Human Trafficking. Part 2: The Role of Dental Professionals in Identifying Victims and Enabling Interventions

Figure 1. Prevalence of physical health issues in sex-trafficked women3Lederer LJ, Wetzel CA. The health consequences of sex trafficking and their implications for identifying victims in healthcare facilities. Ann Health Law 2014;23(1):61-91. https://www.icmec.org/wp-content/uploads/2015/10/Health-Consequences-of-Sex-Trafficking-and-Implications-for-Identifying-Victims-Lederer.pdf.

As noted in Part 1, the United States, as with other developed areas such as Western Europe, is a ‘destination country’ for human trafficking and a ‘top destination for child trafficking.1UNICEF USA. Child Trafficking. https://www.unicefusa.org/mission/protect/trafficking,2US Immigration and Customs Enforcement. Human Trafficking and Smuggling. https://www.ice.gov/factsheets/human-trafficking. The likely number of victims is in the hundreds of thousands. Given these facts, medical and dental professionals may well encounter potential victims at some point. In this article, we will address health conditions suffered by victims and the role of dental professionals in identifying and helping potential victims.

Physical and Mental Health Conditions in Victims
In a US-based study, 85.7% of sex-trafficked women reported at least one physical health issue, typically several, including loss of appetite (46.7%), extreme loss of weight (42.9%), eating disorders (36.2%) and malnutrition (35.2%).3Lederer LJ, Wetzel CA. The health consequences of sex trafficking and their implications for identifying victims in healthcare facilities. Ann Health Law 2014;23(1):61-91. https://www.icmec.org/wp-content/uploads/2015/10/Health-Consequences-of-Sex-Trafficking-and-Implications-for-Identifying-Victims-Lederer.pdf. (Figure 1) Further, 89% of victims reported depression, and other mental health issues included stress, anxiety, flashbacks, low self-esteem, personality disorders, and PTSD. More than 40% of victims had attempted suicide.3Lederer LJ, Wetzel CA. The health consequences of sex trafficking and their implications for identifying victims in healthcare facilities. Ann Health Law 2014;23(1):61-91. https://www.icmec.org/wp-content/uploads/2015/10/Health-Consequences-of-Sex-Trafficking-and-Implications-for-Identifying-Victims-Lederer.pdf.

In one study, more than 40% of sex-trafficked women had attempted suicide.

These findings are corroborated by studies worldwide. In a systematic review of thirty-one studies, the most common physical complaints among trafficked women, men and children were back pain (reported by up to 83% of individuals), stomach pain, dental pain, and dizziness.4Ottisova L, Hemmings S, Howard LM et al. Prevalence and risk of violence and the mental, physical and sexual health problems associated with human trafficking: an updated systematic review. Epidemiol Psychiatr Sci 2016;25(4):317-41. doi: 10.1017/S2045796016000135. Prevalent mental health complaints included depression, anxiety, PTSD, severe stress, and other disorders. Among sex-trafficked females, 33% to 90% reported physical and sexual violence. The prevalence of confirmed sexually transmitted infections and self-reported symptoms together ranged from 23% to 65.9%, with an almost two-fold risk of HIV infection estimated for sex-trafficked women compared to non-trafficked sex workers. Other health issues include unsafe abortion complications, substance abuse, malnutrition, skin conditions, gastrointestinal disorders, and respiratory diseases.5Schwarz C, Unruh E, Cronin K et al. Human Trafficking Identification and Service Provision in the Medical and Social Service Sectors. Health Hum Rights 2016;18(1):181-92.,6Nuzzolese E. Human trafficking: Role of oral health care providers. J Forensic Odontostomatol 2014;32 Suppl 1(Suppl 1):1-8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5734820/.

Figure 2. Percentage of victims reporting dental pain

Oral Conditions
Victims of trafficking report dental problems including dental pain, fractured teeth, and oral disease. In a systematic review, across five studies the reported prevalence of dental pain ranged from 10% to 58%.4Ottisova L, Hemmings S, Howard LM et al. Prevalence and risk of violence and the mental, physical and sexual health problems associated with human trafficking: an updated systematic review. Epidemiol Psychiatr Sci 2016;25(4):317-41. doi: 10.1017/S2045796016000135. (Figure 2) Dental problems were reported by 54% of individuals in a US-based study of sex-trafficked women, and almost 70% reported physical injuries, mainly to the face or head.3Lederer LJ, Wetzel CA. The health consequences of sex trafficking and their implications for identifying victims in healthcare facilities. Ann Health Law 2014;23(1):61-91. https://www.icmec.org/wp-content/uploads/2015/10/Health-Consequences-of-Sex-Trafficking-and-Implications-for-Identifying-Victims-Lederer.pdf.

