Amid the routine of dental check-ups, dental healthcare professionals are often the first to notice more than just dental health issues. They are frontline observers who can uncover potential domestic abuse, child maltreatment, and elder neglect. Their keen eye and compassionate care play a pivotal role in identifying and addressing potential cases of abuse.
Domestic violence and abuse
Domestic violence and abuse (DVA) occur between individuals in intimate relationships and adult family members. It can manifest as physical violence, sexual abuse, financial abuse, psychological abuse, and controlling behavior. Domestic abuse affects people of all gender identities, ethnicities, sexual orientations, ages, disabilities, religions, beliefs, and socio-economic backgrounds.1
Child abuse and neglect
Child abuse is a state of emotional, physical, economic, and sexual maltreatment directed at individuals below the age of 18, and it is a globally prevalent phenomenon. Often, caregivers and trusted figures in children's lives are the perpetrators of this abuse. Child abuse can be classified into various categories, including physical, emotional, and sexual abuse, failure to thrive, intentional drugging or poisoning, and Munchausen syndrome by proxy (fabricated or induced illness where a caregiver creates or induces health issues in their child to gain attention or sympathy). Child neglect can occur in multiple forms, such as healthcare, dental, safety, physical, or educational neglect.2
Older person abuse
Older person abuse involves a knowing, intentional, or negligent act by a caregiver or any other person that causes harm or serious risk of harm to an older (> 60 years of age) or vulnerable adult. This includes physical, sexual, and emotional abuse, neglect, and financial exploitation. The perpetrator is usually in a position of trust with the victim, but this is not always the case.3
Healthcare settings offer a crucial opportunity to inquire about abuse with patients, either opportunistically or when injuries are present. Identifying and responding to abuse in healthcare settings have primarily focused on accident and emergency departments, fracture clinics, primary care, and gynecological and antenatal services.
Since facial injuries are reported in up to 75% of abuse cases, dental settings may also present an untapped opportunity to identify abuse in patients. Dental professionals are well positioned to observe and identify injuries to the head, eyes, ears, neck, face, mouth, and teeth.
Frontline oral and maxillofacial surgeons (OMFS) regularly encounter patients in accident and emergency departments who present with dental and more severe facial injuries.1 The specialized training of pediatric dentists, includes a mandatory curriculum on child abuse, which equips them to offer crucial insights and support to physicians regarding the oral and dental dimensions of child abuse and neglect.2
Parents of abused children often switch doctors to prevent the abuse from being detected. However, they tend to consistently take their children to the same dentist. Routine recall appointments, typically scheduled every 6 to 12 months or even more frequently, provide a valuable opportunity to build trust with patients. This trust can create a supportive environment, allowing dental professionals to identify and assist victims, potentially helping to break the cycle of violence. Dental practices provide a discrete environment, and the long-standing relationships between dental professionals and patients may facilitate disclosure.
Some dental healthcare professionals may not consider the identification of domestic violence and abuse their responsibility, assuming that social services or the police will handle it.1 Some may believe that this responsibility is better suited for general medical practitioners, not recognizing the importance of their own role and the opportunities they have to make a difference.
By using the right tools as dental healthcare professionals, they can create an environment conducive to disclosures of abuse. It is crucial to emphasize that they have a legal obligation to be familiar with and adhere to current regulations regarding abuse and neglect.4 Early detection of abuse in dental practices can significantly contribute to identifying cases of violence.
When the dental healthcare professionals screen their patients for domestic violence and refer them to appropriate providers, they demonstrate their concern for this issue, validate the victim’s experience, and provide an opportunity for them to seek help legitimately. Additionally, hospitals may face professional negligence lawsuits from domestic violence victims for failing to evaluate, diagnose, and intervene appropriately to ensure their safety. This failure can also result in negative health outcomes and costly medical care.
Dentists can play an important role in spotting and reporting abuse if they're trained to recognize the signs. Unlike doctors who might change frequently, people usually stick with the same dentist, so it's crucial for them to know what to look for.
