Oral Maxillofacial Surg Clin N Am 19 (2007) 259265
The Abused Female Oral and Maxillofacial
Surgery Patient: Treatment Approaches
for Identication and Management
Deborah L. Zeitler, DDS, MS
Oral Surgery Associates, 2814 Northgate Drive Suite 2, Iowa City, IA 52245, USA
In the United States, violence and abuse (V/A)
is a serious threat to public health. Success in
preventing injuries is predicated on early diagno-
sis, referral, and interventional strategies for
victims of V/A. Early identication of women
who may have injuries attributable to V/A is the
rst step in successful management strategies to
deal with the immediate and long-term eects of
this chronic, debilitating, and sometimes fatal
condition.
Violence against women has received increas-
ing public attention. In 1994, the US Congress
brought this issue to the forefront and President
Clinton signed into law the Violence Against
Women Act (VAWA) and established the Oce
on Violence Against Women. A stated objective
of the Public Health Services Healthy People
2000 Program is that emergency departments and
the disciplines of medicine, surgery, and dentistry
become more ecient in diagnosing and manag-
ing victims. The American College of Surgeons
statement on intimate partner violence (IPV) is,
Surgeons are encouraged to take a leadership
role in communities, hospitals and health career
schools in preventing and treating domestic vio-
lence [13]. Should the oral and maxillofacial
surgeon be concerned about the incidence and oc-
currence of domestic violence in his or her patient
population? For one answer to this question con-
sider the following excerpts from a local newspa-
per on a single day in June 2006.
 A 25-year-old male arrested for domestic
abuse assault causing bodily injury; accused
E-mail address: deborah-zeitler@earthlink.net
1042-3699/07/$ - see front matter 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.coms.2007.01.003
of pushing victim into the wall and striking
victim on the cheek at their residence.
 A 27-year-old male arrested for serious as-
sault; accused of striking a female in the
nose causing injury.
 An 18-year-old male arrested for domestic as-
sault causing injury; accused of punching the
mother of his 7-month-old child in the mouth
during an argument.
 A 31-year-old male accused of child endan-
germent and going armed with intent; accused
of throwing a 10-year-old child to the oor
and striking him in the face with an open
hand, and threatening a woman with bodily
harm if she did not leave the apartment [4].
Epidemiology of violence and abuse
More than 2.5 million women are abused
annually and 30% to 50% of homicides to women
are attributable to abuse by former or current
intimate partners [1,2]. More women than men ex-
perience IPV. According to the National Violence
Against Women Survey, one out of four women in
the United States have been physically assaulted
or raped by an intimate partner; one out of four-
teen men in the United States reported such an
experience [3,5]. V/A is not a random act, but
a chronic disease characterized by injuries of pro-
gressive severity and frequency. Injuries sustained
from abuse often involve women from socioeco-
nomic environments that make it dicult to leave
their home situations or upset the family units.
In a study in which data were collected from
2003 to 2005 and included more than 3500
oralmaxsurgery.theclinics.com
260
women, 14% reported interpersonal violence of
any type in the previous 5 years. The prevalence
during their lifetime was 44%. Between 10%
and 21% were abused by more than one
partner. IPV rates increased for younger women,
lower income women, women who were less
educated, single mothers, and those who had
been abused as a child [68]. Dating violence
statistics are similarly alarming. A conservative
estimate is that more than 25% of adolescent
women seeking reproductive care have experi-
enced violence by a dating partner in the last
year [7].
Children are frequently victims of V/A. The
most common mechanism of injury in children is
a direct hit. Children who were younger than 2
years were most often injured while being held by
parents. Thirty-nine percent of children who were
injured in their familys domestic violence were
injured during attempts to intervene in the ght
[8]. Clearly any health professional must be ready
to address domestic violence as an issue confront-
ing the female patient.
How is V/A dened? The American College of
Emergency Physicians denes domestic violence
as part of a pattern of coercive behavior which
an individual uses to establish and maintain
power and control over another with whom he
or she has had an intimate, romantic, or spousal
relationship. Behaviors include: actual or threat-
ened physical or sexual abuse, psychologic abuse,
social isolation, deprivation, or intimidation
[9,10].
The oral and maxillofacial surgeon is often the
rst to see and evaluate victims of V/A in the
emergency room setting. Understanding the pat-
tern of injuries and the associated psychosocial
problems is imperative for providing adequate
care.
Head and neck injury in domestic violence victims
Although facial injuries account for a large
number of emergency room visits, there seem to
be few reports detailing the cause and pattern of
facial injuries in women [1012]. Motor vehicle ac-
cidents (MVAs) seem to be the primary cause, fol-
lowed by assaults. Case series reports indicate that
67% of women who had facial injuries had been
assaulted by a husband or boyfriend, with 68%
of battered women in another study sustaining
45% of injuries to the midface [12,13]. When
women seek treatment in the emergency room
for facial injuries in the absence of vehicular
ZEITLER
trauma, the possibility of IPV must be explored
[1113].
