Dr Hawazen N. Sonbol Department of Orthodontic & Paediatric Dentistry University of Jordan PO Box 13850 Amman 11942 Jordan Tel: 00962 6 5355000 Fax: 00962 6 5300248 e-mail: email@example.com
Background: Signs of physical abuse often present in the oro-facial region and dentists are in a strategic position to recognise and report suspected cases. The aim of this study was to assess the knowledge, educational experiences and attitudes of Jordanian dentists towards child abuse and to assess their educational needs.
Methods: A cross-sectional survey of a random sample of Jordanian dentists (n = 400) was conducted using an anonymous, self-administered structured questionnaire.
Results: The response rate was 64%. Thirty-four per cent (n = 88) of the respondents reported having formal training in recognising and reporting child abuse, and 42% (n = 106) had post-qualification/continuing education training on the topic. Half of the dentists (127/256) suspected a case of child abuse in the past 5 years, but only 12% (31/256) reported their suspicions. The main reasons for not reporting suspicions of abuse were fear from anger of parents (43%), uncertainty about diagnosis (41%) and uncertainty about referral procedures (41%). Those dentists who had formal training in dental school (P = 0.0001) and post-qualification courses in child abuse (P = 0.006) were significantly more likely to report suspicions.
Conclusions: A significant gap existed between recognising signs of physical child abuse and responding effectively. Improvements in child abuse education and continuing education courses are advised to provide dentists in Jordan with adequate knowledge of indicators of physical child abuse and to inform them on the protocol to follow when suspicions arise.
Physical child abuse is now recognised as an international issue and has been reported in many countries (1–5). Prevalence figures are difficult to obtain, but some studies have attempted to reveal the extent of the problem in the Middle East. The WHO Global Burden of Disease Database estimates that 1.2 million children experienced some form of violence in 2004 in the WHO Eastern Mediterranean Region (6). A recent survey looking at the extent of child abuse and maltreatment in the same region found that 43% of boys and 29% of girls between 13 and 15 years were physically or psychologically abused in 2006—2007 (7). Figures in Jordan reveal that the reported cases of child abuse are increasing, with 295 reported cases in 1998 and 1423 reported cases in 2004 (8).
At least 50% of cases diagnosed as child physical abuse have orofacial trauma, which may or may not be associated with other injuries elsewhere on the body (9, 10). Some authors believe that this region may be a central focus for physical abuse because of its significance in nutrition and communication (11) or because the head represents the whole being of the child (12). Unintentional or accidental injuries to the mouth and face must be distinguished from abuse by judging whether the history, including timing and mechanism of injury is consistent with the injury and child’s developmental capabilities. Body parts normally affected during an accidental fall include bony prominences such as the forehead, cheek bones, chin, elbows, hands, knees and shins. Soft fleshy areas such as the cheeks, ears, lips, mouth and neck are rarely accidentally traumatised (13). Parents who abuse their children tend to change their child’s physician frequently but are more likely to continue to visit their child’s dentist (14). Dentists are therefore ideally positioned to recognise and report child maltreatment. However of all reported cases of child abuse and neglect, only 1% were reported by dentists in a study in the United States (15). In Jordan, only 1% of cases were reported by healthcare professionals as compared to 75% by police, 9% by government ministries, 5% by schools and 1% by relatives (8).
Unfortunately research has shown that dentists are reluctant to report cases of child cases even in the presence of suspicions of maltreatment (16, 17). In a recent study looking at experience of dental professionals in the UK, there was a significant gap between recognising signs of abuse and responding effectively; 67% of respondents suspected abuse at some time in their career but only 29% had ever made a child protection referral (18).
Many of the barriers to the involvement of the dentist and the dental team in safeguarding patients stem from a lack of knowledge and training (18–20). If dentists were trained and more confident in their ability to recognise child abuse, more cases would be diagnosed and reported by the dental profession. Adair et al. (21) found that the likelihood of dentists to report child maltreatment was associated with a dentist’s exposure to continuing education. Therefore, the quality of the dental education is an important factor to increase the detection and identification of child maltreatment.
The aim of this study was to investigate the self-reported ability of dentists in Jordan to recognise and report child abuse and to record the knowledge of this group. A secondary aim was to assess the educational needs of these healthcare professionals.