Victims of Human Trafficking and Healthcare Access
Victims are frequently isolated and monitored, and fear their traffickers, law enforcement and deportation (if from overseas). As such, a medical or dental professional may be the first encounter that could help. Healthcare is recognized to play a significant role in identifying victims and for interventions.6Nuzzolese E. Human trafficking: Role of oral health care providers. J Forensic Odontostomatol 2014;32 Suppl 1(Suppl 1):1-8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5734820/. ,7Gielas A. Opfer von Menschenhandel erkennen [Identifying victims of human trafficking in the dental healthcare setting]. Swiss Dent J 2021;131(3):241-242. [German],8O’Callaghan MG. Human trafficking and the dental professional. J Am Dent Assoc 2012;143(5):498-504. doi: 10.14219/jada.archive.2012.0211. ,9Sutherland ME. Breaking the Chains: Human Trafficking and Health Care Providers. Mo Med 2019;116(6):454-456.,10American Public Health Association. Expanding and Coordinating Human Trafficking-Related Public Health Research, Evaluation, Education, and Prevention. Nov 3, 2015. https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2016/01/26/14/28/expanding-and-coordinating-human-trafficking-related-public-health-activities. Across several studies, it was reported that an estimated 30% to 87.8% of victims had accessed healthcare.3Lederer LJ, Wetzel CA. The health consequences of sex trafficking and their implications for identifying victims in healthcare facilities. Ann Health Law 2014;23(1):61-91. https://www.icmec.org/wp-content/uploads/2015/10/Health-Consequences-of-Sex-Trafficking-and-Implications-for-Identifying-Victims-Lederer.pdf.,5Schwarz C, Unruh E, Cronin K et al. Human Trafficking Identification and Service Provision in the Medical and Social Service Sectors. Health Hum Rights 2016;18(1):181-92. In one study, 26.5% of victims had seen a dentist, while overall 68% saw a healthcare provider.11Chisolm-Straker M, Richardson LD, Cossio T. Combating slavery in the 21st century: the role of emergency medicine. J Health Care Poor Underserved 2012;23(3):980-7. doi: 10.1353/hpu.2012.0091.

Role of Dental Professionals

Dental visits provide one-on-one opportunities for each member of the dental team to look for and detect general indicators (red flags; see Part 1) and more specific indicators suggesting trafficking. Information obtained while taking a medical and dental history, through observation, and during the patient’s examination includes environmental/social, psychological and physical signs that may be indicative of human trafficking.6Nuzzolese E. Human trafficking: Role of oral health care providers. J Forensic Odontostomatol 2014;32 Suppl 1(Suppl 1):1-8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5734820/. ,9Sutherland ME. Breaking the Chains: Human Trafficking and Health Care Providers. Mo Med 2019;116(6):454-456.,12Withers M. Dentists Are Integral to the Fight Against Human Trafficking Oral health often tells a story that trafficking victims cannot. April 8, 2020. https://www.psychologytoday.com/us/blog/modern-day-slavery/202004/dentists-are-integral-the-fight-against-human-trafficking. ,13Walshaw EG, Patel K. Modern day slavery and the responsibility of the dental team. BDJ Team 2020;23-27. https://www.nature.com/articles/s41407-020-0232-1.pdf?proof=t2019-5-29. Gut instinct also plays a role, resulting in the advice to pay attention ‘if you sense that something is ‘off’. ’9Sutherland ME. Breaking the Chains: Human Trafficking and Health Care Providers. Mo Med 2019;116(6):454-456. For environmental/social indicators, consider the following:6Nuzzolese E. Human trafficking: Role of oral health care providers. J Forensic Odontostomatol 2014;32 Suppl 1(Suppl 1):1-8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5734820/. ,9Sutherland ME. Breaking the Chains: Human Trafficking and Health Care Providers. Mo Med 2019;116(6):454-456.,12Withers M. Dentists Are Integral to the Fight Against Human Trafficking Oral health often tells a story that trafficking victims cannot. April 8, 2020. https://www.psychologytoday.com/us/blog/modern-day-slavery/202004/dentists-are-integral-the-fight-against-human-trafficking. ,13Walshaw EG, Patel K. Modern day slavery and the responsibility of the dental team. BDJ Team 2020;23-27. https://www.nature.com/articles/s41407-020-0232-1.pdf?proof=t2019-5-29.

  • Does the individual have their own address or are you told they are visiting a ‘friend’ or ‘relative’?
  • Does the individual have documentation and who carries it – the patient (if old enough) or the accompanying individual?
  • What does the patient do for a living?
  • Is the medical and dental history form complete, including the patient’s age, and does the information ‘jive’ with what you observe? In young individuals, your professional evaluation of the stage of development and appearance of the dentition may tell a different story.
  • Does the patient sound hesitant, stilted, or scripted?
  • Is your patient left alone with you?
  • Does the patient talk or does the accompanying individual control the conversation? How does your patient behave when this happens?
  • Who decides what treatment will be performed and who pays?
  • Is it a cash payment by the accompanying individual?
  • Does the patient seem poor yet have expensive cell phones/accessories?
  • Has care been delayed?

