large proportion of physical injuries have been observed in the head and neck area. Offenders often change pediatricians to disguise the harm of a child’s well-being. However, they are less suspicious about the dentist reporting and exposing them and thus often stay with the same dentist for orofacial traumas of their children [2, 3].

When the role of dentistry in dealing with suspected child abuse and neglect is analyzed in an international comparison, it has become apparent that in many countries dentists are increasingly involved in the diagnosis [4]. To our knowledge, there are no comprehensive surveys of dentists in Germany on the subject of dealing with or knowledge of child abuse and neglect. In many cases dentists feel that they are not well-informed and are overwhelmed by the question. This problem area has not been present in the study of dentistry up to now. In the new S3(+) Child Protection Guideline of the Association of Scientific Medical Societies in Germany (AWMF), the role of dentistry is discussed in the overall context of child welfare risks and its significance is highlighted [5].

The aim of the study described here was to gather information on the level of knowledge of dentists in Germany and, if necessary, to compare them with other countries.

In order to gain the most comprehensive insight possible into the level of knowledge of dentists in Germany on the subject of child well-being risks, a short online questionnaire was created. Following the ‘CHERRIES’ reporting guidelines the questionnaire could be used throughout the country. The study was reported to the local ethics committee of the University Hospital of Jena and eventually approved under file number 5148-04/17.

The data collected in this study are based on a questionnaire used by Cairns et al. in 2005 [6] which was translated into German and adapted in regard to terminology and socio-demographic data. The German translation was submitted to two physicians with many years of experience in the field of child well-being risk and several dentists to check its comprehensibility [7].

Throughout the questionnaire, ‘child abuse and neglect’ was chosen as a general term, and none of the respondents had to distinguish between the different types of child endangerment. The introduction to the questionnaire pointed out that a transfer of data from the study to third parties was excluded and the anonymized data were collected solely for the purpose of this study. A short instruction on how to fill in the questionnaire was also presented here. Created by using the survey tool ‘Umfrageonline.com’, the questionnaire comprised a total of twenty-seven questions which could be found within four pages. To prevent duplicate entries, Cookies and an IP check were used, both valid and saved for the whole duration of the survey.

The questionnaire was published as a link on the Internet in November 2017 and was closed at the 31st July 2018. It was a voluntary survey without using any incentives. The link to the questionnaire was published by various state dental associations, the ‘Freier Verband Deutscher Zahnärzte’, the websites ‘ZWP Online’ and ‘ZM-Online’ as well as the newspaper ‘Die ZahnarztWoche’ within Germany. Especially the Dental Chambers of the Federal States of Brandenburg, Hamburg, Mecklenburg-Western Pomerania, Lower Saxony, Rhineland-Palatinate, Saarland and Saxony published an accompanying text to the questionnaire in order to raise awareness of the topic and to draw attention to the online questionnaire. In ‘Der Freie Zahnarzt’ of the ‘Freier Verband Deutscher Zahnärzte’, the ‘ZM-Online’ as well as the internet presence of the ‘ZWP’ a similar article was published, while in the newspaper ‘Die ZahnarztWoche’ an overview of earlier results was published - also in order to sensitize for the topic ‘child well-being risk’ and to draw attention to the study still running at this time. A small interview was published at the Chamber of Dentists of Saxony-Anhalt to achieve the same effect. Only dentists were interviewed. This public and anonymous way of distributing the questionnaire was the most effective without additional funding.

The data were initially checked by the evaluation tool of ‘Umfrageonline.com’ and then statistically evaluated. The report on the results subsequently refers to descriptive evaluations (absolute/relative frequencies), which were carried out with the help of the program package SPSS (version 22.0).

Out of 315 participants in the survey, a total of 251 (79.68%) fully completed the questionnaire. Sixty-four participants answered the questionnaire incompletely for unknown reasons and were not included in the further analysis.

Table 1 shows that the study represents a satisfying cross section of the entire dentist population in Germany, since on the one hand all age groups have been represented, and on the other hand the development of the profession of dentistry in Germany tends towards a higher proportion of women [8].

The increased proportion of dental practices in large cities participating in the study (38.6%) confirms the trend of recent years having an increasing relocation of practices to urban areas, while dental practices in rural (< 30,000 inhabitants) and urban areas (< 100,000 inhabitants) were each represented with 30.7% [9].