A retrospective study of facial trauma in
women by Huang [11] in 1998 showed that there
was often inadequate documentation regarding
the circumstances of the facial injury. Huang con-
cluded that this indicates domestic violence may
be severely underreported in maxillofacial injuries
in women. A study by Ochs and coworkers [14]
showed an extremely high incidence of head,
neck, and facial injuries in victims of domestic vi-
olence. In their study, 94.4% of victims who iden-
tied domestic violence as the cause of their
injuries had head, neck, and facial injuries. Nearly
35% of injured women in this study presenting to
the emergency room for treatment injures were
victims of domestic violence. If a woman had
a head, neck, or facial injury she was 11.8 times
more likely to be a victim of domestic violence
than women who had other types of injuries. In
the absence of head, neck, or facial injury it was
unlikely that the patient would be a victim of do-
mestic violence.
A prospective study by Leathers and co-
workers [15] examined 203 adult patients seeking
treatment at King/Drew Medical Center in Los
Angeles. In this study a disproportionate number
of women who had orofacial injury (more than
38%) reported that their injuries resulted from do-
mestic violence. A study by Perciaccante and col-
leagues [12] evaluated head, neck, and facial
injuries as markers of domestic violence in
women. This study sampled 100 injured women,
34 of whom were victims of domestic violence.
Thirty-one of the 34 victims of domestic violence
had head, neck, and facial injuries. Of the 100 in-
jured women, 58 had head, neck, and facial in-
juries and 31 of those were victims of domestic
violence. A woman who had head, neck, and fa-
cial injuries was 7.5 times more likely to be a vic-
tim of domestic violence than a woman who had
other injuries. This was a sensitive but not very
specic indicator of domestic violence. The au-
thors concluded that women presenting to the
emergency room for nonmotor vehicle accident
injury be considered at high risk for domestic
violence.
A study by Greene and colleagues [16] in 1999
drew similar conclusions to some of the studies
previously mentioned. One third of female blunt
assault facial trauma patients were subjects of do-
mestic violence. Le [13] in 2001 performed a retro-
spective review of patients treated for domestic
violence injuries. Eighty-one percent presented
 ABUSED FEMALE ORAL AND MAXILLOFACIAL PATIENT
with maxillofacial injuries in which the middle
third of the face was the most commonly injured
area (69%). Facial fractures occurred in 30%.
Most of the facial fractures (40%) were nasal
fractures.
These studies conrm that victims of V/A fre-
quently suer maxillofacial injuries. Because ap-
proximately one third of patients presenting with
head, neck, or facial injuries are victims of V/A, it is
crucial that oral and maxillofacial surgeons un-
derstand the importance of identifying V/A as
a cause of the trauma and the screening tools
available to elicit such a history (see later discussion).
Response of the dental community to domestic
violence
In a viewpoint article in the American Dental
Association News of April 17, 2006, Colangelo
[17] summarized the importance of increasing the
dental communitys understanding of and re-
sponse to domestic violence. He pointed out that
dental professionals have an obligation to recog-
nize the signs and symptoms of family violence
and that increasing knowledge and awareness is
the rst step they must take. He commented that
dentists are in a unique position to help victims
of V/A because of the common involvement of
the head, neck, and oral cavity. Studies suggest
that abusers and their victims often return to the
same dental oce for care thinking it unlikely
that the dentist will screen for possible abuse
[1720]. He also refers to a study by researchers
at the University of California at San Francisco
who nd that a proportion of dentists do not
screen for domestic violence even when the signs
or symptoms of abuse are present [18].
Inclusion of education on V/A in the training of
health care providers is vital. Articles describing
the ndings of orofacial trauma and its relation-
ship to domestic violence have been published in
the literature [1921]. The Institute of Medicine, in
a major publication entitled Confronting Chronic
Neglect, has described the inadequacy of curricula
on family violence for health professionals, includ-
ing dental professionals [22]. Inadequate education
in dental school may be a major component of the
poor response by dental professionals. Dentists re-
port other barriers to reacting to the potential for
domestic violence, including the patients being ac-
companied by a partner or children, being con-
cerned about oending the patient, cultural
norms and customs, and personal embarrassment.
Lack of time to address the issue and belief that the
261
patients will not follow up on recommendations
were also mentioned [18].
Gerbert and associates have taken major steps
to develop tutorials to try to improve the knowl-
edge and attitudes of dentists regarding V/A.