Materials and methods
An anonymous self-administered 26 question survey was constructed using a multiple choice or true–false format based on previous questionnaires on the topic (22, 23). The questionnaire was translated into Arabic and piloted by 20 dentists and modified according to their suggestions. The questions were designed to obtain information on the demographics of the study population as well as to investigate four general topics of concern:
• Education and training in recognising/reporting child abuse
• Experience in reporting suspicions of child abuse
• Knowledge of social issues related to child abuse
• Knowledge of indicators of child abuse
The questionnaire was randomly distributed to Jordanian dentists during the Jordanian Dental Association Council election meetings. The election takes place on 1 day during which dentists come specifically to elect their representative. Dentists in Jordan may not practice dentistry unless they are registered members of the Jordanian Dental Association Council and its members include all sectors of the dental profession: private practice, universities and royal medical services. This meeting is an important event in the calendar for Jordanian dentists, and dentists from all areas in Jordan are required to attend to elect their representatives.
The dentists were asked to complete the questionnaire with the researcher available for any questions and then returned to the researcher at the same meeting. Dentists could not take the questionnaire with them to return it later so that they would not be tempted to correct or check any of the questions relating to their knowledge of child abuse. Discussion with colleagues was also discouraged to ensure accurate representation of the dentist’s knowledge in relation to their demographic data and educational experiences. As the researcher dealt with the respondents personally, there was no risk of the same dentist completing the questionnaire more than one time.
All data management and statistical analyses were carried out using SPSS version 16.0 (SPSS Inc). Descriptive statistics and frequencies were generated for each of the above categories. Factors relating to the suspicion and reporting of child abuse were tested using the chi-square test. Binary logistic regression was also used to determine the odds ratios for significant factors. Statistical comparison of the average number of correct answers to questions on social issues and indicators of child abuse were conducted using the independent samples t-test. Statistical significance was set at a level of 5% (P < 0.05).
Of the 400 dentists surveyed, 280 returned the questionnaires. A small number of respondents (n = 24) did not answer all the questions and these were excluded from the study. The final number of respondents was 256, who gave a response rate of 64%. The sample was representative of all dentists in Jordan (n = 6000) at a 90% confidence interval and 5% margin of error.
Characteristics of the respondents and their practices
The characteristics of the respondents and their practices are shown in Table 1. The mean years of experience for the respondents was 7.7 years (SD 8.4).
Table 1. Gender, dental practice and years of experience of respondents (n = 256)
Ministry of health
Royal Medical Services
Fixed and removable prosthodontists
Education, training and reporting child abuse
Table 2 shows the distribution of education and training factors and dentists beliefs’ towards the importance of child abuse recognition for all dentists (n = 256), GDP’s (n = 208) and specialists (n = 48). There were significantly more dentists who believed that recognition of child abuse was ‘extremely important’ for those who had formal education (P = 0.004), and those who had continuing education courses (P = 0.003) compared with those who did not.
Table 2. Distribution of education and training factors and beliefs regarding importance of child-abuse recognition for all dentist, GDPs and specialists
Beliefs regarding importance of child-abuse recognition
Not so important
All dentists (n = 256)
GDP’s (n = 208)
Specialists (n = 48)
Oral surgeons (n = 21)
Paediatric (n = 8)
Orthodontists (n = 6)
Periodontists (n = 6)
Prosthodontists (n = 7)
Experience with suspected child abuse
Figure 1 shows the number of respondents who suspected a case of child abuse in the past 5 years and the number who reported a case for all dentists (n = 256), GDP’s (n = 208) and specialists (n = 48). For all dentists questioned, a 38% gap was noted between recognising and reporting suspected cases; 50% suspected abuse but only 12% reported their suspicions. Seventy-seven per cent (98/127) of all dentists who had suspected abuse at some point in the past 5 years had decided not to refer the child.
Seventy-one per cent (15/21) of oral surgeons suspected child abuse but only 3 (14%) reported their suspicions. Of the eight paediatric dentists recruited, 6 (75%) had suspicions but only 2 (25%) reported them. Sixteen per cent (1/6) of the orthodontists and periodontists recruited reported a case of child abuse, whilst none of the prosthodontists recruited made a child protection referral although two of seven had suspicions.
The respondents had many different reasons for not reporting child abuse to the authorities. More than one answer could have been chosen by each respondent. Reasons given for the lack of reporting of all dentists (n = 98), GDP’s (n = 77) and specialists (n = 21) who suspected but did not report the suspected abuse are shown in Table 3. Oral surgeons (n = 12) mostly were influenced by uncertainty of referral procedures (33%; 4/12) and fear of family and parents being angry (25%; 3/12). Amongst the small number of paediatric dentists (n = 4) and orthodontists (n = 1) questioned, uncertainty about diagnosis and lack of knowledge of referral procedures were the main concerns.
