Family Abuse

and
Neglect
BY: TARA THOMPSON, ALISSA CASTELLON, MAEGAN EDGERLY
Domestic Violence

 Abuse by one individual of another in an intimate or family

relationship
 Most at risk: children, elderly, and disabilities.
 Abuse of women: spousal and dating violence
 Categorized: violence, emotional abuse, sexual abuse, neglect, or
financial exploitation.
Detecting Abuse

 Can be seen in initial assessment of patient

 Extra/intraoral exam
 Head and facial injuries
 Oral trauma
 Lesions
 Abnormal pathology
Child Maltreatment

 And act or series of acts of abuse and neglect by parent or other

care giver that results in harm, potential for harm, or threat of harm
to a child under the age of 18.
 Abuse: non-accidental, physical, emotional, or sexual acts against a
child
 Neglect: the intentional or un-intentional failure to provide for a child’s
basic physical, emotional, educational, and medical/dental needs.
 Dental Neglect: the willful failure of a parent or guardian to seek and
follow through with treatment necessary to ensure a level of oral health
essential for adequate function and freedom from pain and infection
Child Maltreatment
 General signs of abuse and neglect:
 Clothing: long sleeves or long pants in warm weather.
 Uncleanliness or lack of care (failure to thrive)
 Malnutrition
 Infestation of lice: live bugs, bug bite marks on scalp, drops that do not
come off/ lice eggs (appear as tiny silver tears)
 Behavioral
 Fearful or cry excessively OR could show no fear at all
 Unhappy or withdrawn
 May not exhibit behavior persistent with the age of the child. May act
differently when parent is not present
 Developmental delays: language or motor skills
Signs of Abuse and Neglect
 Intraoral
 Lacerations on tongue, buccal mucosa or palate
 Lingual and labial frenal tears
 Fractured, displaced, avulsed or non-vital teeth
 Lack of personal daily care, untreated disease (caries, gingivitis, gingival
bleeding)
 Lack of regularity of dental care
 Extraoral
 Injuries to head and neck: on both sides of face, lips, nose, eyes, bite marks, skull
injuries
 Exhibits difficulty in walking or sitting
 Extreme fear of assessment
 Pregnancy- especially in teens
Red Flags

 Condyloma acuminatum- focal sessile based lesion presents also as a

multiple papillary lesion. When present it is necessary to look for other
signs of sexual abuse because it can also occur from contact with
verruca vulgaris or from self inoculation

 Primary herpetic gingivostomatitis- can occur as a primary infection of

herpes simplex virus type 2. (genital infection transmitted through oral
sex)
 Parental Attitude

 General attitudes
 Disinterest or denial in relationship to child: critical, scolding,
and belittling
 Lack of interest or unavailability in treatment plan: only want
pain relief, may not be the same for the other children of the
family, doesn’t show up for appointments- may send sibling
instead
 Inconsistent information regarding signs of abuse
Reasons and Contributing Factors

 Reasons for Abuse and Neglect

 Oral care low priority
 Lack of education of oral and general health care
 Limited finances
 Family isolation
 Religious beliefs
 Contributing factors
 Immature or unpreparedness for parenthood
 The parents may have been abused
 Unable to handle daily stress of financial, work stress, and marital problems
 Drug or alcohol use
Elder Maltreatment

 Elder abuse is much more than physical injury or neglect inflicted at

the hands of the caretaker
 Mistreatment occurs in institutional settings as well as in family home
environments
 Harm to the elder can occur through intentional (active) infliction or
by unintentional (passive) neglect
 It is consistently reported that family members are the primary elder
abusers
 The dental team, as in child abuse, can be a key source for the
gathering of information to prove or disprove abuse of the elder
patient
General Signs of Abuse & Neglect

