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Introduction

The prevalence of abuse and neglect among the United Kingdom population is difficult to accurately ascertain and is most certainly under reported. It is our duty as healthcare providers to be vigilant in the identification and support of people affected by abuse; principle eight of the General Dental Council (GDC) ‘Standards for the dental team' dictates that we must ‘Raise concerns if patients are at risk'.1 The general dental practitioner may be the only healthcare professional that these patients encounter, and it is therefore crucial that we are familiar with signs and indications of abuse, common terminology, and safeguarding pathways. This article describes a series of tips and recommendations for the appropriate management of these issues.

  1. 1.

    Ensure your training is up to date and relevant to your role

Principle seven of the GDC Standards requires us to ‘Maintain, develop and work within your professional knowledge and skills'2and two of the five GDC recommended continuing professional development topics are ‘Safeguarding of children and young people' and ‘Safeguarding of vulnerable adults'. 3Furthermore, reporting of domestic abuse is facilitated by a perception of the healthcare provider being knowledgeable and capable of handling abuse.4,5 It is therefore essential that all members of the team understand common terminology and be appropriately competent. A glossary of common terminology that you should be familiar with is shown in Table 1.

Table 1 Glossary of commonly used terms
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  1. 2.

    Be aware of signs of abuse and neglect

Abuse is defined as treatment with cruelty or violence for a bad purpose or to bad effect. These can be isolated incidents or repeated and may affect any number of people. There are many types of abuse including physical, sexual, financial, discriminatory, emotional, domestic, and organisational abuse, it is also applied in relation to neglect, self-neglect, and modern slavery.6

Neglect is the failure to provide proper care. Anyone can be affected, though vulnerable adults and children are more frequently impacted.

Neglect and abuse may go unnoticed, and people affected by abuse commonly feel unable to report their experiences. In the year ending March 2022, the Office for National Statistics (ONS) Crime Survey for England and Wales estimated that 5% of adults - approximately 2.4 million individuals - had experienced domestic abuse in the past year.7 In an NSPCC study in 2011, approximately 10% of the 2,275 children involved, aged 11-17, self-reported experiencing abuse or neglect.8 The ONS Crime Survey for England and Wales for March 2019 estimates the percentage of adults aged 18 to 74 who experienced physical abuse before the age of 16 at approximately 1.2% and emotional abuse at approximately 9%, only including incidents where perpetrators were over 16 years of age.9 All healthcare practitioners will almost certainly encounter people who have experienced harm, whether they know it or not.

In 2005, the Scottish Executive published the Get It Right For Every Child (GIRFEC) implementation plan. One of the primary policy actions promotes the use of eight indicators of well-being, acronymised as SHANARRI (Fig. 1).10 These indicators are interconnected and give a holistic view of each young person; using them helps consideration of strengths and obstacles to growth and development.

Fig. 1
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The GIRFEC wellbeing wheel reproduced with permission

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Frameworks help to direct our assessment but still require knowledge of the presenting signs that may indicate abuse.

Key things to look for include:

Physical abuse: Look for injuries in areas that are unlikely to have been accidentally injured, for example injury to the side or back of a patient's neck, bilateral ear injury and finger marks on the inside aspect of a patient's arms. Also consider whether the presentation matches the story and whether the story is consistent with all parties. Review notes for repeated injuries and consider if there has been a delay in seeking treatment. Pay attention to the body language and interaction of the patient with other people, notably with the accompanying person.

We should aim to identify the barriers our patients face when seeking care'

Domestic abuse: Domestic abuse should not be seen as isolated from the other types of abuse noted here. It may include aspects of physical and sexual abuse as well as having emotional and psychological elements. The dental team may observe or notice a change in the patient's demeanour or behaviour, including low self-esteem or seeming withdrawn. We may witness deferential behaviour to the wishes of an accompanying partner. If any unusual interactions have been observed by any members of the team such as a receptionist in the waiting room, this should be documented and addressed. Partners may speak on behalf of the abused, even when the patient is capable.

Psychological and emotional abuse: The patient may present with fearfulness, or deference towards their parent/guardian/carer/partner. There may be reported behavioural issues from the patient and they may display low self-esteem, anxiety, negativity and self-deprecation. In children look for attachment disorders and lack of appropriate parental response to the child's behaviour or actions.