Table 3. Reasons for not reporting suspicions of child abuse by those dentists who suspected child abuse but did not report their suspicions
All dentists (n = 98) n (%)
GDP’s (n = 77) n (%)
Specialists (n = 21) n (%)
Fear of anger from parents and family
Lack of knowledge of referral procedures
Uncertainty about diagnosis
Lack of adequate history
Possible effect on the child’s family
No legal obligation or authority to report
Possible effect on my practice
Fear of litigation
No reason given
The respondents were given a chance to add any reason for not acting on their suspicions not included in the questionnaire. Some of the added comments included, ‘because I think that using slight force is ok’ and ‘I don’t think anything would be done’. One oral surgeon replied that the ‘case was resolved with the parents’.
There was no statistically significant difference in gender, years of practice, job type or types of training for suspecting abuse. However, significantly more men reported child abuse than women (P = 0.04). In addition, those who had formal training in dental school (P = 0.0001) and post-qualification courses in child abuse (P = 0.006) were significantly more likely to report suspicions. Logistic regression was carried out, and it was found those who had a formal education were 3.2 times more likely to report abuse than those who did not have child-abuse education in their curriculum (Table 4). In addition, those who attended post-qualification continuing education courses were 2.3 times more likely to report abuse than those who had not (Table 4).
Table 4. Characteristics of respondents in terms of reporting child abuse
Post-qualification training, instruction or courses in child abuse
Yes (n = 106)
7.8* (P = 0.006)
P = 0.04
No (n = 150)
Knowledge of child abuse
The number of respondents who correctly answered each social indicator question is shown in Table 5. The number of respondents who correctly answered each physical indicator question is shown in Table 6.
Table 5. Knowledge of the social indicators of child abuse
Children who have been abused, usually tell someone soon after the abuse
Do not know
If a child readily states that an adult has caused harm, the accusation should be addressed
Do not know
Child abuse and neglect are primarily associated with the stresses of poverty and rarely occur amongst middle- or high-income earners
Do not know
The abuser in most cases is someone the child knows well
Do not know
The best way to deal with suspected cases of child abuse is to confront the parents and accuse them directly of the abuse
Do not know
Table 6. Knowledge of physical indicators of child abuse
Bruises over bony prominences are suspicious of abuse (example chin, elbows, knees)
Do not know
Repeated injury to the dentition resulting in discoloured or avulsed teeth may indicate repeated trauma from abuse
Do not know
Burns are associated with many child abuse cases
Do not know
Bitemarks on a child should be investigated as an indicator of abuse
Do not know
Emotional and psychological signs of abuse may include fear of going home or of the parents
Do not know
A history that is vague and differs every time the parent tells it is a possible indicator of abuse
Do not know
For the social indicators, 27% (n = 70) of the respondents answered four of five questions correctly with only 12% answering all five questions correctly and one respondent (0.4%) answering all questions incorrectly. Approximately half (47%; n = 121) answered four of six answers correctly for the physical indicators, but only 7 (3%) answered all six questions correctly, whilst four respondents answered all physical indicator questions incorrectly.
The mean score for all 256 respondents was 6.9 (SD 1.7). The highest mean scores were recorded for paediatric dentists (8.1, SD 1.6) followed by orthodontists (7.0, SD 2.0), and the lowest scores were recorded for the oral surgeons (6.6 SD 1.7). Table 5 shows the mean scores for different groups according to gender, years in practice, job type, undergraduate formal training, reading literature and post-qualification continuing education courses. Mean scores were significantly higher for women compared with men, those who had less than 5 years of experience, those in the public sector, those who had formal training in dental school, read literature on child abuse and attended post-qualification continuing education courses (Table 7).
Table 7. Mean scores according to sub-groups of Jordanian dentists
Male (n = 160)
P = 0.0001
Female (n = 96)
Years in practice
<5 years (n = 122)
P = 0.0001
≥5 years (n = 134)
Private vs. public sector
Private (n = 149)
P = 0.001
Public (n = 107)
Formal training in dental school
Yes (n = 88)
P = 0.0001
No (n = 168)
Read literature on child abuse
Yes (n = 154)
P = 0.04
No (n = 102)
Post-qualification training, instruction or courses in child abuse
Yes (n = 106)
P = 0.001
No (n = 150)
This cross-sectional study was carried out to investigate the ability of dentists in Jordan to recognise and report child abuse and to assess their knowledge and educational needs. The sample of 256 dentists was representative of all dentists in Jordan with mostly GDP’s and a small number of specialists corresponding to the random manner in which the sample was taken. The number of specialists recruited in this study was small, and as a result, it is not possible to draw any conclusions from the results and comparisons between the different specialists. Further research with a larger sample of specialists is needed.