Language barriers may appear to be present. That may or may not be the case, as the patient may be fearful and the accompanying individual may be lying about a language barrier.12Withers M. Dentists Are Integral to the Fight Against Human Trafficking Oral health often tells a story that trafficking victims cannot. April 8, 2020. https://www.psychologytoday.com/us/blog/modern-day-slavery/202004/dentists-are-integral-the-fight-against-human-trafficking. This individual may also refuse the offer of an interpreter and instead directly translate for the patient; that provides an opportunity to change the message and the responses.12Withers M. Dentists Are Integral to the Fight Against Human Trafficking Oral health often tells a story that trafficking victims cannot. April 8, 2020. https://www.psychologytoday.com/us/blog/modern-day-slavery/202004/dentists-are-integral-the-fight-against-human-trafficking. For individuals that do need a translator, if possible, an official interpreter should be used.

Psychological indicators include a history of care/medications for psychiatric health issues, and the patient’s current state. Is the patient withdrawn, confused, tense, depressed, anxious, tearful? Does the patient avert their eyes and avoid your gaze? Does your patient seem ‘docile,’ distracted or ‘absent’? Is there a history or are there signs of substance abuse? Is there a request for pain killers? Substance abuse is a risk factor for being trafficked.9Sutherland ME. Breaking the Chains: Human Trafficking and Health Care Providers. Mo Med 2019;116(6):454-456. It is also a coping strategy by victims while being trafficked, in an attempt to make the unbearable bearable, or coerced or forced on the victim.14Mukherji P. Recognizing Human Trafficking Victims in the Emergency Department. AHC Media; March 8, 2015. https://www.ahcmedia.com/articles/134799-recognizing-human-trafficking-victims-in-the-emergency-department. It is recommended to look for vulnerabilities that the patient may display.9Sutherland ME. Breaking the Chains: Human Trafficking and Health Care Providers. Mo Med 2019;116(6):454-456.

Gut instinct plays a role, resulting in the advice to pay attention if you sense that something is ‘off.’

Physical health indicators include poor nutrition, sleep deprivation, dehydration, signs of general neglect, multiple physical health complaints, and advanced-stage chronic disease (signifying inadequate medical care).6Nuzzolese E. Human trafficking: Role of oral health care providers. J Forensic Odontostomatol 2014;32 Suppl 1(Suppl 1):1-8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5734820/. ,8O’Callaghan MG. Human trafficking and the dental professional. J Am Dent Assoc 2012;143(5):498-504. doi: 10.14219/jada.archive.2012.0211. ,14Mukherji P. Recognizing Human Trafficking Victims in the Emergency Department. AHC Media; March 8, 2015. https://www.ahcmedia.com/articles/134799-recognizing-human-trafficking-victims-in-the-emergency-department. Signs of trauma and physical abuse may be visible in the head and neck region, and other areas of exposed skin.6Nuzzolese E. Human trafficking: Role of oral health care providers. J Forensic Odontostomatol 2014;32 Suppl 1(Suppl 1):1-8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5734820/. ,8O’Callaghan MG. Human trafficking and the dental professional. J Am Dent Assoc 2012;143(5):498-504. doi: 10.14219/jada.archive.2012.0211. ,14Mukherji P. Recognizing Human Trafficking Victims in the Emergency Department. AHC Media; March 8, 2015. https://www.ahcmedia.com/articles/134799-recognizing-human-trafficking-victims-in-the-emergency-department.,15Zimmerman C, Hossain M, Yun K et al. The health of trafficked women: a survey of women entering posttrafficking services in Europe. Am J Public Health 2008;98(1):55-9. doi: 10.2105/AJPH.2006.108357. Examples include cigarette burns, cuts, welts, ligature marks from restraints, bruises, and scars at varying stages (new, old, mixed age).5Schwarz C, Unruh E, Cronin K et al. Human Trafficking Identification and Service Provision in the Medical and Social Service Sectors. Health Hum Rights 2016;18(1):181-92.,6Nuzzolese E. Human trafficking: Role of oral health care providers. J Forensic Odontostomatol 2014;32 Suppl 1(Suppl 1):1-8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5734820/. Of note, the cheeks and neck are unusual sites for accidental bruising and are considered a strong alert.14Mukherji P. Recognizing Human Trafficking Victims in the Emergency Department. AHC Media; March 8, 2015. https://www.ahcmedia.com/articles/134799-recognizing-human-trafficking-victims-in-the-emergency-department. Similarly, bilateral and symmetrical injuries should raise suspicion as should circular/linear/ patterned injuries.14Mukherji P. Recognizing Human Trafficking Victims in the Emergency Department. AHC Media; March 8, 2015. https://www.ahcmedia.com/articles/134799-recognizing-human-trafficking-victims-in-the-emergency-department. ‘Ownership’ marks that may be visible, often in less obvious areas, include tattoos and branding.16Fang S, Coverdale J, Nguyen P, Gordon M. Tattoo Recognition in Screening for Victims of Human Trafficking. J Nervous Mental Dis 2018;206(10):824-7. (Table 1)

Table 1. Signs of Physical Abuse to Look Out For
Cigarette burns
Cuts and welts
Ligature marks
Bruises – especially of the cheeks and neck
Scars at varying stages (new, old, mixed age)
Bilateral and symmetrical injuries
Circular/linear/ patterned injuries
‘Ownership’ marks – tattoos and branding

