of a bruise may help determine whether the history obtained coincides with the actual date of the injury. Clinicians without extensive forensic background are cautioned against trying to date the actual occurrence of trauma. Clinicians should use the colors of healing as guidelines to assess whether the history given matches the symptoms seen. Bruises that are still Orofacial injuries common in family violence Dental and facial injuries need to be evaluated carefully to determine their cause. Although family violence injuries are many and varied, several types of injuries are common to abuse. Many of these injuries are easily observed in the course of routine dental treatment. Other types of injuries are specifically characteristic of abuse and easily identified by the dentist. Injuries of this type include those that appear simultaneously on multiple body planes in different stages of healing (Singh & Lehl, 2020). Injuries that exhibit patterned marks of an implement or a hand, or bilateral injuries to the face, carry a high index of suspicion of abuse (Gonzalez et al., 2022). The head and face are often attacked in all types of family violence because they represent the “self” of the individual. Some head and face injuries of abuse are a matter of convenience—the victim’s head may be the easiest place for the perpetrator to reach. Crying by an infant or a child can be a trigger for abusive head trauma (AHT), which is the leading cause of death of children younger than two years of age and Sexual abuse Even cases of sexual abuse may exhibit indicators in the perioral region. Oral or perioral lesions of gonorrhea, syphilis, or chlamydia in prepubertal children are indicative of sexual abuse. In addition, unexplained injury or petechiae of the palate, specifically at the junction of the hard and soft palate and the floor of the mouth, are sometimes seen in cases of forced oral sex (Fisher-Owens et al., 2017; Singh & Lehl, 2020). Other indicators of possible child abuse may include pain or difficulty
swollen, red, blue, or purple are new. Bruises that present as yellow, green, or brown are older. Clinicians should be most concerned if the history given is that the injury happened in the past 24 hours, but the marks are obviously many days or weeks old. Delay in seeking treatment is often seen in cases of family violence. can cause other infants or children to lapse into a coma or develop vomiting or respiratory distress (Brown et al., 2022). Surveys of dentists who have reported cases to CPS agencies show a trend in the type of oral injuries encountered in child abuse cases. Some of the most common intraoral and extraoral injuries that can be signs of physical abuse of a child include oral bruises and lacerations of the lips, tongue, or oral mucosa; fractured teeth, burns or blisters in the perioral region; fractures of the mandible/maxilla; and recurrent multicolored oral lesions that are not typical of oral diseases or oral pathology (Oliván Gonzalvo & de la Parte Serna, 2021; Singh & Lehl, 2020). In cases of forced feeding when the bottle is shoved against the child’s mouth, infants can sustain lacerations;, bruising or tearing of the frenal attachments; and contusions of the oral mucosa, particularly around the anterior alveolar ridge (American Academy of Pediatrics, 2017; Voelker 2022). Gags used to silence or punish a child can cause bruising or scarring of the corners of the mouth (Fisher-Owens, et al., 2017). in walking or sitting and extreme fear of any dental treatment. Pregnancy in young children is a sign of confirmed abuse. Not everyone who is afraid of dental treatment is a victim of sexual abuse. However, because of their history of abuse, both adult and child victims of oral rape can be terrorized by having something as benign as a mirror or explorer placed in their mouths.
EDUCATION AND PREVENTION
In recent years, more attention has been placed on educating the dental team about family violence and developing tools to help identify victims among dental patients. The interactive Ask, Validate, Document, Refer (AVDR) teaching modules are widely available to help dentists and dental auxiliaries become more involved in family violence prevention (Burke, 2019; National Resource Center on Domestic Violence, 2021). In addition, a predictive model for patients—using self-reporting of risk, age, and race—has assisted providers in identifying victims of IPV in the emergency department setting. The same protocol could prove to be useful in private practice (Kumar et al., 2015). State and local programs have had remarkable success in raising awareness about family violence. (See the Resources section of this course for information regarding specific family violence prevention organizations.) In 1991, an effort in Massachusetts led to what has become arguably the most successful program to get dentists involved in family violence prevention. In that year, several Massachusetts organizations formed what was then known as the Dental Coalition to Combat Child Abuse and Neglect. The idea spread to other parts of the country, where various dental organizations joined together to form the Prevent Abuse and Neglect through Dental Awareness (P.A.N.D.A.) coalition . The mission of P.A.N.D.A. is to create an atmosphere of understanding in the healthcare community that will result in the prevention of abuse and neglect through early identification and appropriate intervention for anyone who is a victim of abuse or neglect (Northeast Delta Dental, n.d.). To accomplish that goal, the coalition produced a series of educational programs to present to dentists, dental hygienists, and dental assistants, as well as to dental and dental hygiene students.
Although P.A.N.D.A.’s early efforts concentrated on dental continuing education seminars, it quickly evolved into a much broader program. Child abuse and family violence prevention were added to the curriculum of dental schools and dental hygiene programs. P.A.N.D.A. developed programs to educate teachers and school administrators about recognizing and reporting child abuse and neglect. It later refined these presentations for medical seminars, nursing groups, day care workers, and other lay organizations. When P.A.N.D.A. was established in 1992, Missouri was one of only six states that tracked the number of dentists making reports of abuse or neglect. During the early 1990s, a study determined that dentists were identifying less than 1% of child abuse cases, so Delta Dental of Missouri partnered with the Missouri Bureau of Dental Health to start the P.A.N.D.A. coalition (Dentistry IQ Editors, 2014). Additional states now track dentists’ reporting data. The P.A.N.D.A. program has had varying degrees of success in increasing reporting rates as it has trained thousands of physicians, nurses, dentists and allied dental professionals, teachers, and child care providers about the dental aspects of child abuse (Fisher-Owens et al., 2017). The ultimate goal of these efforts is for more people to become involved so that eventually fewer cases of family violence will need to be reported. Although dentists are mandated reporters of child abuse and neglect in every state (ADA, 2017), there is no nationally recognized requirement or protocol for formal training of mandated reporters. This failure leaves dentists and others in the unfortunate position of being required to report, but without formal training to help identify these victims. It is not strange to
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