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Children’s behavior and their priorities are shaped through parental personal experiences and subliminal messages transmitted by the social, political, and economic system. So far, the prevention of dental problems does not seem to be among them.
In the 21st century, in Romania, many adults only visit the dentist if they have a painful or aesthetic emergency, and then ignore the treatments, after these problems were solved.
Here, we do not talk about the psychological reasons behind this behavior – the fear of the dentist – or about the often precarious socio-economic conditions, nor about the acute lack of dental social insurance. We are talking about prevention, because this topic is not yet taken seriously in Romania and because adults, as parents, usually apply the same dental and health habits to their children.
Traditionally, the dental team has adhered to this concept of on-demand treatments. But when the patients are minors, whether younger or older, preschoolers or pupils, healthy or with vulnerabilities or special needs, who cannot eloquently express their pain, they cannot understand or appreciate the benefits of early prevention and treatment or the complications of and the lack of any treatment, we can suspect and accuse their parents of indifference, negligence and even dental abuse.
Although the terms negligence and/or carelessness were originally developed within the concept of general child abuse, they are now applicable in any discussion of a specific abuse. These forms of child abuse refer not only to physical abuse.
Nowadays you can also be accused if you pull your child by its ears. The child’s neglect of his or her emotional, educational, and physical and mental development needs is also abuse. According to the American Academy of Pediatric Dentistry, the dental abuse of a child (1) is defined as the intentional parental neglect to seek specialist advice and follow the necessary treatments to ensure an essential level of oral health, for the correct functions of the oral cavity unimpeded by pain and/or infection. Caries and its complications at children can be the result of ignorance or lack of knowledge of their parents about the etiology and mechanisms involved in the development of caries, but also because of the difficulties in implementing a correct diet or dental hygiene measures, as it is seen at dysfunctional households.
Other indicators that may suggest dental negligence on the parental part are the following:
- postponing the time of the first consultation because of the child’s being too young;
- frequent feeding the child with cariogenic foods (either natural or containing added sugar);
- accidental, irregular and/or repeated visits, canceled appointments;
- discontinuation of treatments before their completion;
- repeated emergency appointments and requests for extractions through analgesia or general anesthesia.
What do other countries do regarding this matter?
More developed societies — such as Australia — have created The Dental Neglect Scale (DNS) with applicability in predicting and understanding the variations in dental health and in designing and targeting strategies on dental health promotion. The questionnaire has seven items, preferably completed by a qualified dental assistant, in an interview with the parents. The answer to each item has five levels of values and, in translation, it looks like this: Analysis of the DMFS index (which calculates the prevalence of caries at an individual) of a group of teenagers in Australia revealed a high correlation between component D (decay – cavities) and the score of negligence scale. In other words, children whose parents have a high score of dental negligence also have the most untreated caries.
Different resource allocation, a problem
However, it would be incorrect and incomplete if we only blame the negligence and the role of family in the dental negligence of he/ she is a child/teenager. And that explains why Coleman’s (2) model of an individual’s health behavior shows that it involves three categories of factors:
- individual factors (education, age, general health, home);
- social / contextual factors (parents/ school);
- structural factors (dental health medical system, hygiene marketing of products or cariogenic/ healthy foods, fluoridation public system of water, table salt, milk or bread, etc.).
Thus, talking about “abuse through structural negligence” means talking about negligence embedded in the social, political and economic system of the society, because abuse can also mean different allocation of goods, resources, opportunities between different social groups, due to its structure that regulates their relationship.
The origins of this abuse must be sought both in the structural and traditional set of values, and in the way in which language serves the needs of the dominant institutions and ideologies.
Example 1:
a) Quoted from a protest letter (3,4) addressed by doctors, leaders of Professional Associations to the Ministry of Health and Family: “Beginner” doctors who have treated only children have are on the maximum level “.
b) Among the quality criteria per dentist, in the Implementing Rules of the Framework Contract of the Health Insurance House in the year 2003 (5), it was introduced the differentiation between those who assisted, in 2002, mainly adults or children patients. The criterion has a financial advantage for the latter, ie those with patients under 18 years old. But, surprisingly, in the weekly Medical Life (6) a concern arises: “In the future, who will treat retirees if the dentists will focus their activity, for financial reasons, exclusively on children?”
Example 2: lack of dental monitoring and any measures to prevent caries of the children with chronic diseases and long-term medication (pediatric medication is usually sweetened with sugar, also very cariogenic);
Example 3: lack of the Dental Home service (which provides consultations and preventive dental counseling services at home);
Example 4: lack of the re-call / patient informative services regarding periodic checks;
Example 5: lack of any school dental offices. In 1972, in Denmark, all children aged 6 to 16 were included in a free dental care program (7.8). When I was a kid, in the 1970s, I benefited from the obligatory and free regular dental visits to the school’s dental office. But if today in Romania these dental services almost no longer exist, in Denmark, a recent official legislative document – Act on dental care – which extends this program and establishes provision of regular and free dental care to all children aged 0 to 16;
Example 6: lack of any fluoridation measures on potable water, but also lack of fluorinated tablets in Romanian pharmacies (9);
Example 7: lack of the non-invasive and minimally invasive periodical-preventive prophylactic approach of dental services, through financial reasons, (this being currently predominantly surgical-curative and on-demand).
Instead of a conclusion, take this piece of mind: from our perspective, there are any absolute truths or universal ethical positions, because there are too many factors that operate in any social situation. This qualitative study only offers the social “story” of this subject, “Children and teenagers, victims of dental negligence.” Unfortunately, knowing the prevalence and causes of a social problem does not always tell us of the most effective ways to solve or change it. But if we do not take the task of monitoring it, we will not obtain the needed information that is indispensable for our predictive practice. Dr. Nicoleta van Gelder
Bibliography
- Curzon M. European Journal of Paediatric Dentistry, Editorial, Nr.2/vol 4, 2003, p. 58
- Coleman J. Resources for social charge. New York: Wiley-Interscience, 1971, 13
- Scrisoarea AMSPPR către Ministerul Sănătăţii şi Familiei, Nr. 131, 07.94.2003, Stomatologia privată, Quo vadis? Nr. 3, iunie, 2003
- Stomatologia privată. Buletin informativ Naţional. Quo vadis? 2002 AnV, Nr. 3-4, p. 23
- Serviciul Contractări CAS, Circulara Nr. 8345, 30 mai, 2002
- Viaţa medicală, Nr. 14, 4 aprilie, 2003, Atitudiniale CMR, p. 5
- Schwartz E. Dental programmes for children and young adults in Denmark in a social perspective. Scand J Prim Health Care 1985; 3: 113-20, 16
- Lissau I., Hoist D., Friis Hasché E. Use of dental services among Danish youths: role of the social environment, the individual, and the delivery system June 1989, https://doi. org/10.1111/j.1600-0528.1989.tb00001.x
- https://ec.europa.eu/health/scientific_committees/opinions_layman/fluoridation/en/l-3/1.htm#0
The article was first published in the Medical Life journal, issue No. 1st of January 10, 2020
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