Table 2 shows that more experienced practitioners apparently perceived the questionnaire only to a small extent, whereas colleagues with treatment experience of 10 years or less showed a great willingness to participate.

Almost all dentists who answered the questionnaire (95.6%) were not part of a child protection group or the German Child Protection Association (literally “Deutscher Kinderschutzbund e.V.” [DKSB e.V.]). Nine participants in the study (3.6%) were members of the DKSB e.V, 11 participants from other child protection societies (4.4%).

A small proportion of the participants in the study had completed training or further training in the subject of child abuse and neglect. This applied both to the time during the studies (19.1%) and to the time after the studies (18.7%). For all other participants, the topic of child welfare hazards during their studies (80.9%) and during their time as a practicing dentist (81.3%) was not covered.

Forty-seven (18.7%) of the interviewed dentists had taken part in a postgraduate training course. In slightly more than half of these training courses, a single hour (53.2%) was devoted to the subject of child well-being risks, while the remaining respondents stated that they had taken part in training courses that provided information and training on the subject for half a day or more (46.8%).

Table 3 shows the opinion expressed by dentists regarding the training of dentists on the subject of child well-being risks. Further training measures were desired by the very largest proportion of respondents (91.2%) and almost none of the participants thought that dentists were adequately and sufficiently informed about the issue of child abuse and neglect as part of their education and training (2.0%). Furthermore, it was found that hardly any of the respondents were familiar with the guiding principles or guidelines of child protection (15.1%).

Figure 1 shows that the majority of the dentists surveyed would have preferred to be involved in the education of child welfare risks (63.03% with ratings between 6 and 10 on a notional scale).

Table 4 shows that more than half of the dentists surveyed had a patient in their clientele who they suspected to be at risk of being harmed. Within the last 6 months before the survey began, 27.9% of those questioned still suspected mistreatment and/or neglect of at least one of their patients. Only 21.1% of these colleagues had reported this suspicion to the Youth Welfare Office, the police, the pediatrician in charge or the German Child Protection Association. The German authorities, i.e, the Youth Welfare Office, confirmed only 26.4% of the suspected cases reported to them by the surveyed dentists. The participants stated that they had experienced a median suspicion in about 6 patients (1 to 30 cases) during their work as dentists. A total of 78.9% of the respondents had not reported even though they suspected a risk to the well-being of a child in one patient, but of these colleagues 40.4% had documented their observations.

Figure 2 shows which factors could influence the interviewed dentists to report suspected child abuse and/or neglect. Multiple Answers were possible. Here it was shown that above all uncertainty regarding their own diagnosis (62.9%) and ignorance of reporting procedures and channels (42.2%) are dominant factors. It was equally important to the interviewees not to provoke further violence against the young patient by their own family (49.8%) and the consequences by intervention of the authorities (41.4%). Less important, however, were points that concerned the respondents themselves.

Figure 3 shows to whom the participants in the study first turned when they suspected a risk to child welfare. They were most likely to raise the suspicion with the treating pediatrician or family doctor (29.5%) or to contact the Youth Welfare Office directly (32.7%). Fewer respondents would have discussed their suspicions with a colleague (19.5%), while hardly any of the dentists in this study wanted to contact the police directly (6.4%) or the German Child Protection Agency (4.3%). A small percentage of those questioned consulted other persons or agencies than those already mentioned (7.6%).

The involvement of dentists in child protection so far has been insufficient in Germany. In the S3(+) Child Protection Guideline of the AWMF, published in 2019, the role and scope of duties of dentists is explicitly mentioned and presented for the first time [5]. It is specified that if a child's well-being is suspected to be at risk, ‘multidimensional diagnostics of at least 30 minutes each in three disciplines’ of medicine, including dentistry, should be carried out and followed by a case discussion of the selected specialist disciplines. Here, the case discussion with a primary care provider and pediatrician should be carried out and documented, only then youth welfare services should be contacted. During the dental examination itself, the examination is carried out on the basis of the Anglo-American definition of ‘dental neglect’ [10-12]. In this context, dentistry is assigned two tasks: to recognize the signs of dental and general neglect and to perform a detailed report according to OPS 1-945 on children referred to by colleagues from other disciplines who also suspected child abuse. However, even in this guideline there is no limit to the number of carious teeth or other dental changes that would involuntarily lead to the suspicion of neglect. Failure of treatment by the carer to provide information about the consequences of pathological changes in the oral cavity is nevertheless an indication of neglect of the child. It was also correctly recognized by the AWMF that in Germany there is no obligation to undergo a dental examination, although dental changes as a former and sensitive factor for medical neglect have already been proven by studies [13-15].