Dr. Shilpa Shree Kuduva Ramesh Babu, MDS, Oral Medicine Specialist and Maxillofacial Radiologist
Domestic abuse may not be immediately apparent, but dental teams can often notice physical signs such as neck or intra-oral injuries. The presence of multiple injuries or injuries at varying stages of healing should raise suspicion of abuse.4
Some signs of domestic violence and abuse are:
Intraoral bruises abrasions or lacerations from slaps or hits where soft tissues (tongue, lips, oral mucosa, hard and soft palate, gingiva, alveolar mucosa, frenum) are pressed against hard structures like teeth and bones.
Patterned bruises such as thumb bruises, ligature marks, and scratch marks on the neck indicate attempted strangulation. Petechiae bruising may be found on the face, mouth, or neck due to attempted strangulation. Symptoms like voice changes, breathing difficulties, and potential brain injury due to pressure on the neck can also be a result of attempted strangulation.
Palate bruises or abrasions from implements of penetration, indicating a forced sexual act.
Fractured teeth, dental dislocations, avulsions and bones in the nose, mandible, or maxilla, detectable in panoramic radiographs.
Abscessed or nonvital teeth caused by blows to the face or traumatic tooth fractures.
Torn frenum as a result of assault or forced trauma to the mouth.
Visible bitemarks
Other injuries like visible hair loss (due to pulling), black eyes, ear bruises, and lacerations to the head, as well as injuries to arms, legs, and hands.
Dental neglect: Domestic violence where patients may be prevented from seeking dental care, leading to untreated conditions like rampant caries, pain, infection, and trauma affecting the orofacial region.
While it's clear that dental professionals have a responsibility to detect dental care neglect, other forms of child abuse and neglect may also manifest in the dental office. In cases of child abuse, injuries to the craniofacial complex typically involve facial, head, and intraoral regions.
Facial injuries including bruises, abrasions, lacerations, and other types of trauma and similar intraoral injuries.
Oral injuries caused by utensils like bottles during forced feeding, or by hands, fingers, stained liquids, or caustic substances.
Oral neglect: Poor oral hygiene, halitosis, Early Childhood Caries (ECC), odontogenic infections (recurrent and previous abscesses), periodontal disease, and aphthous lesions resulting from nutritional deficiencies.
Sexual abuse: Erythema, ulcers, vesicles with purulent discharge, pseudomembranous lesions, and condylomatous lesions affecting the lips, tongue, palate, and nasopharynx. Erythema and petechiae found at the junction of the soft and hard palates or on the floor of the mouth, without a clear cause, can serve as clear evidence of forced oral sex.4
Slap marks, pinched ears, adult handprints or bite marks.
Even though the use of corporal punishment in any form should not be supported, given its prevalence in society, it's essential for dental healthcare professionals to have clear guidelines distinguishing between them and signs of physical abuse.2
Signs of possible abuse during a dental check-up include things like unusual bruises or injuries in the mouth or on the face, a torn piece of tissue under the tongue, or broken teeth or jaws. Also, if a child seems overly defensive or scared during the exam, that could be a red flag. If what a parent or child says about how an injury happened doesn't match up with how serious it is, or if they can't explain how it happened, that could be a sign of abuse. For example, the direction and force of a hit to the face can indicate if there might be a serious injury like a broken jaw.
Dr. Shilpa Shree Kuduva Ramesh Babu, MDS, Oral Medicine Specialist and Maxillofacial Radiologist.
In the case of older abuse, physical abuse results
Bruises, lip trauma
Bone fractures
Fractured or loose teeth
Unexplained missing teeth
Broken eyeglasses or frames
Bruising of the eyes
Pressure marks, welts, lacerations, cuts, or burns.
Financial exploitation leading to abrupt changes in financial documents including healthcare directives and unpaid dental bills.
Neglect in elders include ill-fitting dentures, lack of dental care, poor dental or personal hygiene, signs of being restrained, report of confinement or isolation, failure to appear at scheduled appointments, and delays in seeking care.
Beyond these clinical indicators, other signs may raise suspicion of domestic abuse:5
Denial or minimization of abuse or injuries.