 When assessing for the possibility of abuse, it is necessary to have a

working knowledge of lesions related to aging, health problems, or
medications. Taking a thorough history and comparing it with lesions
present will help determined an appropriate differential diagnosis.
 Appears withdrawn, anxious and shy and has low self-esteem
 Give an illogical explanation of how an injury happened
 Depression and hostility may be evident
 May seem to dodge a motion of another person as if expecting to
be hit
 Overly eager to please and to be compliant
Physical Signs:
 Bruises in various degrees of healing, particularly in areas of restraint
like the legs or wrists
 Traumatic alopecia (baldness)
 Human bite marks
 Dislocations or sprains accompanied by fingertip pattern
 Poor personal hygiene
 Inadequate clothing for the season
 Scratches or burns
 Patterned marks and bruises indicating object used to inflict injury
such as belt buckle, ropes or a hand
 Cachexia (ill health, malnutrition, wasting)
 Extraoral signs:
 Lip trauma
 Bruising of facial tissues
 Eye injuries
 Fractured or bruised mandible
 Temporomandibular joint pain

 Intraoral signs:
 Fractured, displaced or avulsed teeth
 Bruising of the edentulous ridge (may indicate forced oral sex)
 Sexually transmitted disease lesions such as condyloma acuminatum and primary herpetic
gingivostomatitis
 Lesions or sore areas in the mouth from ill-fitting dentures
 Fractured dentures
 Poor oral hygiene
 Rampant dental caries
 Untreated periodontal disease
Intimate Partner Abuse & Violence

 Spousal or partner abuse is another type of abuse that can be

detected in the dental setting. The dental team is in a good position
to examine and evaluate the oral areas of injury to a battered
partner. The majority of intimate partner violence (IPV) cases have
female victims. Such abuse often goes unreported.
Signs & Attitudes of the Abused

 Many of the same injuries listed for the elder person are also evident
with partner abuse. They involved most frequently the face, eyes
and neck
 Battered partner may be very reluctant to admit abuse because of
threats of more serious harm
 Abused may deny the abuse, defend the abuser or provide excuses
 Battering is a choice in order to gain power and control over
another individual
 Types of abuse are physical, sexual, emotional, psychological and
economic deprivation
Dental Hygienist’s Approach

 Provide support; encourage open communication; be a source of

reassurance
 Discuss clinical findings in a nonjudgmental manner
 Respect and maintain confidentiality; talk in a private setting (door closed
to treatment room)
 Provide references for counseling; telephone numbers; community services
 Respect patient’s autonomy; ask about plans for future safety
 Prepare to share your findings with authorities when called to provide
evidence
 When it is known that the interview will be used in a legal setting, a witness
needs to be present
 Document clinical findings, including extra/intraoral photographs of injuries
Dental Concerns Associated with
Abuse
 Age range for childhood abuse is approximately 2-18 years
 No single factor can be identified as to why some adults behave
violently toward children or the elderly
 Reporting maltreatment, including physical and sexual abuse and
neglect is legally required of dentists in all states.
 The most important consideration is complete documentation of the
case (photos, charting of intra/extraoral findings)
 Abuse can impact oral hygiene because there will probably not be
scheduled dental visits and regular cleanings contributing to
periodontal disease
 There are no pre-meds, certain patient positioning or appointment
length
 Recall intervals should be at least every 6 months to be able to
document whether the abuse/neglect is still going on or getting worse
Reporting Maltreatment

Discuss findings:
 The decision is made by the dental team
 Never directly accuse anyone
 Refrain from being judgmental
 Legal obligation to report a suspected case of abuse

Proper Training:
 The dental team should have training
 Abusers may avoid the same physician but return to the same dentist
 Many states require CE courses on abuse and neglect before licensure
and re-licensure
PANDA

 “Prevent Abuse and Neglect through Dental Awareness (PANDA) –

program for training dental personnel
 Founded in 1992
 Missouri Bureau of Dental Health and Delta Dental of Missouri
 Organization committed to the education of all dental professionals in
the recognition and reporting of suspected cases of child abuse and
neglect
AVDR