Despite the mention of the topic in the catalogue of learning objectives in dentistry, university education has proven to be insufficient [16]. The catalogue of learning objectives speaks of a ‘basic competence with knowledge of action and justification’ in order to be able to ‘recognize signs of domestic/family violence and document them in a way that can be used in court and to be able to classify the options for action offered legally and ethically’. However, the topic of child welfare risks is usually discussed on the fringes of other case subjects such as jaw fractures, oral mucous membrane diseases and general oral injuries. This potentially results in a discrepancy between the uncertainty caused by the low or even lack of diagnostic training on the part of dentists and the chance to uncover child well-being risks, since offenders seem to mistrust dentists less than their pediatric colleagues [2]. There are also no significant elements on child protection in the curriculum of postgraduate training for dentists [17].

Since the links between dentistry and child protection have been  a relatively new topic in Germany, the study's announcement of articles in newsletters mentioned the importance of dentists in identifying child welfare risks and the definition of the American Academy of Pediatric Dentistry [11] to ensure a general understanding of the concept.

The results of this study on questions of procedure, safety with regard to the dental handling of child well-being risks in Germany and on the barriers or the need for further post-university training in the field of child protection are consistent with the results of similar studies in different countries [6, 18-20]. The relevance of studies on this topic and their significance for future decisions as well as learning effects could be demonstrated in Denmark and Scotland. For example, a follow-up study after seven years showed an increased sensitivity to the topic [18, 20].

In our study a similar number of participants could be reached as in the other studies[6, 18, 19, 21], but the sample is naturally not representative for the large number of practicing dentists in Germany.

The figures of the study by Cairns et al. are comparable [22]. There, 700 questionnaires were sent out and a total of 375 questionnaires were evaluated. Similarly, the number of participants in the study by Manea et al. is comparable with 106 dentists [19]. A major exception in the number of participants in studies of a similar design is the study by Uldum et al. conducted in Denmark in 2010. Here, the responses of 1145 (76.3%) participants could be evaluated in a population of 1501 participants [21]. The reasons for the relatively low number of answers in our study can only be suspected. For example, the lack of funding for our study could play a role, combined with the fact that the questionnaires could not be given to dentists in paper form or enclosed in the newsletters of the dental associations. In addition, due to the strict data protection guidelines in Germany, it was not possible to obtain addresses of colleagues working in dentistry and to contact their practices directly. In general, a presumed ‘research fatigue’ could also play a role, which is shown in many surveys, as well as a lack of interest in the subject itself. Uncertainty (re-confirmed by this study) in the area of child welfare risks and diagnostics by dentists could also be significant. Nevertheless, the sample of selected participants represents a good cross-section of practicing dentists in Germany, as the demographic data show.

It is noteworthy that 62.5% of the participants already had a suspicion of child abuse or neglect during their time as a practicing dentist. However, only 21.1% of these colleagues had reported their suspicions. This sobering result is comparable with the initial results from Scotland and Denmark [6, 21]. It was only in the follow-up studies of these countries that a sensitization to the issue of child well-being hazards became apparent, with governmental organizations in particular likely to have contributed to this through legislation and guidelines[18, 20]. In Scotland, ‘Child Protection and the Dental Team’ - a manual in combination with a supplementary website - was sent to all dental practices, providing guidance on the responsibilities of dentists in child protection [23]. This led to a significant reduction in the diagnostic uncertainty in cases of abuse (2005: 88% vs. 2013: 74%, n=465) and the uncertainty in the required reporting channels if there was a suspicion of child welfare (2005: 71% vs. 2013: 43%, n=271). In Denmark, the ‘Social Assistance Act Section 153’ introduced in 2013 obliges every dental team to report concerns about additional social support needed by minors to the social services [24]. In the follow-up study conducted five years later, a decrease in uncertainty in the diagnosis of child well-being risk was found (original study: 80%, follow-up study: ~70%) [20]. In the Netherlands, the so-called ‘Mandatory Reporting Code Act’ was enacted in 2013, creating an obligation for practices and all care and medical institutions to report. In addition, a Model Reporting Code was published, which explains the procedure to be followed in the event of suspected child welfare problems. Unfortunately, Germany shows a lower willingness to take further measures than the countries mentioned above [25].