Injuries that do not fit the explanation of their cause.
Delays between an injury occurring and seeking medical treatment.
Missed appointments and non-compliance with treatment.
Public and private demeaning actions by an intimate partner.
An overbearing or overly solicitous partner who is always present and reluctant to leave the patient alone during the appointment.
A partner who is domineering, or answers all questions for a patient who would otherwise be capable of answering for themselves.
Drastic behavioral changes in the victim in the presence of an intimate partner like appearing embarrassed, vague, anxious, or depressed.
An exaggerated startle response, spontaneous tears, dissociation from eye contact (or a sudden fading out of the patient’s attention/responses to cues), appearing evasive, socially withdrawn, and hesitant.
An inability to talk clearly due to breathing patterns or panic.
Reluctance or insecurity in answering questions posed by the dental professional.
Inappropriate clothing wearing scarves and long sleeves in very warm weather to cover bruises or other marks.
Reluctance to return home.
ASK
Many dental professionals may feel reluctant to bring up the subject for fear of being intrusive, yet patients often find it acceptable and even relieving to be asked. Also, the public values doctors' opinions highly. On the other hand, it is important to recognize that patients may choose not to disclose abuse for various reasons, even when screened. As a healthcare provider, they may be the only person to inquire about the abuse before it leads to adverse health consequences.
Including a few basic questions about domestic violence in a general health-status questionnaire, routinely completed by all patients before entering the practitioner’s examination room is suggested as an effective approach. Writing an answer may be more comfortable and less intrusive for the patient than responding verbally. Additionally, patients are more likely to perceive such questions as routine if they are given to all patients to complete. Computer-assisted self-interviews have proven effective in eliciting a high rate of domestic violence disclosure.
Dental professionals should use their professional judgment to determine the most appropriate way to ask follow-up questions. They should ask open questions with sensitivity, consideration, and without judgment in a non-threatening manner. Questions such as 'Are you afraid of anyone at home?' or 'Does anyone try to control you or what you do?' or 'How is your relationship with your husband/partner/family?' or 'Has someone hurt you?' 'Do you feel safe?' 'Are you ever afraid of, humiliated, or hurt by anyone?' can open up the conversation.
I enquire to gather information from the patient by raising open-ended questions and maintaining a casual conversational tone. I would also try to make sure the child trusts me to confide any such incident with me.
Dr. Bharkhavy K V, MDS, Pediatric and Preventive Dentistry
In some cases, perpetrators may attend appointments with the patient. If the dental team has concerns and wants to speak to the patient alone, they could suggest a follow-up appointment for a review, or ask the perpetrator to sit in the waiting room. Sometimes, it may not be safe in such situations to ask if the patient would prefer to be seen alone. So the dental team might arrange some private consultation time to conduct an examination.
When discussing sensitive topics such as domestic abuse to an adult patient, it is crucial not to ask these questions in the presence of children to protect their emotional well-being and to ensure the patient can speak freely. If a professional interpreter is necessary for communication, they should be the only person speaking on behalf of the patient. If someone else (a partner or family member) is speaking for the patient instead of allowing the patient to speak for themselves, it might be a sign that the patient is being controlled or coerced by that person.
Patients are typically more open when they know their disclosures will be treated confidentially. So, ensuring privacy and confidentiality is essential. It's crucial to provide a private and secure setting for conversation when a dental professional suspects domestic abuse while treating a patient.
Dental professionals need to respect their patients' choice regarding whether to disclose abuse and/or seek help. Attempting to leave an abusive relationship is frequently dangerous (increase of assault, financial risks) for a domestic violence victim. Pressure from a victim's social system, family may negatively impact their willingness to disclose abuse. But it is important to let patients know that assistance is available in the future if they choose to seek help. Concerns and treatment should be documented in the patient's medical chart, with a notation to follow up at future visits.
VALIDATE
Dental professionals should respond to a disclosure calmly, empathetically and professionally. They should acknowledge the patient's courage, provide reassurance and ensuring confidentiality within legal limits such as in cases of child protection and vulnerable adults. They should avoid any promises about the outcomes to prevent creating false expectations. They should avoid providing advice beyond scope and focus on validating patient emotions and experiences.