 “Ask, Validate, Document, Refer (AVDR) Tutorial for Dentists” –

interactive tutorial program the uses a case study to demonstrate
the four step process in response to domestic violence
 Asking the patient about the abuse
 Validating messages that acknowledge battering is wrong
 Documenting the signs, symptoms, and disclosures
 Referring victims to specialists and community resources
RADAR
 Project RADAR seeks to enable healthcare providers to recognize
and respond to IPV (intimate partner violence) by providing them
access to
 “Best Practices” policies, guidelines, and assessment tools
 Training programs and specialty-specific curricula
 Awareness and educational materials
 Information on the latest research/data related to IPV
 Routinely inquire about current and past violence
 Ask direct questions
 Document findings
 Assess safety
 Review options and referrals
Reporting Laws:
 Varies state-to-state
 Each state has laws for reporting abuse and neglect to the proper authorities
 Research the laws for the state and have them available for reference in the office
 Have a written protocol for the documentation and reporting of abuse and neglect
 Reportable Required Information:
 All states mandate healthcare workers to report suspected violence, abuse, and neglect of children to CPS
agencies
 Only a few states require healthcare workers to report IPV
 When reporting suspected abuse:
 Name of victim and parents
 Address of victim and parents
 Child’s age
 Names of siblings if there are any
 Nature of the child’s condition, and evidence of pervious injuries
 Information that might be helpful in the case of abuse/neglect
 Identity of the person believed to be responsible for abuse/neglect
Forensic Dentistry
 Dental science that relates and applies dental facts to legal problems
 Forensic dentistry encompasses:
 Dental identification
 Malpractice litigation
 Legislation
 Peer review
 Dental licensure
 Use of Forensics in Abuse Cases:
 Forensic odontologists are used to determine if a particular injury, usually a bite mark, is a
result of abuse by a particular suspect
 Abusers may say the bite resulted from a sibling squabble, animal bite, or child biting him/herself
 Photographs should be taken for the forensic odontologist to analyze
 History of the injury should be documented to determine if the location matches
 Impressions and bite registration are taken from the suspect and caregiver
 This can all be used in the legal process of prosecuting the child abuse
Other Uses of Forensics

 Identification of victims of a disaster

 Forensic teams include:
 Dentists
 Dental hygienists
 Assistants with special training in the process of identifying remains by
comparing the dentition of the remains with dental records
 Gives families of victims closure after loss of a loved one
Content of the Record

 Obtain thorough histories of the injury caregiver and patient (identify

inconsistencies)
 Document the date, time, and place of the examination
 Record all observable facts
 Record questions asked of the abused patient and document all
answers in exact words
 Document lesions be descriptive (location, size, shape, and color)
 Bilateral injuries
 Use diagrams
 Photographs and radiographs (photos only taken with patient consent)
 Scale photography necessary for bite marks for further analysis
 Box 62-2 Pg.1055 documenting example
Documentation

 Purposes of Thorough and Accurate Documentation:

 For future reference and comparison
 To provide authorities information to support an investigation
 To protect the abused patient from harmful circumstances or even
death
 A second person needs to be present to witness the examination
and interview
Factors to teach the Patient
 Child
 Value of oral hygiene with age-appropriate materials
 What dental biofilm is and disclosing solution
 How to use new toothbrush
 Importance of brushing teeth and tongue before bedtime

 Elder
 Where help can be obtained: emergency assistance including phone
numbers and referrals
 Maltreatment to increase in severity and frequency over time
 Battering is a choice. Used to gain power and control over another
individual
Questions
Which of the following are reasons for Abuse and Neglect?
 A. Oral care low priority/Lack of education of
 B. Limited finances
 C. Religious beliefs
 D. All the above

ABUSE OR NEGLECT CAN CONTRIBUTE TO PERIODONTITIS.

 True/False

Which of the following is NOT a purpose for thorough documentation?

 A. For future reference and comparison
 B. To take up time during the appointment
 C. To provide authorities meticulous information to support an investigation
 D. To protect the abused patient from harmful circumstances or even death
References

Reitsema, A. M. and H. Grietens. "Is Anybody Listening? The Literature

on the Dialogical Process of Child Sexual Abuse Disclosure
Reviewed." Trauma, Violence, & Abuse, vol. 17, no. 3, July 2016, pp.
330-340. EBSCOhost, doi:10.1177/1524838015584368.
Wilkins, Esther M. Clinical Practice of the Dental Hygienist. Philadelphia,
PA. Wolters Kluwer, 2017. 12th edition.
Wikipedia contributors. "Child abuse." Wikipedia, The Free
Encyclopedia. Wikipedia, The Free Encyclopedia, 4 Dec. 2017.
Web. 5 Dec. 2017.