Forensic Science International 159S (2006) S121–S125

Short communication

Domestic violence: A complex health care issue for dentistry today
John P. Kenney *
DuPage County Illinois Coroner’s Office, 101 S. Washington, Park Ridge 60068-4290, IL, USA
Available online 20 March 2006

As a natural outgrowth of the dental professional’s role in recognizing and reporting child abuse the topic has been broadened in recent years to
domestic violence, that is child, spouse/intimate partner, disabled and elder abuse. Forty years ago in the US there were 662 cases of child abuse
reported to authorities. Today that reported number is in excess of 3 million per year [D. Wiese, D. Daro, Current trends in reporting and fatalities;
the results of the 1994 annual 50 state survey, National Committee to Prevent Child Abuse, Working Paper 808, 1995]. The ‘‘dirty secret’’ of
spousal/intimate partner violence is believed to affect 3–4 million individuals per year in the US. Studies have also found that between 50 and 70%
of these perpetrators also abuse their children or those of their intimate partner [J. Kessman, Domestic violence, identifying the deadly silence,
Texas Dent. J. (2000) 43].
Just as child abuse is most often manifested in the head or neck regions, likewise the evidence of physical violence to intimate partners and the
elderly can be seen in the head or neck regions. The insidious part of partner and elder abuse is that often the largest component of these behaviors is
psychological, emotional and indirect neglect, which leave no physical evidence [M. Bowers, Forensic Dental Evidence: An Investigator’s
Handbook, Elesevier, San Diego, CA, 2004, p. 119].
# 2006 Elsevier Ireland Ltd. All rights reserved.
Keywords: Domestic violence; Child abuse; Intimate partner abuse; Elder abuse; Disabled abuse

1. Introduction
The abusive party will use any means necessary to obtain the
control he or she seeks in a given situation. That may be
psychological threats such as harm to children, pets or personal
possessions with a significant intrinsic meaning to the victim.
Humiliation, ridicule, withholding of affection and belittling
are all types of emotional abuse. Financial dependence,
exploitation or isolation–prohibition from working in order
to preclude independence from the abuser are also part of a
pattern of control. Social isolation from family or friends, or
monitoring of telephone calls are prevalent. Physical and sexual
abuse includes hitting, slapping, choking, beating, restraining
or forced intimate contact in painful or degrading ways.
The parallels between the various categories of abuse are
always there, and crossover from one victim type to another is
common. Domestic violence is a learned behavior. Just as we
parent the way we were parented, we treat our spouse or elders
the way we saw it happen in our own lives be it as perpetrator or

* Tel.: +1 847 698 2088; fax: +1 847 698 2091.
E-mail address:
0379-0738/$ – see front matter # 2006 Elsevier Ireland Ltd. All rights reserved.

accepting adult or child victim. The serial predator perpetrators
of intimate partner violence often seek out the weak and
vulnerable as their partner, because they know they can easily
control, intimidate and exploit the situation. Being partner
abusive when there are vulnerable children also present will
lead to their abuse and exploitation as well. How often we see in
abuse cases, the perpetrator is the ‘‘paramour’’.
This paper will present an overview of these types of abuse,
their recognition by the dental health professional and what we
need to do to protect and assist these patients.
2. Domestic or intimate partner violence
It is estimated that between 20 and 30% of women and 7.5%
of men have been physically and/or sexually abused by an
intimate partner at some point in their lives [4]. This is a cycle
that will beget future violence as it becomes a ‘‘norm’’ for the
children growing up in this setting. Fifty percent of all female
homicides are the result of intimate partner violence [5].
Chronic but often non-specific problems are often reported by
the adult victim. They include headaches, sleep disorders, GI
discomfort and bowel problems, depression, fatigue, anxiety
and post traumatic stress disorder (PTSD). Neurological