Another explanation for the results of our study could be the high proportion of younger participants in the sample (just over a third aged 30-39), which could also explain the low confidence in correctly identifying signs of childhood harm (62.9% expressed uncertainty). It can be assumed that dental practices with a focus on pediatric dentistry would have to show more certainty especially with this topic, since here, in further training courses, the risk to children's well-being is also addressed in profound courses and treated with a sufficient amount of time of at least half a day. However, this could not be verified in our study.

When a report was passed on, only 26.4% of the participants had their suspicions confirmed by the Youth Welfare Office. On average, about six patient cases were discovered and confirmed in the last five years. Besides, there is often no feedback from the youth welfare office to the reporting dentist or doctor, which could also explain the low rate of cases confirmed by the participants. On the one hand in Scotland, the Netherlands and Denmark the above-mentioned funding, both from the state and the social services, has created more security in the dental practitioner's environment as shown by follow-up studies from Denmark and Scotland [18, 20]. In Germany, on the other hand, parental education is culturally conditioned as a private and personal task, which is why direct influence from outside is reluctantly accepted and the reference to it defines a social taboo. This is shown by the low number of suspected cases reported overall.

The study also reveals the most common barriers that prevent colleagues from making the correct diagnosis. These include the above-mentioned diagnostic uncertainty, fear of the consequences for the child, both by the perpetrators and by the authorities, and a certain tiredness in dealing with the authorities or the bureaucracy associated with reporting a child's well-being in Germany, which is stressed in our study primarily through statements in the free text field. It was pointed out several times that the catalogue of measures to be taken in the event of suspicion is very complex and designed for lengthy analysis processes. Added to this is the time required to process such cases - for example, through the detailed documentation, the questions and statements made in the course of the case work, and possible court appearances. This also includes the fact that dentists often do not know when the duty of confidentiality may be violated. On the positive side, the economic side is not a significant barrier for the majority of dentists (at only 4.0%).

The collection of open comments at the end of the questionnaire provides indications of the need for further discussion. For example, there have been frequent requests to differentiate more between neglect and abuse of children. This is a topic that can and must be examined more closely in follow-up studies. The background is the often-desolate condition of the teeth of neglected children. It was also noted that Early Childhood Caries should be seen as an early sign of neglect, as the enamel of the teeth only gives way to plaque and acids after some time. This would also have to be investigated more closely in a separate study.

Deficits in the development of proper oral hygiene for children by persons entitled to care should be remedied, here it is important to distinguish whether parents lack education and knowledge in this area or whether a lack of oral hygiene is deliberately accepted. However, this can only be determined after a detailed, legally binding clarification and the subsequent review of the compliance of the persons having custody. At the same time, the participants emphasized the importance of minimizing the risk of changing doctors or achieving a better possibility of networking medical findings in order to render a possibly intended ‘doctor-hopping’ ineffective. This is already being worked on in Germany by the health insurance companies, from January 2021 it should be possible to have a so-called electronic patient file (“ePA”) with comprehensive documentation of patient data by means of the insurance card. So far there has been talk of voluntarily keeping an ePA, which unfortunately does not stop the possibility of changing doctors - but it is nevertheless a step in the correct direction.

Dentists in Germany cannot adequately fulfil their role in the area of child protection. According to the perception of the dentists surveyed, the lack of university and post-university training and compulsory further training in this area plays a particularly important role. Moreover, some of the answers in our study showed that there is fatigue in relation to the bureaucratic processes in Germany, should a dentist report a suspicion. This would have to be proven by further studies in order to make a final judgment on this.

The role of the dentist within the protection of children is not clear to most of those concerned. The German AWMF S3(+) Child Protection Guideline[5] describes the role of the dental practitioner as part of child protection for the first time and provides guidance and examples by which suspicions can be confirmed or refuted. Consequently, the level of awareness of this guideline must be increased. Interdisciplinary case conferences are to be aimed for, as also described by the guideline, and dental colleagues have to be better integrated into child protection groups. Overall, there is a lack of knowledge among the surveyed dentists. The legal situation for dentists in reporting procedures is generally unclear to many colleagues.

This study was financed by the authors with no additional funds raised. All of the provided support was at no charge.

The authors declare no conflicts of interest.