Sexual abuse: Signs of sexual abuse may be observed in both adult and paediatric patients. Examples include bruising of the palate, torn fraenum/frenulae, inability to accept people in their personal space and the inability to accept instruments in their mouth.

Financial or material abuse: Patients may report the inability to pay for treatment and may disclose financial concerns to trusted dental team members. Financial proxies such as those with Power of Attorney may refuse to pay for treatment or even dispute the need for treatment or seem evasive and uncooperative in relation to settling a patient's bill.

Modern slavery: Although this may not seem immediately relevant to the dental team, having an awareness of the signs associated with Human Trafficking and Modern Slavery is essential as both types of abuse and criminality are seen nationally across the UK and internationally.

Signs to be aware of include lacking a CHI or NHS number. A complete lack of healthcare service engagement is suspicious. Patients may present for help with acute issues and may report dates of birth which do not appear consistent with physical appearances. Inconsistencies with family, social and living arrangements may also warrant investigation. Appearing malnourished, unkempt, or inappropriately attired for the situation and weather may also arouse suspicion.

  1. 3.

    Be vigilant and ask questions in an open and non-judgemental manner

Gathering information is essential to providing appropriate care. We should therefore aim to promote disclosure at every opportunity. A positive and trusting relationship is proven to facilitate disclosure.6,7,11,12,13,14,15,16,17 It is important to ask open questions which encourage patients to volunteer information. Individuals who have experienced abuse have stated that feeling a healthcare setting is safe and having confidence their disclosure would be kept confidential increased their likelihood of disclosing information.6,7,13,18However, transparent communication with patients is crucial and they should be informed that in certain circumstances it may be necessary to share information with other relevant services to ensure comprehensive and effective care.19

Avoid being judgemental, stay kind and calm while employing active listening. Show that you are taking the patient seriously. Ask about any concerns you have directly - vocalising difficult topics can help patients feel more comfortable talking about them.7

Remember to be tactful. Understand that a patient may not feel safe discussing some or any issues. Practitioners should therefore be attentive to signs of duress. If a patient appears unable to disclose information it may be beneficial to speak with them privately, for example in a radiography room. Also consider other methods of recording your assessment; clinical photos or drawings may be useful. Documentation of these events is also important.

  1. 4.

    Take thorough notes and know who the key colleagues are for individual patients

Principle 4.1 of the GDC Standards for practice requires us to ‘Make and keep contemporaneous complete and accurate patient records'.16 It is essential that information regarding other organisations supporting the patient be recorded for all vulnerable adults or children within our care. This should include contact details for the patient and their care workers, general medical practitioner, and school/nursery/childcare provider. It is also important to record the identity of any legal guardians and details of any social support involvement. Having this information available allows for effective and efficient inter-organisational coordination.

Patient notes should detail observations beyond the clinical assessment of oral health. This may include, but is not limited to, the patient's emotional state, feelings towards receiving care, attitude towards their carer, injuries (accidental or otherwise), and their attendance history. These recorded observations may help when attempting to identify and report both isolated and repeated incidents of abuse or neglect.

  1. 5.

    Know the legislation of the country you work in

England, Northern Ireland, Scotland, and Wales all have different procedures and legislation regarding the safeguarding of adults, though they have similar underlying aims. Table 2 illustrates some of the key points for these organisations.

Table 2 Adult safeguarding legislation
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The four nations of the United Kingdom also have different child protection systems and laws, though they are all based on similar principles.17Table 3 illustrates this.

Table 3 Child safeguarding legislation
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  1. 6.

    Be aware of your workplace policy on safeguarding/adult/child protection

All organisations in the UK that work with children or families must have safeguarding policies and procedures in place. There should be a Safeguarding Adults Policy and Procedure Document19 and a separate Safeguarding Child Protection Policy Statement, with accompanying procedures.20

A Safeguarding Adults Policy and Procedure Document provides a framework for responding to safeguarding concerns. It should define the roles, responsibilities, and accountability of the members of your organisation. Legislation, guidance, and procedures should be signposted, along with contact details for relevant agencies and people. You may also wish to include case studies related to your organisation.21

A Safeguarding and Child Protection Policy Statement sets out the organisation's commitment to protecting children and details how this will be implemented. The statement document should identify who it applies to, key contact details, the legislation and guidance supporting it, and the contact details of the most senior member of the organisation with a responsibility for safeguarding and child protection.