Economics also drives the situation. numbness or tingling. review options and referrals for the victim. The victim may act unusually aggressive or withdrawn or exhibit a sudden behavior change. The abusive partner will often beg forgiveness. embarrassment or guilt can also trigger a ‘‘responsibility’’ response for the abuse (‘‘I deserved it for being . are trapped in the situation. did someone do that to you? Document your findings Record statement in patient’s own words Use assailant’s name in record if offered Record pertinent physical findings Body diagram to document evidence Photography if indicated and consented Preserve physical evidence Document an opinion. The author has personal experience in his practice where the mother of a child patient was being badly abused. In 1996 the American Dental Association enacted a policy to encourage efforts to educate the dental health professional in identification of abuse and neglect of adults. Once the victim has disclosed. punched by your partner? I notice you have a number of bruises. if the abuser is prominent in the business or political community and there is concern that they could possibly ‘‘influence’’ the court system. bruises in various stages of healing. Kenney / Forensic Science International 159S (2006) S121–S125 symptoms can include headache. A tip-off here would be self denigrating terminology to describe how the injury occurred.’’). or ridicule that accompanies the physical abuse. ‘‘I am clumsy and fell’’. . i. The victim will often dress in inappropriate attire such as long sleeved dresses and pants in hot weather. all point to physical abuse. The head and neck area is readily visible during a dental examination. Religious beliefs where women are ‘‘second class’’. In 2001 the US Department of Justice reported that 85% of intimate partner violence victims are women. child or elder abuse does not occur! A good way of screening patients for domestic violence is found in the acronym RADAR developed by the Massachusetts Medical Society and made into a laminated hand out card by the Illinois Violence Prevention Authority (Table 1): routinely screen female patients. however males in heterosexual relationships as well as members of the gay. Shame. Specific physical injuries such as dental trauma and head or neck injuries of any kind without adequate explanation. The victims are fearful of physical retribution from the abuser or their threats. The American Dental Association amended its code of ethics in 1993 to state that ‘‘dentists shall be obliged to become familiar with the signs of abuse and neglect and to report suspected cases to the proper authorities consistent with state laws’’ In 1996 the ADA enacted a policy to increase efforts to education dental professionals on how to identify abuse and neglect of adults [7]. the patient who has a history of repeated ‘‘accidents’’ or uses a vague/rare illness or disease process as their explanation. patients statement is consistent/ inconsistent with injuries Assess patient safety Is she afraid to go home Increase in severity/frequency lately of the abuse Threats of homicide/suicide Threats to the children Is there a firearm in the household Review options and referrals If in imminent danger. if any. that could become a trigger for the abusive party Phone numbers of hotlines in stalls of women’s restrooms Follow up appointment necessary . defensive injuries on the forearms. and the office has done its part to inform the patient about what options are available or to at least provide the telephone number of a shelter or counseling center for abused individuals (never identify what the phone number is on the card or piece of paper). did those who knew the family find out. assess the patient’s safety. even of reporting to immigration authorities in the case of illegal aliens. This choice of words might be due to the emotional abuse such as belittling. 94% of the victims will show an injury in the head or neck region [6]. i. ask direct questions.S122 J. bisexual and transsexual relationship communities have been affected. that she and her children. social or immigration status all can contribute to the problem. The victim of the abuse may not be willing to articulate what happened. They may recoil back from a simple touch as part of the examination process. They will bear signs of previous injuries or have multiple injuries in various stages of healing.P. It was so well concealed that only after the local police became involved when a neighbor witnessed an event. or will offer an explanation inconsistent with the actual injury. a history that is inconsistent.e. The victim has a feeling of hopelessness. What do we look for as symptoms? A presenting history that conflicts with the clinical appearance of the injury. . or offer a gift or attention to keep the spouse dependent.e. is there a friend or relative who has safe harbor Need immediate access to a shelter Have hotline/resource numbers available Do not force literature on victim. lesbian. These victims will come from all educational and socioeconomic levels. especially bilaterally. kicked. Just because you practice in a middle or upper middle class area does not mean that the dirty little secret of domestic violence/partner. and oversized dark sunglasses even when it is overcast. contradictory or vague. document your findings. They lived in an upper middle class suburb and had a second home on an island in a resort area about 150 miles away where the woman would go after a beating to await the bruising to disappear. presence of multiple injury sites. thus they will often lie or mislead practitioners. In domestic violence. they can also be supportive of the victim by providing free or reduced cost Table 1 RADAR: screening patients for domestic violence Routinely screen Interview patient alone No partner/relative present Female assistant in room if male DDS Simple direct questions Non-judgmental attitude Ask direct questions State that because violence is common in women’s lives we now ask about it routinely Are you in an abusive relationship? Ever been hit.