Their eorts indicate that a short tutorial can be
eective in improving the identication of victims
and aiding in their care. More is discussed later in
this article about the techniques presented in this
tutorial [2224].
Screening for violence and abuse
There is much controversy about routine
screening among those who study V/A and care
for these victims. Much debate centers around
whether routine screenings should be performed
in health care settings. Several systematic reviews
and guidelines have been published in the last few
years with recommendations on this subject. The
United States Preventive Services Task Force [25]
in 2004 found insucient evidence to recommend
for or against routine screening of women for
IPV. A systematic review was published in June
of 2006 to answer the question, Should health
professionals screen women for domestic vio-
lence? Some of the papers in this review sug-
gested that women respondents were often
accepting of screening in the health care setting
but health professionals were frequently not in fa-
vor of screening. Several studies showed that
when screening was used a greater proportion of
abused women were identied. Overall, little evi-
dence was found in this review to suggest a dy-
namic impact on improved diagnosis with the
routine use of screening. The conclusion of this
systematic review, therefore, was that universal
implementation of screening programs in health
care settings cannot be justied [26].
A systematic review was published in the
Cochran Database of Systematic Reviews in
2005 regarding domestic violence screening and
intervention programs for adults who had dental
or facial injuries. The authors found no eligible
randomized controlled trials on this topic. They
concluded that there is no evidence to support or
refute the eectiveness of screening and interven-
tion programs detecting and supporting victims of
domestic violence with dental or facial injuries
[27].
There are individual studies that suggest the
value of screening for violence and abuse. A study
performed using oce-based screening question-
naires suggested that there was a signicant
262 ZEITLER
increase in the ability to identify families exposed
to violence and abuse to provide appropriate
referral information [28]. Another study in which
participants were screened for V/A and then fol-
lowed up 4 months later suggested that women
who had a positive history were 11.3 times more
likely to experience physical violence and 7.3
times more likely to experience verbal abuse.
This study highlights the likelihood that previous
victims of V/A are at high risk for subsequent ep-
isodes [29].
Another study compared two screening ques-
tionnaires: the Partner Violence Screen and the
short Woman Abuse Screening Tool. This study
also included information regarding injury loca-
tion (head/neck/facial or other). The study con-
cluded that injury location and the partner violence
screen were statistically associated with an inter-
personal violence-related cause of injury [30]. A
2006 study using a randomized controlled trial of
computer screening for domestic violence showed
an increase in the likelihood that domestic violence
would be addressed during emergency department
encounters. This study underscored the concerns
that physicians may need additional training to in-
terpret the computer-generated data and recognize
and respond to violence and abuse issues [31].
Taliaferro [32] has written a review article on
the topic of screening and identication of V/A.
She emphasized the need to assess risk versus
benet of such screening to individual patients.
Although anecdotal evidence suggests the bene-
ts of screening, there are potential risks to
such questionnaires. These study limitations in-
clude selection bias and misclassication. Selec-
tion bias is usually accounted for by the study
design depending on the selection of patients.
Misclassication is more important. Measuring
the outcome variable (injury cause) at one point
in time and relying on subject self-report may re-
sult in misclassication. Clearly, subject report of
injury as the standard for diagnosing runs the
risk for misclassication, most commonly a false
negative (ie, subject denies injury from IPV and
reports a dierent injury cause, such as a fall).
The clinical reality, however, is that subject
self-report is the standard for identifying injury
cause for nonveriable injuries in the absence
of using more signicant resources, such as pri-
vate investigators or the police. In the absence
of alternative methods, subject self-report will re-
main the standard for identifying injury cause in
virtually all clinical settings for the near future.
Anecdotal evidence suggests the benets of
screening, whereas there is no evidence of harm
[33]. Gerbert and coworkers [34] used focus
groups to evaluate how experienced practitioners
approach domestic violence screening. They em-
phasize that compassionate asking about abuse
should be the rst step in helping potential vic-
tims. This alone can provide validation and
help the victims move toward safety.
There are states with mandatory reporting
laws that are strict for child and elder abuse
but are variable for adult abuse (ie, IPV). Those
in favor of mandatory reporting believe that laws
protect women from further injury and facilitate
prosecution of batterers. Those opposed believe
that such laws may increase violence by perpe-
trators and put victims at risk for retaliation.
Concerns about compromised condentiality and
diminished patient autonomy have also been
raised. It is feared that such laws discourage
victims from seeking health care [35,36]. The risks
and benets of mandatory reporting have not
been tested in multicenter or randomized trials.
Oral surgeons should know and follow the laws
of their individual states in determining the
need for reporting violence and abuse when iden-
tied in their patients.