When an intraoral examination is performed, victims of trafficking can find it traumatic and experience severe discomfort.12Withers M. Dentists Are Integral to the Fight Against Human Trafficking Oral health often tells a story that trafficking victims cannot. April 8, 2020. https://www.psychologytoday.com/us/blog/modern-day-slavery/202004/dentists-are-integral-the-fight-against-human-trafficking. Intraorally, fractured, or missing teeth, other dental injuries and advanced oral disease may be present.6Nuzzolese E. Human trafficking: Role of oral health care providers. J Forensic Odontostomatol 2014;32 Suppl 1(Suppl 1):1-8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5734820/. Neck pain may also be present as well as peri-oral and intra-oral soft-tissue trauma such as bruising, lacerations, petechiae and tears. It’s important to ask yourself whether any purported reason you are given (if any) for an injury is consistent with your clinical observations.9Sutherland ME. Breaking the Chains: Human Trafficking and Health Care Providers. Mo Med 2019;116(6):454-456. Or, are the injuries consistent with violence, gagging or (forced) oral sex?6Nuzzolese E. Human trafficking: Role of oral health care providers. J Forensic Odontostomatol 2014;32 Suppl 1(Suppl 1):1-8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5734820/. ,17American Academy of Pediatrics. When oral injuries lead to suspicion of abuse or neglect. Ed: Wyckhoff AS. AAP News. July 31, 2017. https://publications.aap.org/aapnews/news/14905. ,18Oliván Gonzalvo G, de la Parte Serna CA. Manifestaciones orales y dentales del maltrato infantile [Oral and dental manifestations of child abuse]. Rev Pediatr Aten Primaria 2021;23:15-22. [Spanish] https://www.researchgate.net/publication/354312440_Oral_and_dental_manifestations_of_child_abuse.,19Hammond GC, McGlone M. Entry, Progression, Exit, and Service Provision for Survivors of Sex Trafficking: Implications for Effective Interventions. Glob Soc Welf 2014;1:157-68. https://doi.org/10.1007/s40609-014-0010-0. Evidence of sexually transmitted infections may be present intra-orally, including gonorrhea, chlamydia, and syphilis, as well as signs of substance abuse.6Nuzzolese E. Human trafficking: Role of oral health care providers. J Forensic Odontostomatol 2014;32 Suppl 1(Suppl 1):1-8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5734820/. ,12Withers M. Dentists Are Integral to the Fight Against Human Trafficking Oral health often tells a story that trafficking victims cannot. April 8, 2020. https://www.psychologytoday.com/us/blog/modern-day-slavery/202004/dentists-are-integral-the-fight-against-human-trafficking. ,14Mukherji P. Recognizing Human Trafficking Victims in the Emergency Department. AHC Media; March 8, 2015. https://www.ahcmedia.com/articles/134799-recognizing-human-trafficking-victims-in-the-emergency-department.,20Ahn R, Alpert EJ, Purcell G et al. Human trafficking: review of educational resources for health professionals. Am J Prev Med 2013;44(3):283-9. doi: 10.1016/j.amepre.2012.10.025. (Table 2) All findings from the patient’s examination must be thoroughly and accurately documented – they may become part of the evidence for prosecution.12Withers M. Dentists Are Integral to the Fight Against Human Trafficking Oral health often tells a story that trafficking victims cannot. April 8, 2020. https://www.psychologytoday.com/us/blog/modern-day-slavery/202004/dentists-are-integral-the-fight-against-human-trafficking.

It is important to ask yourself whether any purported reason you are given (if any) for an injury is consistent with your clinical observations.
Table 2. Signs from examination that may suggest trafficking
Intraoral examination is traumatic
Dental injuries and advanced oral disease
Neck pain
Intra-oral soft-tissue trauma – e.g., bruising, petechiae, lacerations
Intra-oral evidence of sexually transmitted infections
Signs of substance abuse

What to do when trafficking is suspected
Building rapport is critical, and is built through appropriate eye contact, facial expressions, body language, active listening, and empathetic interactions.21Department of Health and Human Services. Adult Human Trafficking Screening Tool and Guide. https://www.acf.hhs.gov/sites/default/files/documents/otip/adult_human_trafficking_screening_tool_and_guide.pdf.

The next step beyond this is to try to separate the potential victim from any accompanying individual. One option is to request that this individual remain in the waiting area,12Withers M. Dentists Are Integral to the Fight Against Human Trafficking Oral health often tells a story that trafficking victims cannot. April 8, 2020. https://www.psychologytoday.com/us/blog/modern-day-slavery/202004/dentists-are-integral-the-fight-against-human-trafficking. due to policy or lack of space in the operatory, although they may refuse or use language barriers as an excuse.

For the safety of the potential victim, as well as others in the office, it is extremely important to avoid raising suspicion by the accompanying individual. If it is not possible to separate the suspected victim from an accompanying individual, there may be an opportunity at a subsequent appointment.

For the safety of the potential victim, as well as others in the office, it is important to avoid raising suspicion by the accompanying individual.

