CLINICAL REPORT

Guidance for the Clinician in Rendering Pediatric Care

Susan A. Fisher-Owens, MD, MPH, FAAP,​a James L. Lukefahr, MD, FAAP,b​ Anupama Rao Tate, DMD,Oral MPH,c​ AMERICAN and ACADEMY Dental OF PEDIATRICS, SECTION Aspects ON ORAL HEALTH, COMMITTEE of ON CHILD ABUSE AND NEGLECT, AMERICAN ACADEMY OF PEDIATRIC DENTISTRY, COUNCIL ON CLINICAL AFFAIRS, ChildCOUNCIL ON SCIENTIFIC Abuse AFFAIRS, AD HOC and WORK GROUP Neglect ON CHILD ABUSE AND NEGLECT

In all 50 states, health care providers (including dentists) are mandated abstract to report suspected cases of abuse and neglect to social service or law Departments of aPediatrics and Preventive and Restorative Dental enforcement agencies. The purpose of this report is to review the oral and Sciences, University of California, San Francisco, San Francisco, California; bDepartment of Pediatrics, University of Texas Health dental aspects of physical and sexual abuse and dental neglect in children Science Center at San Antonio, San Antonio, Texas; and cDepartment of and the role of pediatric care providers and dental providers in evaluating Pediatrics, The George Washington University School of Medicine and Division of Oral Health, Children’s National Medical Center, Washington, such conditions. This report addresses the evaluation of bite marks as DC well as perioral and intraoral injuries, infections, and diseases that may Drs Fisher-Owens, Lukefahr, and Tate were each responsible for raise suspicion for child abuse or neglect. Oral health issues can also be all aspects of writing and editing the document and reviewing and responding to questions and comments from reviewers and the Board associated with bullying and are commonly seen in human trafficking of Directors. victims. Some medical providers may receive less education pertaining to This document is copyrighted and is property of the American oral health and dental injury and disease and may not detect the mouth Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy and gum findings that are related to abuse or neglect as readily as they of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of detect those involving other areas of the body. Therefore, pediatric care Pediatrics has neither solicited nor accepted any commercial providers and dental providers are encouraged to collaborate to increase involvement in the development of the content of this publication. the prevention, detection, and treatment of these conditions in children. Clinical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, clinical reports from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. Children may be exposed to multiple kinds of maltreatment that manifest All clinical reports from the American Academy of Pediatrics in the mouth, so health care professionals (including dental providers) automatically expire 5 years after publication unless reaffirmed, need to be aware of how to evaluate and address these concerns. revised, or retired at or before that time. Maltreatment includes physical and sexual abuse and can include This report is being published concurrently in Pediatric Dentistry evidence of bite marks and dental neglect. Bullying and the human August 2017. The articles are identical. Either citation can be used when citing this report. trafficking of children also occur and can have serious long-term effects. These issues may be the presenting problem, noticed during a physical To cite: Fisher-Owens SA, Lukefahr JL, Tate AR, AAP AMERICAN examination, or children or adolescents may disclose information about ACADEMY OF PEDIATRICS, SECTION ON ORAL HEALTH COMMITTEE experiencing abuse or neglect. It is important for all health care providers ON CHILD ABUSE AND NEGLECT, AMERICAN ACADEMY OF PEDIATRIC DENTISTRY, COUNCIL ON CLINICAL AFFAIRS, COUNCIL (including dental providers) to be alert to and knowledgeable about signs ON SCIENTIFIC AFFAIRS, AD HOC WORK GROUP ON CHILD ABUSE and symptoms of child abuse and neglect and to know how to respond. AND NEGLECT. Oral and Dental Aspects of Child Abuse and Because different communities have different resources, not all providers Neglect. Pediatrics. 2017;140(2):e20171487 of a certain job specification may be available everywhere, and thus, job roles may sometimes overlap. Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 140, number 2, August 2017:e20171487 FROM THE AMERICAN ACADEMY OF PEDIATRICS Physical Abuse