J. dentures to intimidate or humiliate their victim. if the abuser is deceased or in prison. Also threats or breakage of items very sentimental to the victim is psychological abuse. but the pregnancy went unnoticed by the supervisory staff. Physical abuse is the affliction of physical pain or injury. 3. Statistics vary. Threats of abandonment or precluding medical care also are psychological abuse. 4. or ecchymosis from medicines. A 5 years retrospective review was done. The American Association of Cosmetic Dentistry’s Charitable foundation created a partnership with the National Coalition Against Domestic Violence for a ‘‘Give Back A Smile’’ program that began in 1999. Based upon these numbers and the prevalence of this issue not only in the US but across the world. It was not until a staff member felt her stomach move that action was taken. Remember that these senior citizens often have had to drastically downsize their lives into small apartments or nursing homes. There are many health conditions in seniors that can be mistaken for abuse. The few possessions they have kept are very special to them. Not only did she suffer the indignity of the sexual assault. Categories of elder abuse are as follows: passive neglect. but may indicate a tumor or systemic disease. covering some 236 emergency department admissions. another mentally challenged girl of the same high school was forced into her own locker at school and locked inside by fellow students who thought it was ‘‘funny’’. and even fellow students. We recently had an instance in the Chicago area of a 23-year-old profoundly disabled woman (cerebral palsy from birth anoxia) who was sexually assaulted while a resident of a long term care facility. According to the study 81% of the victims presented with maxillofacial injuries. This data is quite impressive. The U. active neglect. Material (financial) abuse is the illegal or unethical exploitation and/or use of funds/property/assets belonging to the elderly person. educational and economic groups. along with the signs and symptoms. diabetes and peripheral vascular ulcers or decubitus ulcers (bed sores) all can have legitimate causes. walker. wheelchair. care can begin immediately upon acceptance [8]. Examples are: failure to provide food. and that one in three adult women experience at least one physical assault by a partner. physical coercion (confinement against ones will) and/or sexual abuse. Abuse of the disabled Another area of concern is abuse of those among us with mental or physical disabilities. and pallor. psychological abuse. Psychological abuse is where the caretaker will threaten to withhold necessary medical appliances such as glasses. Systemic diseases such as lupus erythematosis or erythema multiforme. Kenney / Forensic Science International 159S (2006) S121–S125 dental care. often the tables are turned and the male abuser turns into the victim of the spouse he abused for years. however is reported only half as often. The types and locations of the physical abuse again seem to center on the head and neck. An interesting point to note is that in situations where the couple has stayed together in spite of the abuse. as in intimate partner violence. It manifests in all social. In another lesser incident related by the mother of a disabled patient of this author. depriving of dentures or eyeglasses. Passive neglect is where there is an unintentional failure to fulfill a caretaking obligation. health related or other services because of the caregiver’s infirmity or inadequate skill. Persons with developmental disabilities and other special needs are abused and neglected at four times the rate within the general population [10]. This can make them a convenient target for not only caregivers but neighbors. The ‘‘Face to Face’’ program conducted by the American Academy of Facial Plastic and Reconstructive Surgery began in 1995 to assist victims of domestic violence. As of late 2004. physical abuse. Bureau of Justice Statistics (National Center for Justice 154348) in August of 1995 estimated 1 million women in the US were affected annually. or a bedroom in their child’s home. Anterior teeth are often damaged or lost due to physical abuse. The middle third of the face was the most frequent target (69%) with soft tissue injuries making up the most common type (61%). Deliberate denial of food. Active neglect is the intentional failure to fulfill a caretaking obligation. The American Psychological Association in 1996 put the number at 4 million in an average 12 month period. and again tells us as dental professionals that we do see this type of injury in our practice.S. There is a 1 year waiting period after the abusive relationship is terminated so that the treatment time and effort expended will not be in vain. knowledge or understanding of the necessity of prescribed or other essential services. 280 domestic violence cases had been completed with a value of over US$ 1 million. The majority of victims are women over the age of 75 years with one or more physical impairments that precludes them living alone. S123 cane. Elder abuse It is assumed that elder abuse is at least as prevalent as child abuse (estimated 3 million cases yearly). The Journal of Oral and Maxillofacial Surgery addressed the issues head on in an article [9] discussing ‘‘Maxillofacial Injuries Associated with Domestic Violence’’. They include venous lakes and stasis. even though her missed menstrual periods and morning vomiting were marked in her chart and brought to the attention of supervision.P.32. or deliberate abandonment all take the psychological abuse to the next level. it is important that dentistry become aware of this issue. The ‘‘deinstitutionalization’’ of these individuals away from state run facilities into local community . and another 167 patients were under treatment. whether we realize it or not. material (financial) abuse. The average number of mandible fractures per patient was 1. now that he is dependent and weak. but there is a great prevalence of intimate partner violence. dehydration and weight loss are not necessarily an indication of neglect. Malnutrition in seniors is common. There are two exceptions to this program. or health related services. Fractures to the left side of the face were more common (right handed perpetrators).