Even if an individual does not disclose abuse directly, it is still important for dental healthcare professionals to consider reporting their concerns. They should use their professional discretion to decide the best course of action. Their decision to act on a concern could be crucial for the individual's safety and well-being.
DOCUMENT
The dental team should accurately record all relevant evidence and patient statements, using direct quotes where possible and neutral language to avoid bias. An abuse report should include essential details such as the names and addresses of the patient, the victim's current condition and age, specifics of any injuries with documentation like size, shape, and location, observations of the victim's behavior particularly around family members (parents, partners) and any relevant context aiding in identifying the cause of abuse. It should also indicate the identity of alleged perpetrators if known. Documenting injuries with photographs or detailed descriptions supports potential legal proceedings.
All interviews with the victim must be thoroughly documented. The report should be signed and dated by the reporter, ideally witnessed by another individual for verification of details. These elements collectively ensure a comprehensive and credible account to support effective intervention and protection measures for the victim.9
REFER AND REPORT
The dentist should treat injuries within expertise and refer patients to appropriate healthcare providers for comprehensive care. They should provide patients with information on local resources and domestic abuse advocacy organizations.
We have guidelines on reporting which were taught to through programs, like PANDA. Also, AAPD has put forth guidelines on documentation and reporting of such crimes. The guidelines say we have to report the suspected cases of child abuse to social and child welfare authorities. We can utilize the child protection helpline the Childline (1098) to report such cases to help protect the child. We may need to collaborate with other medical professionals to assess further and to better identify the form of abuse and also to initiate the necessary intervention and therapy.
Dr. Bharkhavy K V, MDS, Pediatric and Preventive Dentistry
Dental teams should facilitate contact with appropriate local services. They should familiarize themselves with state and territory laws regarding reporting requirements for family and domestic abuse and violence. State-specific mandatory reporting laws govern maltreatment of children, elders, and victims of domestic violence. Reporting procedures vary by jurisdiction. They must adhere to these laws, reporting suspected abuse regardless of the victim's age. Compliance with legal obligations ensures timely intervention and support for victims.
In India, for cases of child abuse, various agencies such as the police, Child Welfare Committees, and ChildLine can be contacted for assistance.8 Child abuse laws in India are continually evolving to strengthen children's rights and protection. Acts like the Protection of Children from Sexual Offenses (POCSO) Act, 2012, the Juvenile Justice (Care and Protection of Children) Act, Integrated Child Protection Scheme (ICPS), and Integrated Child Development Services (ICDS) focus on safeguarding children from abuse and exploitation.
Helplines such as ChildLine (1098) provide 24-hour assistance to children in distress, offering emergency aid, referrals for long-term care, and protection from abuse. The Child Welfare Committee (CWC) under the Juvenile Justice Act ensures the welfare of abused or neglected children and facilitates their rehabilitation. It is crucial for healthcare professionals including dentists and regulatory bodies to work together to safeguard children from all forms of abuse, emphasizing their responsibility under relevant laws like POCSO. Elder maltreatment cases are usually often handled by adult protection services.
Dentists have a legal duty to report suspected abuse to the authorities. In India, there's a specific law called the Protection of Children from Sexual Offenses (POCSO) Act, which makes it a crime to sexually abuse children. Failure to report the crime may lead to 6 months of imprisonment, with or without penalty. In the United States, dentists, like other healthcare workers, can face penalties for not reporting abuse, but they're protected from legal trouble if they report it honestly and in good faith.
Dr. Shilpa Shree Kuduva Ramesh Babu, MDS, Oral Medicine Specialist and Maxillofacial Radiologist
The role of the dental team is to identify abuse and refer patients to specialist help. It is not their role to provide advice, as this could be dangerous. Well-intentioned but uninformed advice, such as advising someone to leave an abusive relationship, can increase the risk of assault. The dentist's role in identifying abuse is critical yet delicate. While they should not continue the investigation beyond their expertise, they bear the responsibility of promptly notifying the appropriate authorities.