Accompanying procedures to the Safeguarding and Child Protection Policy Statement should outline the steps that must be taken if there are concerns about a child or young person's safety. There should be a procedure written for everyone who encounters children or young people. These documents should start with a summary of useful information, such as the types and signs of abuse, and follow with clear instructions on how to respond if you have concerns. Typically, this will involve reporting concerns to the nominated child protection lead, or their deputy. Remember, procedures should be clear, helpful, and concise.

  1. 7.

    Make a workplace contact list so that relevant phone numbers and email addresses are accessible, ensure everyone knows that it is there and where it is kept

GDC standard 8.5.1 states that ‘You must raise any concerns you may have about the possible abuse or neglect of vulnerable adults. You must know who to contact for further advice and how to refer concerns to an appropriate authority'.1 Creating a reference sheet with up-to-date information will ensure this standard can be followed; an accessible and well signposted summary of key contact details is a simple but effective enhancement to your organisation's safeguarding practice. All members of the organisation with a responsibility for safeguarding should be aware of the existence of this document and may benefit from multiple copies throughout their workplace.

‘It is important for professionals to trust their feelings when they perceive children to be suffering, and not make assumptions that others have also perceived it and are better placed to act. It is simpler to lift the telephone than to live with the regret of not having done so' - Laming Report 2009.22

As discussed, the relevant organisations and people are different for each nation. You may wish to include details of the following: secondary care services, Child Protection Services (England and Wales), Health and Social Care Trust Gateway Services (Northern Ireland), Children's Social Work Team or Children's Reporter (Scotland), and local police non-emergency services.

  1. 8.

    Be trauma aware and act in a trauma informed manner

It is essential that we practise in a way that is attentive to the wellbeing and unique needs of individuals who have experienced trauma. Procedures that may be considered harmless by a practitioner could be intensely distressing to the people in our care.23Asking patients to lie down, take off their coat, and then invading their personal space can be triggering.There are nine Principles of Sensitive Practice that contribute to the ‘Umbrella of safety'.24 These are respect, rapport, sharing control, taking time, sharing information, demonstrating an understanding of abuse, fostering mutual learning, understanding non-linear healing and respecting boundaries.

Most of these principles apply to our practice with all patients but can be particularly important when working with a vulnerable person. It has been pointed out many times that Trauma Informed Care has a high degree of overlap with good standard practice.23 Patients receiving care in a trauma informed manner will often require additional appointment time, which provides an opportunity to build rapport. Giving frequent explanations and getting step-by-step consent is beneficial for apprehensive patients; it may feel repetitive but ensures the patient retains control and can help manage their anxiety. Establishing, practising, and respecting a stop signal also promotes control and gives power to the patient over their health.

We should aim to identify the barriers our patients face when seeking care. Common barriers include a fear of consequences of disclosure,7,13,17,25,26,27fear of judgement,15,27 fear of broken confidentiality,17,25 and continuing fear of their abuser.7,15,16,17,28,29 It is important to recognise and follow up on any indications of abuse or neglect; this includes asking about negative body language or physical signs. This may be aided through affect labelling - a psychological technique in which an individual verbally expresses and labels their emotions. If a patient seems anxious it may be helpful to encourage them, in a compassionate and non-judgmental way, to put their ‘feelings into words' thereby reducing the conscious experience, psychological response and behaviour resulting from an emotional state.30 Opening the conversation promotes disclosure and improves rapport by demonstrating your understanding of, and investment in, the patient's health and emotions.

People affected by abuse may expect to be judged, admonished, and given bad news; subverting this expectation begins to build rapport immediately. It is therefore beneficial to start every examination with a positive comment; a supportive and complimentary remark sets a good tone.

Conclusion

Delivering care for vulnerable adults and children is an essential and meaningful aspect of dentistry. We have a unique opportunity to help and support individuals who may not be accessing other health or social care services. We have a responsibility to protect our patients and advocate for their needs, and we can provide care in a manner that enables and encourages our patients to feel empowered in their own health and lives.

It is essential that we remain compassionate, non-judgemental, and invested in our patients' well-being. When working to maximise the welfare of those in our care, your attention will be felt and appreciated by someone who needs your support.

All tables created by the Dundee Dental Connect group with full permissions given for publication.

Top tips are intended as a series of experiential tips, rather than a compendium of the evidence.