Violence and abuse in the pediatric population
Although the focus of this article is on V/A
in the adult female, it is important to recognize
the eect on children who live in households
where violence and abuse occurs. Children who
live in violent households are at risk for physical
injury either directly or indirectly. In one study
of 159 children injured during violent episodes,
the mother was involved in the conict more
than 80% of the time. In almost 70% of the
cases, the ght involved the childs father. Other
perpetrators included the mothers boyfriend or
another male relative [37]. The most common
mechanism of injury was a direct hit. Children
younger than 5 years were ve times more likely
to sustain head or facial injury than older chil-
dren. Some 60% of these younger than 2 years
were injured while being held by a parent. A
high proportion of adolescents were injured dur-
ing an attempt to intervene in the altercation be-
tween the adults [38]. Witnessing domestic
violence has signicant eects on children and
adolescents in the area of cognitive, behavioral,
and emotional well-being. This study clearly sug-
gests that violence and abuse extends beyond the
adult female victim in many cases. When
 ABUSED FEMALE ORAL AND MAXILLOFACIAL PATIENT
children and adolescents are seen by the oral
surgeon for a facial or dental injury, violence
and abuse should be considered as a possible
cause [8].
Suggested treatment strategies
McDowell and coauthors [38] have published
recommendations for examination and documen-
tation of the ndings for the victim of violence
and abuse. These are listed in Box 1.
Gerbert and coworkers [34] have developed
a technique for identifying victims and providing
an outlet for intervention. They call this the
AVDR model. This model is simple and allows
standardization of the health professionals role
(Box 2).
The National Guideline Clearing House [39]
has available recommendations for identifying
and providing interventional strategies for victims
of V/A in health care settings. These guidelines
are extensive and can be accessed through www.
guideline.gov.
In addition, the National Domestic violence
hotline provides additional information and
support.
Box 1. Recommendations for
identification and documentation of
victims of V/A
 Have an office member present for
the examination
 Use confidentiality in interviewing
the patient
 Be supportive and nonaccusatory
 Record patient statements regarding
the abuse in the patients own words
 Document all physical findings
accurately
 Consider using photographs for
documentation and obtain consent for
photographs when possible
 Use radiographs when indicated
 Be prepared to follow the laws of the
state for reporting suspected domestic
violence when appropriate [38]
Adapted from McDowell J, Kassebaum D,
Stromboe S. Recognizing and reporting vic-
tims of domestic violence. J Am Dent Assoc
1992;123:4450.
263
Box 2. The AVDR model for
identification of victims of V/A
Asking
Practitioners should ask about abuse
privately and confidentially. Family
members should not be used to
interpret. Be nonjudgmental in tone
and wording.
Validating
Dentists should provide validating
messages showing compassion and
providing comfort.
Documenting
Findings should be carefully and
completely documented. Use direct
quotations, accurate charting,
radiographs, and photographs when
indicated.
Referring
Victims should be referred to community
advocates. Although victims may
refuse referral, repeated offering
assures them that help is available
when they are ready [18,23].
Adapted from Love C, Gerbert B, Caspers
N, et al. Dentists attitudes and behaviors re-
garding domestic violence. J Am Dent Assoc
2001;132(1):8593; and Danley D, Gansky S,
Chow D, et al. Preparing dental students to
recognize and respond to domestic violence:
the impact of a brief tutorial. J Am Dent Assoc
2004;135(1):6773.
National Domestic Violence Hotline
1-800-799-SAFE (7233) TTY 1-800-787-3224
www.ndvh.org
Summary
Oral and maxillofacial surgeons, in their role
as rst responders to traumatic injuries, are in
a unique position to recognize the impact that
violence and abuse may play in these patients. It is
imperative to identify these women, men, and
children, document their injuries, and provide
interventional options. The use of simple validat-
ing sentences (Box 3) may expedite this process.
By doing so, we, as surgeons, may play an invalu-
able role in the prevention of future injuries and
264
Box 3. Suggestions for approaching the
oral and maxillofacial surgery patient as
a victim of V/A
How are things at home?
Sometimes when I see bruises like this,
it means that the person is being hurt
by someone they love. Is this
happening to you? Has this ever
happened to you?
You do not deserve to be hit or hurt no
matter what happened.
I am concerned about your safety and
well-being [18,23].
Adapted from Love C, Gerbert B, Caspers
N, et al. Dentists attitudes and behaviors re-
garding domestic violence. J Am Dent Assoc
2001;132(1):8593; and Danley D, Gansky S,
Chow D, et al. Preparing dental students to
recognize and respond to domestic violence:
the impact of a brief tutorial. J Am Dent Assoc
2004;135(1):6773.
provide a better health-related quality of life for
our patients.
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