Once a suspected victim is alone with you, disclosure and screening can occur. It is important to understand and gently explain to suspected victims whether you must report suspected human trafficking (mandatory reporting) and if so to what extent, both for legal reasons and to avoid damaging patient-provider trust.12Withers M. Dentists Are Integral to the Fight Against Human Trafficking Oral health often tells a story that trafficking victims cannot. April 8, 2020. https://www.psychologytoday.com/us/blog/modern-day-slavery/202004/dentists-are-integral-the-fight-against-human-trafficking. ,21Department of Health and Human Services. Adult Human Trafficking Screening Tool and Guide. https://www.acf.hhs.gov/sites/default/files/documents/otip/adult_human_trafficking_screening_tool_and_guide.pdf. ,22Chisolm-Straker M. Measured Steps: Evidence-based Anti-Trafficking Efforts in the Emergency Department. Acad Emerg Med 2018;25(11):1302-5. doi: 10.1111/acem.13552. Screening tools should be short, simple questions with a yes or no answer. Their sole purpose is to identify those who may have been trafficked or are at risk, they do not confirm trafficking. A screening tool is available on the Department of Health & Human Services website.21Department of Health and Human Services. Adult Human Trafficking Screening Tool and Guide. https://www.acf.hhs.gov/sites/default/files/documents/otip/adult_human_trafficking_screening_tool_and_guide.pdf. Another option is to use questions that are a modified version of the Safety, Abuse, Friends’ and Family’s knowledge and Emergency plans (SAFE) screening tool originally designed for identification of domestic abuse.13Walshaw EG, Patel K. Modern day slavery and the responsibility of the dental team. BDJ Team 2020;23-27. https://www.nature.com/articles/s41407-020-0232-1.pdf?proof=t2019-5-29. ,23Neufeld B. SAFE questions: overcoming barriers to the detection of domestic violence. Am Fam Physician 1996;53(8):2575-80, 2582. (Figure 3)

Figure 3. SAFE Questions
Do you feel safe at home?
What stresses do you experience day to day?
Have there been situations where you feel afraid at home?
Have you been physically hurt or threatened?
Have you been forced to engage in sexual activities that you didn’t want?
Are your friends and family aware of where you are and who you live with?
Do you have a safe place to go in an emergency?
Are you allowed to leave if you feel unsafe?

Source: Walshaw and Patel13Walshaw EG, Patel K. Modern day slavery and the responsibility of the dental team. BDJ Team 2020;23-27. https://www.nature.com/articles/s41407-020-0232-1.pdf?proof=t2019-5-29.

If you suspect/are unsure a patient is being trafficked, it is recommended to call the National Human Trafficking Hotline (with the patient’s permission).24U.S. Department of Health & Human Services. Public Health Emergency. Human Trafficking & Health Professionals: Questions and Answers. https://www.phe.gov/Preparedness/planning/abc/Pages/human-trafficking-faqs.aspx. The specialist you reach will advise you on next steps, referrals, and resources for the potential victim (e.g., shelter and food). Then, you can assist the patient by giving them the phone number for the hotline, scheduling a follow-up visit, or arranging for a social worker or other specialist to help them. If your patient does not want you to call the hotline, you can give the patient the contact information for the hotline and encourage them to self-report.12Withers M. Dentists Are Integral to the Fight Against Human Trafficking Oral health often tells a story that trafficking victims cannot. April 8, 2020. https://www.psychologytoday.com/us/blog/modern-day-slavery/202004/dentists-are-integral-the-fight-against-human-trafficking.

Important Legal and Ethical Considerations
Dental professionals are legally required to report suspected child abuse and neglect throughout the United States, including human trafficking of minors.25Fisher-Owens SA, Lukefahr JL, Tate AR et al. Oral and Dental Aspects of Child Abuse and Neglect. Pediatrics 2017;140(2):e20171487. doi: 10.1542/peds.2017-1487. The requirements regarding human trafficking of adults vary by state, and under the ADA Principles of Ethics and Code of Professional Conduct dentists are obliged to report suspected abuse and neglect to appropriate authorities in consistence with state laws where they practice.26American Dental Association. Principles of Ethics Code & of Professional Conduct. 2020. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/about/ada_code_of_ethics.pdf?rev=86aeaa6fb0d0467f8a380a3de35e8301&hash=89BAA88FB9305B8F134414E337CAE55A. Alternatively, you could call your State Dental Board. The possibility of violating HIPAA may be a concern for providers. However, according to the U.S. Department of Health & Human Services website, a patient’s gender, age, and type of trafficking may be disclosed to the National Human Trafficking Hotline provided ‘individually identifiable patient health information’ is not divulged.24U.S. Department of Health & Human Services. Public Health Emergency. Human Trafficking & Health Professionals: Questions and Answers. https://www.phe.gov/Preparedness/planning/abc/Pages/human-trafficking-faqs.aspx. In addition, if a patient authorizes disclosure of specific information, then that may be disclosed. Provided certain conditions are met, the HIPAA Privacy Rule allows reporting on injury and abuse.24U.S. Department of Health & Human Services. Public Health Emergency. Human Trafficking & Health Professionals: Questions and Answers. https://www.phe.gov/Preparedness/planning/abc/Pages/human-trafficking-faqs.aspx. More information and details can be found on the Department of Health & Human Services website, and information on reporting to law enforcement officials can be found on the Health Information Privacy webpage.24U.S. Department of Health & Human Services. Public Health Emergency. Human Trafficking & Health Professionals: Questions and Answers. https://www.phe.gov/Preparedness/planning/abc/Pages/human-trafficking-faqs.aspx. ,27U.S. Department of Health & Human Services. Health Information Privacy. When does the Privacy Rule allow covered entities to disclose protected health information to law enforcement officials? http://www.hhs.gov/ocr/privacy/hipaa/faq/disclosures_for_law_enforcement_purposes/505.html. Another possible concern is that of potential civil and criminal liability. The Victims of Child Abuse Act Reauthorization Act (2019) protects individuals making reports in good faith concerning child abuse and neglect, as well as those providing information or help.28Wikipedia. Child Abuse Prevention and Treatment Act. https://en.wikipedia.org/wiki/Child_Abuse_Prevention_and_Treatment_Act.