regardless of mechanism, should be collected within 24 hours19 of exposure reported for further investigation. in prepubertal children and within Craniofacial, head, face, and neck – Unintentional or accidental injuries 72 hours in adolescents. Evidence injuries occur in more than half of 1 6 to the mouth are common and collection should be repeated as child abuse cases. ‍‍ All suspected can be distinguished from abuse clinically indicated. Oral and perioral victims of abuse or neglect, including by judging whether the history gonorrhea in prepubertal children children in state custody or foster (including the timing and mechanism (which is diagnosed with appropriate care, should be examined carefully of the injury) is consistent with the culture techniques and confirmatory by the appropriate provider at ’ characteristics of the injury and the testing) is pathognomonic of sexual some point during the course of the 20,21​ child s developmental capabilities. abuse but is rare. ‍ Rates are evaluation for signs of oral trauma, Multiple injuries, injuries in different higher in sexually abused adolescents caries, gingivitis, and other oral Chlamydia stages of healing, or a discrepant (12% with gonorrhea; 14% with health problems, which are more 22 history should arouse suspicion for ). Pharyngeal gonorrhea prevalent in maltreated children than 23 7 abuse. Consultation with or referral frequently is asymptomatic. in the general pediatric population. to a knowledgeable dentist or child Although culture has been Some authorities believe that the abuse pediatrician may be helpful. considered the gold standard, nucleic The clinical report from the American acid amplification tests are more oral cavity may be a central focus “ 24 Academy of Pediatrics (AAP) entitled commonly used now because they for physical abuse because of its ” significance in8 communication The Evaluation of Suspected Child are more sensitive,25 less invasive, and and nutrition. Oral injuries may Physical Abuse15 provides additional less expensive. Although they have be inflicted with instruments guidance. not been approved by the US Food such as eating utensils or a bottle Sexual Abuse and Drug Administration for the during forced feedings, hands, prepubertal age group or for rectal fingers, scalding liquids, or caustic or oropharyngeal swab specimens, substances. This form of abuse the Centers for Disease Control and Although the oral cavity is a frequent may result in contusions; burns 16 Prevention does cite nucleic acid site of sexual abuse in children,​ or lacerations of the tongue, lips, amplification tests on vaginal swab visible oral injuries or infections buccal mucosa, palate (soft and specimens or urine as an alternative are rare. When oral-genital contact hard), gingiva, alveolar mucosa, to cultures in girls. However, culture is suspected, referral to specialized or frenum; fractured, displaced, or remains the preferred method for clinical settings equipped to conduct avulsed teeth; or facial bone and jaw testing urethral swab specimens or 9 comprehensive examinations is fractures. Naidoo cited the lips as “ urine for boys and for extragenital recommended. The AAP clinical the most common site for inflicted swab specimens (pharynx and report entitled The Evaluation of 26,27​ oral injuries (54%) followed by ” rectum) for all children. ‍ Although Children in the Primary Care Setting the oral mucosa, teeth, gingiva, and 17 human papillomavirus infection When Sexual Abuse Is Suspected ‍ tongue. Lacerations to the oral frena may result in oral or perioral warts, provides information regarding in premobile infants are often the “ the mode of transmission remains these examinations as does the result of physical abuse and are uncertain. Human papillomavirus Updated Guidelines for the Medical frequently associated with other infections may be transmitted 10 Assessment and Care of Children findings of serious physical abuse. ” sexually through oral-genital contact, Who May Have Been Sexually Trauma to the teeth may result in 18 vertically from mother to infant Abused. ‍ during birth, or horizontally through pulpal necrosis, leaving11,12​ the teeth ’ gray and discolored. Gags applied When oral-genital contact is nonsexual contact from a child or to the mouth may result in bruises, confirmed by history or examination caregiver28,29​ s hand to the genitals or lichenification, or scarring13 at the findings, universal testing for sexually mouth. ‍ corners of the mouth. Some serious transmitted infections within the oral injuries of the oral cavity, including cavity is controversial; the clinician Unexplained injury or petechiae of posterior pharyngeal injuries and may consider risk factors (eg, chronic the palate, particularly at the junction retropharyngeal abscesses, may be abuse or a perpetrator with a known of the hard and soft palate, may ’ 30 inflicted by caregivers14 who fabricate sexually transmitted infection) and result from forced oral sex. As with illness in a child to simulate the child s clinical presentation all suspected child abuse or neglect, hemoptysis or other symptoms when deciding whether to conduct when sexual abuse is suspected or requiring medical care. All findings such testing. Accuracy to diagnose diagnosed in a child, the case must be in cases in which there is reasonable sexually transmitted infections of the reported to child protective services suspicion of abuse or neglect, oral cavity is increased if evidence is and/or law enforcement agencies for Downloaded from www.aappublications.org/news by guest on September 28, 2021 2 FROM THE AMERICAN ACADEMY OF PEDIATRICS –