Dental professionals encounter several barriers to intervening in cases of abuse, including:9
Insufficient knowledge and training regarding abuse issues.
Limited practical experience in how to effectively intervene.
Misunderstandings about the nature and effectiveness of intervention.
Apathy to the severity of the crime.
Concern about confrontation with the family.
Fear of losing patients.
Worries about offending the patient.
Concerns about potential legal repercussions, despite good intentions and legal protections.
Lack of awareness about available resources for reporting.
Presence of others in the examination room, such as the patient's partner or children.
Feelings of discomfort or embarrassment when broaching the topic.
Dental care professionals often feel uneasy about asking patients about the causes of dental or facial injuries. They may lack confidence in posing what they see as intrusive questions about domestic violence and abuse. They might not know how to proceed if a patient reveals such information.
Their undergraduate education may not have sufficiently prepared them for these sensitive inquiries, and postgraduate training opportunities are limited. Additionally, oral and maxillofacial surgery frontline staff report a lack of confidence in handling such personal conversations.
Role of dental schools and regulatory bodies
The confidence to inquire about domestic violence and abuse in a sensitive and appropriate manner can be significantly acquired through interactive learning and practical experience. Brief intervention training can enhance knowledge and shift attitudes. Addressing stigma, myths, and stereotypes forms a crucial component of such training.
Dental schools, continuing education programs, dental associations, and regulatory bodies should provide comprehensive education on how to effectively address domestic violence and ensure a streamlined approach to screening and intervention in dental practice. They should integrate comprehensive training modules that equip dentists with the knowledge and skills necessary to identify, document, and respond to signs of domestic violence sensitively and effectively. This training should encompass the various forms of abuse, common oral health indicators, appropriate screening techniques, legal and ethical considerations, and referral pathways to support services.
Programs similar to the Prevent Abuse and Neglect through Dental Awareness (PANDA) scheme, which has been operational since 1992 in the USA, should be developed to train healthcare providers, teachers, and childcare providers in India. The introduction of certificate courses focused on this subject could significantly enhance awareness and competence among professionals in identifying and responding to cases of abuse and neglect.
In cases of potential child abuse, dental professionals should be empathetic and supportive while stating the facts and clinical findings which are raising suspicion to parents or guardians. However, we should also keep in mind that we may be communicating our concerns to potential perpetrators of the crime, as it is more commonly those closest and known to the child that engages in such crimes. Hence caution should also be exercised and prompt reporting to child protection services is vital. I also think periodic education programmes on this topic would help us be updated.
Dr. Bharkhavy K V, MDS, Pediatric and Preventive Dentistry
Role of dental office teams
Providing patients with interactive questionnaires and assessments, enable individuals to confidentially and accurately report their experiences, risk factors, and potential signs of domestic violence. This approach enhances patient engagement, ensures privacy, and facilitates standardized data collection, allowing dentists to identify and address domestic violence cases more effectively.9 Additionally, information pamphlets on abuse can be provided in the waiting rooms, and examination rooms.
Dental professionals should contact their state dental licensing board and local legal authorities to understand the dental team's obligations concerning the identification and reporting of domestic violence. They should maintain an updated list of local resources including information on local emergency response services, law enforcement agencies, support groups, local hotlines for immediate assistance and child protective services and reporting procedures in the office manual.
Each dental practice should annually review consistent protocols and best practice policies in accordance with state and federal laws and the guidelines set by each state's dental board. Each practice can establish appropriate strategies for reporting and intervention based on these reviews.
Collaboration of dental professionals with multidisciplinary abuse prevention teams
Encouraging interdisciplinary collaboration between dental professionals, other healthcare providers, social workers, and domestic violence organizations will help establish a robust and comprehensive support network for victims. Physicians involved in multidisciplinary child abuse prevention teams should engage with pediatric dentists who specialize in forensic dentistry to enhance their expertise.