Challenges and Considerations
Victims of human trafficking may remain unidentified due to a reluctance to discuss/disclose it out of fear of the perpetrator or shame, and due to a lack of questions from healthcare professionals.29McAmis NE, Mirabella AC, McCarthy EM et al. Assessing healthcare provider knowledge of human trafficking. PLoS One 2022;17(3):e0264338. doi: 10.1371/journal.pone.0264338. In addition, information about potential victims may be lacking or go unnoticed in electronic health records, and the individual’s identity may have been falsified by the victim or an accompanying individual during a dental/medical visit.29McAmis NE, Mirabella AC, McCarthy EM et al. Assessing healthcare provider knowledge of human trafficking. PLoS One 2022;17(3):e0264338. doi: 10.1371/journal.pone.0264338. In a survey assessing knowledge of human trafficking across multiple medical disciplines, less than half of respondents had received any formal training and almost all stated that they would benefit from training and increased knowledge.29McAmis NE, Mirabella AC, McCarthy EM et al. Assessing healthcare provider knowledge of human trafficking. PLoS One 2022;17(3):e0264338. doi: 10.1371/journal.pone.0264338. Further, medical professionals are not as well equipped as dental professional to identify oral signs and conditions.25Fisher-Owens SA, Lukefahr JL, Tate AR et al. Oral and Dental Aspects of Child Abuse and Neglect. Pediatrics 2017;140(2):e20171487. doi: 10.1542/peds.2017-1487. Ideally, each dental office would have a protocol in place for your office on what to do if human trafficking is suspected.

Conclusions

Trafficking is a global issue with tragic consequences. Dental professionals are in a unique position to help identify potential victims and to refer them for help. It has also been recommended that dental and medical professionals collaborate, as dental professionals are better equipped to identify oral conditions that could be associated with trafficking-related abuse or neglect.25Fisher-Owens SA, Lukefahr JL, Tate AR et al. Oral and Dental Aspects of Child Abuse and Neglect. Pediatrics 2017;140(2):e20171487. doi: 10.1542/peds.2017-1487. There is a need for more training among both medical and dental professionals, including on behavioral science and cultural sensitivity as misunderstandings and cultural alienation are additional reasons for victims remaining unidentified.6Nuzzolese E. Human trafficking: Role of oral health care providers. J Forensic Odontostomatol 2014;32 Suppl 1(Suppl 1):1-8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5734820/. ,29McAmis NE, Mirabella AC, McCarthy EM et al. Assessing healthcare provider knowledge of human trafficking. PLoS One 2022;17(3):e0264338. doi: 10.1371/journal.pone.0264338. To date, a minority of State Dental Boards mandate continuing education on human trafficking as part of licensure/licensure renewal. Renewed efforts in training the dental team have the potential to further the identification of potential victims of human trafficking and to save lives.