31 34 investigation. ‍ A multidisciplinary of the distortion presented and DNA is present in oral epithelial child abuse evaluation for the the time elapsed between36 the cells and may be deposited in bites. child and family is preferred when injury and the analysis. Recent Even if saliva and cells have dried, available. investigations have led to questions they can be collected by using the double-swab technique. First, a Children who present acutely with about the scientific validity of sterile cotton swab moistened with a recent history of sexual abuse forensic patterned evidence (bite distilled water is used to wipe the may require specialized forensic mark analysis in particular) 38and area in question, then dried and testing for semen and other foreign its role in legal proceedings. The placed in a specimen tube. A second materials resulting from assault. pattern, size, contour, and color of a ’ control sample is collected by Specialized hospitals and child bite mark ideally can be evaluated swabbing the victim s buccal mucosa protection clinics equipped with by a forensic odontologist; a forensic to distinguish his or her DNA from protocols and experienced personnel pathologist can be consulted if a 39 that of the perpetrator. All evidence are best suited for collecting such forensic odontologist is not available. should be collected, documented, specimens and maintaining a chain of If neither specialist is available, a and labeled according to standards evidence necessary for investigations. medical provider or dental provider with a clear chain of custody and If a victim provides a history for oral- experienced in identifying the 39 submitted for forensic analysis. penile contact, the buccal mucosa patterns of child abuse injuries may Questions regarding the evidentiary and tongue can be swabbed with a examine and document the bite mark procedure should be directed to a sterile, cotton-tipped applicator; the characteristics photographically with law enforcement agency. swab can be air dried and packaged an identification tag and scale marker appropriately for laboratory analysis. (eg, ruler) in the photograph. The Bullying Bite Marks photograph should be taken such that the angle of the camera lens is directly over the bite and in the same 39 Thirty percent of children in the Acute or healed bite marks may plane of the bite to avoid distortion. sixth to 10th grades report having indicate abuse. Dentists trained as A special photographic scale was been bullied and/or having bullied forensic odontologists can assist developed by the American Board of 40 others. Children with orofacial health care providers in the detection Forensic Odontology (ABFO) for this or dental abnormalities (including and evaluation of bite marks related purpose as well as for documenting 35 malocclusion) are frequently to physical and sexual abuse. Bite other patterned injuries (ABFO No. 41,42​ subjected to bullying ‍ and, marks should be suspected when 2 Reference Scale). ABFO-certified as a result, may suffer serious ecchymoses, abrasions, or lacerations odontologists and the ABFO bite psychological– consequences, are found in an elliptical, horseshoe- mark analysis flow sheet can be 36 including depression and suicidal shaped, or ovoid pattern. Bite found on the ABFO Web site (www.​ 43 45 ideation. ‍ Children who reported marks may have a central area of abfo.org).​ In addition to photographic physical abuse, intimate partner ecchymoses (contusions) caused by evidence, every bite mark that shows violence, forced sex, and bullying the following 2 possible phenomena: indentations ideally will have a were found to also report poor (1) positive pressure from the 46 polyvinyl siloxane impression made oral health. Also of great concern closing of the teeth with disruption immediately after swabbing the bite are the more subtle psychosocial of small vessels or (2) negative mark for secretions containing DNA. consequences that can be associated pressure caused by suction and This impression will help provide with bullying behavior. Health tongue thrusting. Bites produced a three-dimensional model of the care providers (including dental by dogs and other carnivorous bite mark. Written observations and providers) can ask patients animals tend to tear flesh, whereas photographs should be repeated about bullying and advocate for human bites compress flesh and at intervals to best document39 the antibullying programs in schools and can cause abrasions, contusions, 44 evolution of the bite. Because other community settings. Health and lacerations but rarely avulsions “ each person has a characteristic care providers can become familiar of tissue. An intercanine distance ” bite pattern, a forensic odontologist with Connected Kids: Safe, Strong, (ie, the linear distance between the ’ may be able to match dental models Secure,​ the primary care violence central point of the cuspid tips) (casts) of a suspected abuser s teeth prevention protocol from the AAP measuring more than 3.0 cm is 37 with impressions or photographs of that offers preventive education, suspicious for an adult human bite. the bite. (This is the responsibility screening for risk, and linkages Bite marks found on human skin of the police and not the health care to community-based counseling are challenging to interpret because provider.) and treatment resources (https://​ Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 140, number 2, August 2017 3 Dental Neglect patiented.solutions.