Similarly, physicians experienced in child abuse should collaborate with dentists and dental organizations to provide consultation and education. Dentists specializing in child abuse and trained in forensic dentistry should offer their services as dental consultants to state welfare departments and hospital trauma teams. It is crucial for agencies at various governmental levels to integrate dental expertise into their practices for evaluating oral injuries in suspected abuse cases.2
In conclusion, the role of healthcare professionals in diagnosing lesions caused by domestic abuse is crucial for interrupting its cycle. Particularly dental professionals with specialized knowledge of the oral-maxillofacial complex, are well-positioned to identify these injuries. However, many of them feel uncertain or inadequately trained to make accurate diagnoses and may rely on professionals from other fields for confirmation. This lack of confidence stems from insufficient education on domestic abuse during dental training.
Enhancing education on abuse detection and notification procedures in dental curriculum is essential to empower dentists to confidently handle such cases. The disparity between recognizing abuse cases and reporting them underscores the need for improved training and support for dental professionals. Increasing awareness and knowledge among dentists can lead to more effective reporting, ultimately aiding in the prevention and resolution of domestic abuse cases through public policy and intervention.6 By staying informed about legal obligations, maintaining patient confidentiality within ethical limits, and addressing challenges with sensitivity, dental health professionals can effectively contribute to the protection and well-being of patients experiencing abuse.
References:
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Nagarajan SK. Craniofacial and oral manifestation of child abuse: A dental surgeon’s guide. J Forensic Dent Sci [Internet]. 2018 [cited 2024 Jun 30]; 10(1):5–7. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6080162/.
CDC. About Abuse of Older Persons. Abuse of Older Persons [Internet]. 2024 [cited 2024 Jun 30]. Available from: https://www.cdc.gov/elder-abuse/about/index.html.
COSTACURTA M, BENAVOLI D, ARCUDI G, DOCIMO R. Oral and dental signs of child abuse and neglect. Oral Implantol (Rome) [Internet]. 2016 [cited 2024 Jul 3]; 8(2–3):68–73. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4969728/.
How dentists can identify domestic abuse. British Dental Association [Internet]. 2023 [cited 2024 Jul 3]. Available from: https://www.bda.org.
Department of Dentistry, Federal University of Sergipe, Brazil., Renato Paranhos L, Rodrigues JL, Department of Dentistry, State University of Feira de Santana, Brazil., De Mello Rode S, Department of Dental Materials and Prosthesis, São Paulo State University - UNESP, Brazil. The role of the dentist facing neglect and domestic violence. J Oral Res [Internet]. 2016 [cited 2024 Jul 3]; 5(3):97–8. Available from: http://www.joralres.com/index.php/JOR/article/view/237/228.
Intimate Partner Violence and Elder Abuse: The Basics | Dentalcare [Internet]. [cited 2024 Jul 3]. Available from: https://www.dentalcare.com/en-us/ce-courses/ce674.
Department of Pediatric and Preventive Dentistry, Coorg Institute of Dental Sciences - CIDS, SH 88B, Kodagu Coorg District, Virajpet, Karnataka 571218, India, Sowndarya G, Mallikarjun Bhuthanahosur S, Department of Pediatric and Preventive Dentistry, Coorg Institute of Dental Sciences - CIDS, SH 88B, Kodagu Coorg District, Virajpet, Karnataka 571218, India, George B, Department of Pediatric and Preventive Dentistry, Coorg Institute of Dental Sciences - CIDS, SH 88B, Kodagu Coorg District, Virajpet, Karnataka 571218, India, et al. Child abuse and neglect: understanding the role of a pediatric dentist. EDUJ [Internet]. 2020 [cited 2024 Jul 4]; 7(4):286–93. Available from: https://www.stomaeduj.com/wp-content/uploads/Art-7-4-2020.pdf.
Levin L, Bhatti C. The role of dental professionals in identifying, reporting, and supporting domestic violence victims. Dental Traumatology [Internet]. 2024 [cited 2024 Jul 4]; 40(S2):3–9. Available from: https://onlinelibrary.wiley.com/doi/10.1111/edt.12897.