Resources

References

  • 1.American Association of Pediatric Dentistry. Policy on Early Childhood Caries (ECC): Classifications, Consequences, and Preventive Strategies. 2016. https://www.aapd.org/media/policies_guidelines/p_eccclassifications.pdf.
  • 2.Fleming E, Afful J. Prevalence of Total and Untreated Dental Caries Among Youth: United States, 2015-2016. NCHS Data Brief 2018;(307):1-8.
  • 3.Chen J, Duangthip D, Gao SS et al. Oral Health Policies to Tackle the Burden of Early Childhood Caries: A Review of 14 Countries/Regions. Front Oral Health 2021;2:670154. doi: 10.3389/froh.2021.670154.
  • 4.Zhang M, Zhang X, Zhang Y et al. Assessment of risk factors for early childhood caries at different ages in Shandong, China and reflections on oral health education: a cross-sectional study. BMC Oral Health 2020;20(1):139. doi: 10.1186/s12903-020-01104-8.
  • 5.Srisilapanan P, Nirunsittirat A, Roseman J. Trends over Time in Dental Caries status in Urban and Rural Thai Children. J Clin Exp Dent 2017;9(10):e1201-06. doi: 10.4317/jced.54054.
  • 6.Castillo JL, Palma C, Cabrera-Matta A. Early Childhood Caries in Peru. Front Public Health. 2019;7:337. https://doi.org/10.3389/fpubh.2019.00337.
  • 7.Gao XL, Hsu CY, Loh T et al. Dental caries prevalence and distribution among preschoolers in Singapore. Community Dent Health 2009;26(1):12-7.
  • 8.Pierce A, Singh S, Lee J et al. The Burden of Early Childhood Caries in Canadian Children and Associated Risk Factors. Front Public Health 2019;7:328. doi: 10.3389/fpubh.2019.00328.
  • 9.Petersen PE, Bourgeois D, Ogawa H et al. The global burden of oral diseases and risks to oral health. Bull World Health Org 2005;83(9):661-9.
  • 10.Alkhtib AO, Mohamed HG. Current knowledge about early childhood caries in the gulf cooperation council with worldwide reflection: Scoping review of the scientific literature (2010–2021). PLOS Glob Public Health 2023;3(1): e0001228. https://doi.org/10.1371/journal.pgph.0001228.
  • 11.Tinanoff N, Baez RJ, Diaz Guillory C et al. Early childhood caries epidemiology, aetiology, risk assessment, societal burden, management, education, and policy: global perspective. Int J Paediatr Dent 2019;29:238-48.
  • 12.Meyer F, Enax J. Early Childhood Caries: Epidemiology, Aetiology, and Prevention. Int J Dent 2018:1415873. doi: 10.1155/2018/1415873.
  • 13.Abanto J, Carvalho TS, Mendes FM et al. Impact of oral diseases and disorders on oral health-related quality of life of preschool children. Commun Dent Oral Epidemiol 2011;39(2):105-14.
  • 14.Shokravi M, Khani-Varzgan F, Asghari-Jafarabadi M et al. The Impact of Child Dental Caries and the Associated Factors on Child and Family Quality of Life. Int J Dent 2023;2023:4335796. doi: 10.1155/2023/4335796.
  • 15.Díaz S, Mondol M, Peñate A et al. Parental perceptions of impact of oral disorders on Colombian preschoolers’ oral health-related quality of life. Acta Odontol Latinoam 2018;31(1):23-31.
  • 16.Corrêa-Faria P, Silva KC, Costa LR. Impact of dental caries on oral health-related quality of life in children with dental behavior management problems. Braz Oral Res 2022;36:e041. doi: 10.1590/1807-3107bor-2022.vol36.0041.
  • 17.Barbosa TDS, Gavião MBD. Evaluation of the family impact scale for use in Brazil. J Appl Oral Sci 2009;17(5):397-403.
  • 18.Pakkhesald M, Riyahi E, Alhosseini AAN, Amdjadi P. Impact of dental caries on oral health related quality of life among preschool children: perceptions of parents. BMC Oral Health 2021;21:68. https://doi.org/10.1186/s12903-021-01396-4.
  • 19.Scarpelli AC, Oliveira BH, Tesch FC et al. Psychometric properties of the Brazilian version of the early childhood oral health impact scale (B-ECOHIS). BMC Oral Health 2011;11(1):19.
  • 20.Petersen PE. The World Oral Health Report 2003: continuous improvement of oral health in the 21st century—the approach of the WHO Global Oral Health Programme. Commun Dent Oral Epidemiol 2003;31:3-24.
  • 21.American Academy of Pediatric Dentistry. Policy. The State of Little Teeth. https://www.aapd.org/assets/1/7/State_of_Little_Teeth_Final.pdf.
  • 22.BaniHani A, Deery C, Toumba J et al. The impact of dental caries and its treatment by conventional or biological approaches on the oral health-related quality of life of children and carers. Int J Paediatr Dent 2018;28(2):266-76. doi: 10.1111/ipd.12350.
  • 23.Alkarimi H A, Watt R G, Pikhart H et al. Impact of treating dental caries on schoolchildren’s anthropometric dental, satisfaction and appetite outcomes: a randomized clinical trial. BMC Public Health 2012;12:706-14.
  • 24.Chrisopoulos S, Harford JE. Oral Health and Dental Care in Australia: Key Facts and Figures 2015, Australian Institute of Health and Welfare and the University of Adelaide, Canberra, ACT, Australia, 2016.
  • 25.Ramos-Gomez FJ, Weintraub JA, Gansky SA et al. Bacterial, behavioral and environmental factors associated with early childhood caries. J Clin Pediatr Dent 2002;26(2):165-73. doi: 10.17796/jcpd.26.2.t6601j3618675326.
  • 26.Kawashita Y, Kitamura M, Saito T. Early childhood caries. Int J Dent 2011;2011:725320. doi: 10.1155/2011/725320.