​ aap.​ org/​ Handout-​ 47​ more likely to be victims of human Collection.​aspx?​categoryid=32034)​ . trafficking (particularly if they are Dental neglect, as defined by the experiencing survival sex); this can “ Human Trafficking American Academy of Pediatric include international abduction, Dentistry, is the willful failure of although geographical dislocation parent or guardian, despite adequate is not required in the definition of Human trafficking is a serious child 52 access to care, to seek and follow trafficking. health issue involving medical through with treatment necessary to and dental ramifications, among ensure a level of oral health essential Although children who are victims ” others, but it is just beginning for adequate function and freedom of human trafficking are often 59 to be addressed in the United from pain and infection. ‍ Dental disenfranchised from most of States. The US Department of caries, periodontal diseases, and “ society, more than one-quarter State defines human trafficking other oral conditions can lead to pain, of them still will see a health care as [T]he recruitment, harboring, 53 infection, loss of function, and worse professional while in captivity. transportation, provision, or if left untreated. These undesirable Victims of trafficking have complex obtaining of a person for labor or outcomes can adversely affect psychosocial and physical challenges services through the use of force, learning, communication, nutrition, that affect how they perceive and fraud, or coercion for the purpose and other activities necessary for respond to a given situation. Rescued 4,60​ of subjection to involuntary normal growth and development. ‍ ” § victims often have complex health servitude, peonage, debt bondage, Some children who first present 48 needs, including infectious diseases, or slavery ([22 USC 7102(9)]). for dental care have severe early “ reproductive health problems, “ ” “ ” Of these, children most commonly childhood caries (formerly termed substance abuse, and mental health experience sex trafficking, in which infant bottle or nursing caries). problems. Dental problems also a commercial sex act is induced by Caregivers with adequate knowledge rank high in this list: for trafficked force, fraud, or coercion, or in which and willful failure to seek care must women and adolescents in Europe, the person induced to perform 54 be differentiated from caregivers ” § 58% reported tooth pain. In the ’ such act has not attained 18 years without knowledge or awareness of “ United States, more than half (54.3%) of age ([22 USC 7102(9)]). Sex a child s need for dental care when ” of women and adolescents reported trafficking is considered commercial determining the need to report such dental problems, the most common sexual exploitation of children as 55 cases to child protective services. being tooth loss (42.9%). Child are pornography and survival sex Several factors are considered trafficking victims have twice the (defined as the exchange of sexual “ necessary for the diagnosis of risk for dental problems because 61 activity for basic necessities such as •neglec• t : 49,50​ they often suffer from inadequate shelter, food, or money). ‍ nutrition leading to retarded growth a child is harmed or at risk for and poorly formed teeth, as well as harm because of lack of dental Precise numbers of children ” •• health care; experiencing human or sex dental56 caries, infections and tooth trafficking are difficult to obtain loss. ‍ For older children, dental the recommended dental care because of the complicated nature of problems may trace back to their offers significant net benefit to the these definitions and underreporting. situations of origin, with limited •• child; However, it is estimated that access to or poor quality of care. >100000 children are victims of Dental problems may also come from the anticipated benefit of the prostitution each year in the United being in a trafficking situation, during dental treatment is significantly 51 “ States ; see the AAP Clinical Report which time children may have had greater than its morbidity, so entitled Child Sex Trafficking and unattended problems in addition parents would choose treatment ” •• Commercial Sexual Exploitation: to forgone preventive care or, even over nontreatment;