The response rate of 64% is higher than most other studies using postal questionnaire as this study was carried out with the researcher available for one on one interaction with the respondents. Distribution of questionnaires personally was preferred to postal questionnaire to avoid the temptation by the respondents to check and possibly correct their answers to questions related to knowledge of child abuse resulting in inaccurate results for the level of knowledge amongst dentists. The Dental Association Council election meeting was chosen as a venue as this is when all Jordanian dentists from all sectors of the dental services and from all parts of Jordan are available. The elected Jordanian Dental Association Council members are responsible for organization of professional dental training, the continuing education courses and conferences in Jordan as well as overseeing union issues such as health insurance for dentists and their families and retirement pensions. Therefore, the election meeting is one which dentists are most likely to attend regardless of their academic standing or interest in continuing education. However, it is difficult to be sure that the dentists recruited were typical of all Jordanian dentists and there may be bias in terms of the respondents’ characteristics with those who attended being more interested in board elections and other council matters.
It was found in this study that 50% of respondents suspected physical child abuse which is similar to the 42% who suspected abuse in an earlier study in Jordan (24) but higher than that reported in most worldwide studies of dentists (19, 22, 25–29). This proportion is similar to a recent study of Texas dentists (15) but lower than a study of dentists with an interest in paediatric dentistry, in the UK (18). A possible explanation for this high proportion of dentists with a suspicion of physical child abuse is the fact that Jordan has a relatively young population; 42.2% are 14 or younger (30). This means that a larger number of children are being treated by dentists and as a result there may be more occasions when suspicions arise.
Only 12% of the respondents in this study made a child protection referral or report representing a 38% gap between recognising and reporting suspected cases. This large gap was also seen in Nigerian dentists (29) and in the UK (18). Although this study only asked for at least one case that was reported, it does not take into consideration the number of cases of child abuse that were suspected but not reported by the same individual. Therefore, the actual percentage reported may be an overestimate when the number of children is considered.
The main reasons for Jordanian dentists not to report cases that had otherwise been suspicious were fear of anger from parents/family, uncertainty about referral procedures and uncertainty about diagnosis. Uncertainty about diagnosis was similarly an influencing factor for dentists in Australia (25), Scotland (19), the UK (18), Northern Ireland (23), Denmark (27), the US (22, 31) and Nigeria (29). Uncertainty about referral procedures is a major issue for Jordanian dentists and remains a major factor, whilst in other parts of the world this has become a less influential although not unimportant (18, 22, 28). In a survey of dentists, doctor and nurses in Northern Ireland, it was found that a lower percentage of dentists (18%) compared with nurses (44%) and GPs (38%) knew the mechanisms for reporting child physical abuse and they had lower scores in identifying abuse compared with nurses and GP’s (23). These uncertainties may be lessened by adequate child protection training (17). Factors which few Jordanian dentists were influenced by in reporting their suspicions were fear of litigation and impact on their practice. This is similar to other studies (18, 25).
Education is the critical factor in enhancing the ability of professionals to detect cases and increase their confidence and commitment to reporting suspicious cases. An analysis of the sources of information about child abuse for Jordanian dentists showed that 34% of dentists in Jordan had formal education in child abuse. This is higher than results from the UK (18), the US (22, 26) and in Scotland (19) but similar to dental therapists in the UK (32). It was found that in terms of reporting abuse, formal education was an important factor with those who had education as part of their dental training being 3 times more likely to report the abuse than those who had not. In Jordan, both the dental schools devote only one or two class hours to this topic. This is similar to accredited dental schools in the United States and Canada (16).
Forty-two per cent of the respondents had undertaken post-qualification training which is higher than 16% reported in the US (22) and Scotland (19) and 33% in the US (26) but lower than 87% reported for dental professionals with an interest in paediatric dentistry in the UK (18). Sixty per cent of dentists in this study read literature on the subject which is comparable to 56% reported in the US (26) but lower than 84% reported by dentists in California (22).
Education factors also influenced Jordanian dentists’ beliefs in realising how important recognising signs of child abuse are by the dental profession. It is promising that only a small number of the respondents believed that child abuse recognition by the dentist was ‘not so important’.
