RECOGNIZING FAMILY VIOLENCE
Dentists and dental hygienists in all 50 states are mandated reporters of child abuse and neglect. They are, in other words, required by law to report suspected cases of child abuse or neglect (ADA, 2017; Burgette et al., 2020; Lopez, 2022). Although most states require licensed healthcare professionals to report suspected cases of elder abuse and neglect, the requirement for reporting suspected IPV is far from universal. Currently, most state laws include dentists and dental hygienists in the list of healthcare professionals designated as mandatory reporters. Dental assistants often spend more time with patients than dentists do, but few states specifically require dental assistants to report suspected cases of abuse or neglect. Although state laws mandate these reports only from certain individuals, anyone is able to make a report. According to §39.201(1)(a) of the Florida statutes, any person who suspects child abuse, abandonment, or neglect is a mandatory reporter (Florida Department of Children and Families, 2019c). A couple of facts about abuse make it likely that dental professionals will see it in their practice, even if they don’t recognize it. First, more than half of all child abuse cases involve Clinical protocol Every dental office needs a protocol that will heighten awareness of abuse and neglect and delineate the process for identification and reporting. Oral healthcare providers need to evaluate the patient’s and parent/caregiver’s behaviors as well as the patient’s health history and conduct a general physical assessment along with the oral examination. The warning signs of abuse should be in the back of the dental professional’s mind every time they see an injured patient. Repeated injuries, multiple bruises, General physical assessment Dental professionals must think about the patient as a whole person, not just a mouth and set of teeth. Clinicians should evaluate the patient’s stance or gait as they move through the dental office, note anything that does not appear normal, and decide whether that condition needs further evaluation. Bruises or welts may also indicate abuse. Any injury to the face, lips, mouth, or neck should be a cause for concern, as well as any injury to the ankles or wrists that may be visible in the course of the normal dental visit. Injuries to both Behavior assessment Behavior assessment is an important part of the patient evaluation. Dental assistants often spend the longest amount of time with a patient during a dental visit and may be best able to evaluate behaviors. Abused or neglected patients, particularly those who have been sexually abused, may be extremely apprehensive and inordinately fearful of an oral exam. On the other hand, some abuse victims are extremely eager to please— they have learned that less than perfect behavior may result in Patient histories It is advisable to obtain histories about an injury from the patient and parent/caregiver separately. It is important to keep in mind, however, that an abuser may not want the clinician to be alone with the patient. If radiographs are indicated for a dental reason, separating the patient from the parent/caregiver may be facilitated while taking the radiographs. However, dental professionals should not take radiographs merely as an excuse to have the parent/caregiver leave the operatory. Taking unauthorized or inappropriate radiographs may constitute Oral examination The oral examination should be routine in every dental office. The examination should include a thorough evaluation of all conditions of not only the teeth but also the lips, gingiva, oral mucosa, tongue, and oropharynx. Anything that appears
trauma to the mouth, face, or head (Patel et al., 2021; Singh & Lehl, 2020; Wyckoff, 2017). Second, abusive parents, intimate partners, or elder caregivers often will not take the patient to the same physician (for fear the physician will recognize the abuse) but are likely to return to the same dentist (Singh & Lehl, 2020). Dentists are among healthcare professionals who lack training in the recognition, documentation, and reporting of domestic violence whether it is a child, an elder, or an individual involved in intimate partner violence (Oliván Gonzalvo & de la Parte Serna, 2021). Data from various states show that the vast majority of reports come from teachers, social workers, and “permissive reporters”—those individuals who are not mandated to report but do so out of concern for the child. If dental professionals are in the best position to see the injuries from these various forms of family violence, why don’t they recognize these injuries? If they suspect the abuse, why don’t they report it? All members of the dental team should be concerned about family violence and the lack of reporting by dental professionals. bilateral injuries to the face, or injuries that do not match the history given may all signal instances of abuse. If there is some indication that abuse is taking place, but not enough evidence to warrant a report, it is suggested that an acronym such as SCAN (suspect child abuse/neglect) or a similar unobtrusive notation be placed on the cover of the chart to alert all staff members that this may be an at-risk family or patient and that they should be vigilant at future visits. eyes, or to both cheeks, are always suspicious because accidents are most typically unilateral. It is rare, although not impossible, to fall down and hit both sides of the face. Bilateral injuries of abuse may also occur on other easily observable areas of the patient’s body. Injuries that form a pattern are also suspicious—even a slap with an open hand can leave marks indicative of the abuser’s fingers. Grab marks on arms or shoulders may indicate excessive force in punishing a child. more abuse. One way to determine whether a patient’s behavior is appropriate is to judge it against personal experience in similar circumstances with patients of similar maturity (which is often different from chronological age). Combining the evaluation of the patient’s behavior with other information in the patient’s history and oral examination may lead a dentist to consider a diagnosis of suspected abuse. technical battery and expose the dentist or dental auxiliary to liability. Dental staff members must determine whether any discrepancies exist in how and when the injuries occurred, and if the injuries themselves are consistent with the explanations. The dentist must document any discrepancies in the stories given and note if the physical findings are inconsistent with the history provided.
out of the ordinary should be noted and evaluated further as appropriate.
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