Health Care Needs of Victims for worse, physical54,57​ abuse or torture to access to health care is available more information on identifying50 and the head. ‍ •• but not used; and serving these patients. The average the parent understands the dental age of children who are exploited for Human trafficking is not a problem advice given. sex is 12 years old, and children as46, 51​ exclusive to girls and women. As young as 6 years old are targeted. ‍ many as 50%58 of victims may be Failure to seek or obtain proper Children who49 are or have been52 in boys or men,​ although they are not dental care may result from factors foster care,50​ are homeless,​ are discussed as much in the literature. such as family isolation, lack of runaways,​ or are incarcerated50 in For both sexes, a commonality is a finances, transportation difficulty, juvenile detention facilities are history of child abuse. parental ignorance, or lack of Downloaded from www.aappublications.org/news by guest on September 28, 2021 4 FROM THE AMERICAN ACADEMY OF PEDIATRICS –

62 64 perceived value of oral health. ‍ ‍ documentation, and/or consultation report injuries that are concerning The point at which to consider with experts when appropriate. for abuse or neglect to child ’ a parent negligent and begin Furthermore, injuries that are protective services in accordance intervention occurs after the parent inflicted by a perpetrator s mouth with local or state legal has been properly alerted by a health or teeth may leave clues regarding requirements. Abusive injuries ’ care provider about the nature the timing and nature of the injury frequently involve the face and and extent of the child s condition, as well as his or her identity. oral cavity and, thus, may be first the specific treatment needed, and Health care providers should be encountered by dental providers. the mechanism62 of accessing that knowledgeable about such findings, treatment. Because many families their significance, and how to 2. Similarly, sexual abuse may face challenges in accessing dental meticulously observe and document involve the mouth, even without care or insurance for their children, them. When questions arise or overt signs, and thus, health the health care provider (including consultation is needed, a pediatric care providers (including dental the dental provider) will evaluate dentist or a dentist with formal providers) should know how whether dental services are readily training in forensic odontology can to collect a history to elicit available and accessible to the ensure appropriate testing, diagnosis, this information as well as ’ child when considering whether and treatment. how to appropriately collect negligence has occurred. A child s laboratory tests to support Pediatric dentists and oral and social, emotional, and medical ability forensic investigations. The maxillofacial surgeons, whose to undergo treatment also should be general provider is encouraged advanced education programs considered when determining dental to become aware of and consult 64 include a mandated child abuse neglect. with appropriate specialists in curriculum, can provide valuable his or her area for specialized To the best of his or her ability, information and assistance to other forensic interviews and specimen the health care provider should health care providers about oral collection. be certain that the caregiver and dental aspects of child abuse 3. Bite marks found on human understands the explanation of the and neglect. The Prevent Abuse and65 disease and its implications and, Neglect through Dental Awareness skin are challenging to interpret when barriers to the needed care coalition (http://​www.​healthy.​ because of the distortion exist, attempt to assist the family in arkansas.​gov/​programsServices/​ presented and the time elapsed finding financial aid, transportation, oralhealth/​Pages/​PANDA.aspx),​ between the injury and the or public facilities for needed which has trained thousands of analysis. Ideally, the pattern, size, services. Risks and benefits of dental physicians, nurses, teachers, child contour, and color of the bite treatment should be explained, care providers, dentists, and other mark should be evaluated by a and parents should be told that dental providers, is another resource forensic odontologist when one is appropriate analgesic and anesthetic for physicians seeking information available. ’ procedures will be used to ensure on this issue. Physician members of 4. Health care providers (including the child s comfort during dental multidisciplinary child abuse and dental providers) are encouraged procedures. If, despite these efforts, neglect teams are encouraged to to ask their patients about the parent fails to obtain therapy, identify such dental providers in their bullying and advocate for the case should be reported to the communities to serve as consultants antibullying programs in schools appropriate62 child protective services for these teams. In addition, medical and other community settings. agency. providers with experience or Conclusions expertise in child abuse and neglect 5. Health care providers (including can make themselves available to dental providers) should be dentists and dental organizations aware of the risk factors for as consultants and educators. Such human trafficking, identify these It is important for health care efforts will strengthen our ability to in their patients (both girls and providers (including dental prevent and detect child abuse and boys), safely connect the patients providers) to be aware that physical neglect and enhance our ability to to resources, and advocate for or sexual abuse may result in oral care for and protect children. antitrafficking efforts. or dental injuries or conditions. Recommendations Health care providers should be 6. If parents fail to obtain therapy aware of when and how to document after barriers to care have been suspicious injuries and how to 1. Health care providers (including addressed, the case should be obtain laboratory evidence, photo dental providers) are required to reported to the appropriate child Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 140, number 2, August 2017 5 Jeffrey Karp, DMD Harriet MacMillan, MD, American Academy of Child and Adolescent Psychiatry protective services agency as Liaisons Elaine Stedt, MSW, Office on Child Abuse and Neglect, Administration for Children, Youth and concerning for dental neglect. Amr Moursi, DDS, PhD, American Academy of Families Pediatric Dentistry 7. Providers are encouraged to Anne Clancy, RDH, MS, American Dental work with colleagues (including Association Staff psychological and educational Tammy Piazza Hurley resources) to provide support Staff to families if any of the American Academy of Pediatric Lauren Barone, MPH Dentistry aforementioned maltreatment has Council on Clinical Affairs occurred. AAP Committee on Child Abuse and Lead Authors Council on Scientific Affairs Neglect, 2015 2016 Susan A. Fisher-Owens, MD, MPH, FAAP – Ad Hoc Work Group on Child Abuse and Neglect James L. Lukefahr, MD, FAAP Emalee G. Flaherty, MD, FAAP, Chairperson Anupama Rao Tate, DMD, MPH Sheila M. Idzerda, MD, FAAP Lori A. Legano, MD, FAAP AAP Section on Oral Health Executive John M. Leventhal, MD, FAAP Abbreviations Committee, 2015–2016 James L. Lukefahr, MD, FAAP Robert D. Sege, MD, PhD, FAAP David Krol, MD, MPH, FAAP, Chairperson Patricia Braun, MD, MPH, FAAP Liaisons Susan A. Fisher-Owens, MD, MPH, FAAP AAP: American Academy of Rani Gereige, MD, FAAP Beverly Fortson, PhD, Centers for Disease Control Pediatrics Lisa Jacob, DDS and Prevention ABFO: American Board of Forensic Odontology