Originally conceived as a child abuse prevention . Mouden of the Arkansas State Department of Health. multiple fractures of varying ages. with an explanation that they thought it was a minor situation that would resolve. physically or mentally handicapped. Two seconds at 150 8F. 75% abuse occurs above 2 years of age. either because they caused them or the other parent/paramour did and the parent presenting with the child fears retribution. The injury is usually one where a reasonable person would have sought immediate or nearly immediate care. Fear of being reclined in the dental chair in a vulnerable position is also common [21]. Poisoning or munchausen syndrome by proxy is another subtle abuse process [17]. and multiple root fractures or an unusual (likely trauma induced) malocclusion. It can begin with seemingly innocent actions and proceeds to a more overt form of sexual content. brother. The signs of abuse are the same. neighbor or friend of an older sibling or parent. or being alone with adults of a particular sex [20]. which is frequently caused by hair pulling. clinical manifestations of AIDS and petechial palate. Research over the past 40 years has shown that at least half and up to 75. Preventing abuse and neglect through dental awareness. High water marks from forcible immersion. Orofacial injuries include a torn labial or lingual frenum. trust no one. or an inconsistent. Hot objects or water may be used to burn a child. subdural hematoma and subgaleal hematoma. Patient has a history of repeated ‘‘accidents’’ or the caretaker/ parent ascribes the cause to a vague or rare disease process. drink or medications. finger marks on the victim’s upper arms or identifiable patterns such as hand prints. and under a great deal of stress. are very reluctant to give information about the child’s injuries. maxillary and mandibular fractures. skull fractures. especially with a lack of splash marks. loop or ‘‘U’’ shaped marks. They may exhibit subtle signs such as difficulty sitting or walking. repetitive shapes. Persons from all educational and economic levels can be abusive. unhappy or depressed. Oral manifestations include evidence of sexually transmitted diseases (gonococcal phayryngitis/oral syphilis/condolomyta acuminatum. Child abuse Child abuse continues as a prime concern of health care providers. symmetrical injuries with well defined margins. about equal from ages 1 to 12 years and then above 12 years primarily female because of the prevalence of sexual abuse. The child will bear signs of previous injury. or the circular burns from a cigarette (1/2–1 cm diameter) all are highly suspicious [15]. They will have a generally unkempt appearance. or PANDA is a wonderful acronym and a program that was developed by Dr. but the majority of physical abuse occurs from birth till the second birthday. because of the very dependent nature of the infant/toddler. Other contributory factors will include a perception that the child is ‘‘different’’. In the US there are both federal and state laws that cover abuse and neglect of senior citizens and disabled adults.P. sister. 5.S124 J. It is also noted that a higher incidence of oral health problems are present in mentally challenged individuals. which is caused by fellatio) [19]. Neglect of oral health needs. Abusive parents/caretakers are usually isolated from family support. The caregiver will often give them inappropriate food. There will be a refusal to consent to diagnostic testing. do not interact in a normal fashion with their child and fail to return for routine or follow up care. and may be lonely. Bruising again in multiple locations or of varying ages. only 1 s is necessary to produce a full thickness (second or third degree) burn. scarring of the lips. They see ‘‘Value’’ in punishment of the child. such as a parent. caregiver. Kenney / Forensic Science International 159S (2006) S121–S125 based residential facilities has increased the presentation for care in the average dental office. so considers it a ‘‘normal behavior’’. They will often be unduly afraid of an unrelated person of the same sex as the abuser. There is a refusal to cooperate with health care provider to care for the problem or its root cause. The targeted children will often appear different physically or have emotional issues. At 155 8F. stepparent. contradictory or vague story. or heater. Other diagnostic injuries include retinal hemorrhage. They are usually the primary caretaker. the abuser was often mistreated as a child. More than 70% of women with developmental disabilities are sexually assaulted in their lifetime. injury that conflicts with the history given by the parent/ caretaker. or have been a premature birth The physical signs of abuse include spiral or greenstick fractures. The sexual abuser is usually someone well known and trusted by the victim. A child/teen patient who in the past has been normal and cooperative is suddenly extremely fearful of a dental examination should be carefully screened for possible sexual abuse. hand and digital fractures. even as an accidental injury. grandparent. belt buckle marks or human bite marks all indicate serious physical abuse is taking place [12]. In terms of age. and there is usually a delay of 12–24 h in seeking treatment. fractures or avulsion of teeth. Dental neglect such as untreated but previously diagnosed dental caries. and sexual abuse all can manifest in ways readily apparent to the dental health professional [14]. leather belts. Home water systems should be kept below 120 8F for maximum safety [16]. or rampant caries with multiple abscesses are in many jurisdictions are grounds for neglect charges with the appropriate authority [18]. Under a year of age. they may be hyperactive. Hot water from the tap can be very dangerous. As abuse is a learned behavior. Those responsible for the child’s well being may be overly critical of the child. or metaphyseal (growth center) fractures.5% of all physical injury occurs in the head or neck region [11–13]. it is primarily male children that are abused. Sexual abuse is usually a progressive action over a long period of time. or exhibit a sudden behavior change. There is unexplained injury. Ninety percent of the abusers are related to the child. 5 s at 140 8F and 30 s at 130 8F. The offenders in many of these cases are those charged with caring for the disabled individual. and patterned burns such as from a stove grid. Hospital or doctor ‘‘shopping’’ to avoid detection is a common thread.

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