In terms of the different dental specialities in this study, the results give an idea of the distribution of education and knowledge factors in each field, although the number of specialists recruited was small and are not representative of specialists as a group. It was found that most of the paediatric dentists questioned (63%) had formal education in their curriculum for child abuse. In comparison, a relatively small percentage of oral surgeons (36%) had formal training in this topic. In addition, 71% of oral surgeons suspected abuse (15/21), but only three reported their suspicions. This may be an area of concern as most severe cases of child abuse may present to surgeons compared with other dentists. However, it is not possible to confirm this point from the small number of specialists and a larger sample would be needed to verify these findings. Of the eight paediatric dentists, six found situations that were possibly because of child abuse and only two specialists (25%) reported these patients which is similar to results reported in Australia where 24/45 (54%) of paediatric dentists suspected abuse but only 11 (23%) reported it (25).
An important prerequisite for reporting suspected cases of child abuse is the basic knowledge about what to look for and how to diagnose these cases. The results in this study show that the knowledge of the respondents about the indicators of child abuse was unsatisfactory with 12% of respondents answering all five social indicator questions correctly and only 3% answering all six physical indicator questions correctly. It is noteworthy that only 29% correctly answered that the child does not tell someone soon after the abuse with 36% of the respondents not knowing the answer. It appears that this is a serious misconception by most of the Jordanian dentists where they expect the child to ‘diagnose’ himself as abused and be responsible for communicating the abuse to someone, relieving dental professionals of their role in the detection of maltreatment. Of note also is that 54% of the respondents thought that bruises over bony prominences are suspicious of abuse when they are in reality most likely due to accidental injury (13). This compares poorly with 63% of dentists in the US who answered this question correctly (22). The results of this question may explain the high proportion of dentists being suspicious of child abuse in this study as opposed to other studies around the world (19, 22, 25–29).
The significantly higher knowledge mean scores for dentist who had formal training, read literature and attended continuing education courses on child abuse further highlights the importance of education in all its forms in adding to the knowledge of dentists. Interestingly it was found that those dentists who have been in practice for <5 years had significantly higher scores than those who had been in practice for more than 5 years (P = 0.0001). A similar finding was found by Welbury et al. (17) with dentists that had <15 years experience being more aware of child-abuse issues. This may be explained by the fact that child-abuse education has been recently added into the dental curricula of the dental faculties in Jordan. This has also been documented in the US, where it was found the time dental schools spent educating students about child-abuse issues has increased over the past 20 years (16).
In addition, it was found that Jordanian dentists working in the public sector were found to have significantly higher mean scores than dentists in the private sector. The municipal dental services (the Royal Medical Services and the Ministry of Health), in addition to the two main universities in Jordan, are responsible for internship training of undergraduate and postgraduate dental students and are therefore more likely to be knowledgeable of child-abuse indicators.
Results of this survey suggest that dentists in Jordan need more extensive and effective education to increase their knowledge and awareness of all the aspects of child abuse and to recognise the signs of this abuse so they can detect and report suspected cases. The education that is given in dental schools at the present time most frequently occurs in a classroom setting and may not be reinforced in clinical settings. Therefore, it is important that improvements in the curriculum occur to provide dental students concrete educational experiences about the process of detecting and reporting child abuse specifically oriented to the country.
For reporting abuse, it is important that dental care providers have reporting materials ready and a plan of action in place to address abuse should it present itself in their practice (33). Production of training documents for the dental team may be a good introduction to achieve this goal. In addition, continuing professional development courses should be provided for dentists. Interactive multimedia tutorials tailored to dental professionals have shown promising results in helping dentists improve their knowledge and attitudes with respect to victims of domestic violence (34). This is similar to what is provided for dentists in the UK where they are encouraged to access on-line training for abuse by receiving continuing professional development (CPD) points (20). Use of such training methods in Jordan would be helpful.
It is important to realise that to act on a suspicion of child abuse, dentists must believe that their interventions will make a difference. Therefore, there should be better communication with protection agencies that are responsible for investigating and supporting maltreated children. In addition, legal issues and ethical questions related to dentists reporting child abuse should be addressed.
Our study showed a significant gap between recognising signs of physical child abuse and responding effectively. In addition, knowledge of Jordanian dentists about the indicators of physical child abuse is poor and needs to be improved. The main reasons for dentists not reporting child abuse included uncertainty about diagnosis and referral procedures. Addressing these two issues with improvements in dental education and continuing education courses are advised.