DOI: https://​doi.​org/​10.​1542/​peds.​2017-​1487

Address correspondence to Susan A. Fischer-Owens, MD, MPH, FAAP. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2017 by the American Academy of Pediatrics and American Academy of Pediatric Dentistry. FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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Downloaded from www.aappublications.org/news by guest on September 28, 2021 8 FROM THE AMERICAN ACADEMY OF PEDIATRICS Oral and Dental Aspects of Child Abuse and Neglect Susan A. Fisher-Owens, James L. Lukefahr, Anupama Rao Tate, AMERICAN ACADEMY OF PEDIATRICS, SECTION ON ORAL HEALTH, COMMITTEE ON CHILD ABUSE AND NEGLECT, AMERICAN ACADEMY OF PEDIATRIC DENTISTRY, COUNCIL ON CLINICAL AFFAIRS, COUNCIL ON SCIENTIFIC AFFAIRS and AD HOC WORK GROUP ON CHILD ABUSE AND NEGLECT Pediatrics 2017;140; DOI: 10.1542/peds.2017-1487 originally published online July 31, 2017;

Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/140/2/e20171487 References This article cites 51 articles, 11 of which you can access for free at: http://pediatrics.aappublications.org/content/140/2/e20171487#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Current Policy http://www.aappublications.org/cgi/collection/current_policy Council on Child Abuse and Neglect http://www.aappublications.org/cgi/collection/committee_on_child_a buse_and_neglect Dentistry/Oral Health http://www.aappublications.org/cgi/collection/dentistry:oral_health_s ub Section on Oral Health http://www.aappublications.org/cgi/collection/section_on_pediatric_ dentistry_and_oral_heath Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news by guest on September 28, 2021 Oral and Dental Aspects of Child Abuse and Neglect Susan A. Fisher-Owens, James L. Lukefahr, Anupama Rao Tate, AMERICAN ACADEMY OF PEDIATRICS, SECTION ON ORAL HEALTH, COMMITTEE ON CHILD ABUSE AND NEGLECT, AMERICAN ACADEMY OF PEDIATRIC DENTISTRY, COUNCIL ON CLINICAL AFFAIRS, COUNCIL ON SCIENTIFIC AFFAIRS and AD HOC WORK GROUP ON CHILD ABUSE AND NEGLECT Pediatrics 2017;140; DOI: 10.1542/peds.2017-1487 originally published online July 31, 2017;

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/140/2/e20171487

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2017 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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