  • 27.Martínez AR, Ruiz-Guillén A, Romero-Maroto M et al. Impact of Breastfeeding and Cosleeping on Early Childhood Caries: A Cross-Sectional Study. J Clin Med 2021;10:1561. https://doi.org/10.3390/jcm10081561.
  • 28.Alade M, Folayan MO, El Tantawi M et al. Early childhood caries: Are maternal psychosocial factors, decision-making ability, and caries status risk indicators for children in a sub-urban Nigerian population? BMC Oral Health 2021;21:73. https://doi.org/10.1186/s12903-020-01324-y.
  • 29.Avila WM, Pordeus IA, Paiva SM, Martins CC. Breast and Bottle Feeding as Risk Factors for Dental Caries: A Systematic Review and MetaAnalysis. PLoS ONE 2015;10(11): e0142922. doi:10.1371/journal.pone.0142922.
  • 30.Peres KG, Nascimento GG, Peres MA et al. Impact of prolonged breastfeeding on dental caries: A population-based birth cohort study. Pediatrics 2017;140:e20162943.
  • 31.Perera PJ, Fernando MP, Warnakulasooriya TD, Ranathunga N. Effect of feeding practices on dental caries among preschool children: a hospital based analytical cross sectional study. Asia Pac J Clin Nutr 2014;23(2):272-7. doi: 10.6133/apjcn.2014.23.2.13.
  • 32.Iida H, Auinger P, Billings RJ, Weitzman M. Association between infant breastfeeding and early childhood caries in the United States. Pediatrics 2007;120: e944-52.
  • 33.Nirunsittirat A, Pitiphat W, McKinney CM et al. Breastfeeding Duration and Childhood Caries: A Cohort Study. Caries Res 2016;50(5):498-507. https://doi.org/10.1159/000448145.
  • 34.Lapps Wert KM, Lindemeyer R, Spatz DL. Breastfeeding, co-sleeping and dental health advice. MCN Am J Matern Child Nurs 2015;40:174-9.
  • 35.Clark MB, Slayton RL, AAP Section on Oral Health. Fluoride Use in Caries Prevention in the Primary Care Setting. Pediatrics 2020;146(6):e2020034637.
  • 36.Public Health England. Guidance Breastfeeding and dental health. Updated 30 January 2019. https://www.gov.uk/government/publications/breastfeeding-and-dental-health/breastfeeding-and-dental-health.
  • 37.Guidance. Delivering better oral health: an evidence-based toolkit for prevention. https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-prevention.
  • 38.Lee JY, Bouwens TJ, Savage MF, Vann WF Jr. Examining the cost effectiveness of early dental visits. Pediatr Dent 2006;28(2):102-5, discussion 192-8.
  • 39.U.S. Public Health Service Recommendation for Fluoride Concentration in Drinking Water for the Prevention of Dental Caries. Public Health Rep 2015;130(4):318-31.
  • 40.American Association of Pediatric Dentistry. Caries-risk Assessment and Management for Infants, Children, and Adolescents. Latest revision, 2019. https://www.aapd.org/media/Policies_Guidelines/BP_CariesRiskAssessment.pdf.
  • 41.Weyant RJ, Tracy SL, Anselmo T et al. Topical fluoride for caries prevention: Executive summary of the updated clinical recommendations and supporting systematic review. J Am Dent Assoc 2013;144(11):1279-91. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4581720/.
  • 42.American Association of Pediatric Dentistry. Fluoride therapy, revised 2023. https://www.aapd.org/globalassets/media/policies_guidelines/bp_fluoridetherapy.pdf
  • 43.American Association of Pediatric Dentistry. Oral Health Policies & Recommendations (The Reference Manual of Pediatric Dentistry). Use of Pit-and-Fissure Sealants (2016). https://www.aapd.org/research/oral-health-policies–recommendations/pit_and_fissure_sealants/.
  • 44.Ferreira Zandona AG, Ritter AV, Eidson RS. Dental caries: Etiology, caries risk assessment, and management. Ch2, p43. In: Ritter AV, Boushell LW, Walter R. Sturdevant’s art & science of operative dentistry-e-book. 7th Ed. Elsevier Health Sciences, 2017.
  • 45.Slayton RL, Urquhart O, Araujo MWB et al. Evidence-based clinical practice guideline on nonrestorative treatments for carious lesions: A report from the American Dental Association. J Am Dent Assoc 2018;149(10):837-49. e19. doi: 10.1016/j.adaj.2018.07.002. https://www.aapd.org/media/Policies_Guidelines/R_ChairsideGuide.pdf.
  • 46.American Academy of Pediatric Dentistry. Policy on the use of silver diamine fluoride for pediatric dental patients. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2022:72-5. https://www.aapd.org/media/Policies_Guidelines/P_SilverDiamine.pdf.
  • 47.American Association of Pediatric Dentistry. Guideline on Restorative Dentistry, 2016. https://www.aapd.org/assets/1/7/G_Restorative1.PDF.
  • 48.Krol DM, Whelan K, AAP Section on Oral Health. Maintaining and Improving the Oral Health of Young Children. Pediatrics 2023;151(1):e2022060417.
  • 49.American Academy of Pediatrics. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. www.aap.org/en-us/Documents/ oralhealth_RiskAssessmentTool.pdf.
  • 50.Moyer VA, US Prevention Services Task Force. Prevention of dental caries in children from birth through age 5 years: US Preventive Services Task Force recommendation statement. Pediatrics 2014;133(6):1102-11.
  • 51.Macpherson LM, Rodgers J, Conway DI. Childsmile after 10 years part 2: programme development, implementation and evaluation. Dental Update 2019; 46(3):238-46.
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