Abuse and Neglect

Presented by: Tara Thompson, Alissa Castellon, Maegan Edgerly

DOMESTIC VIOLENCE
 Abuse by one individual of another in an intimate or family relationship
MOST AT RISK
 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
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 Unhappy or withdrawn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 ATTITUDES
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 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 MATREATMENT
 Mistreatment occurs in institutional settings & 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.
 Withdrawn, anxious, shy & low self-esteem
 Give an illogical explanation of how an injury happened
 Depression & hostility
 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
 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 (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( 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 & NEGLECT
 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.
 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
o Battered partner may be very reluctant to admit abuse because of threats of more
serious harm
o Abused may deny the abuse, defend the abuser or provide excuses
o Battering is a choice in order to gain power and control over another individual
o Types of abuse are physical, sexual, emotional, psychological and economic deprivation
DENTAL HYGIENST’S ROLE
 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 AND NEGLECT
 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 whether or not the suspicion of abuse should be
discussed with the caregiver
 The professional should never directly accuse anyone and refrain from being judgmental
 The legal obligation to report a suspected case of abuse can be explained

 Proper Training:
 The dental team should have training in the recognition and reporting of abuse and neglect
 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
 “Prevent Abuse and Neglect through Dental Awareness (PANDA) – program for training dental
personnel
o Founded in 1992
o Missouri Bureau of Dental Health and Delta Dental of Missouri
o Public-private partnership committed to the education of all dental professionals in the
recognition and reporting of suspected cases of child abuse and neglect
 “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
o Asking the patient about the abuse
o Validating messages that acknowledge battering is wrong
o Documenting the signs, symptoms, and disclosures
o Referring victims to specialists and community resources
 Project RADAR seeks to enable healthcare providers to recognize and respond to IPV (intimate
partner violence) by providing them access to
o “Best Practices” policies, guidelines, and assessment tools
o Training programs and specialty-specific curricula
o Awareness and educational materials
o 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
o Each state has laws regarding the reporting of abuse and neglect to the proper authorities
o It is imperative to research the laws for the state and have them available for reference
in the office
o Each dental practice needs 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
 When reporting suspected abuse:
o Name and address of the child and parents or persons with legal custody
o Child’s age
o Names of siblings if there are any
o Nature of the child’s condition, including evidence of pervious injuries
o Any information that might be helpful in establishing the case of abuse or neglect
o Identity of the person believed to have caused such abuse or neglect
 Most states require healthcare workers to report suspected abuse
 Only a few states require healthcare workers to report IPV
FORENSIC DENTISTRY

 Dental science that relates and applies dental facts to legal problems
o 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
o Abusers may say the bite resulted from a sibling squabble, animal bite, or child biting
him/herself
o Photographs should be taken for the forensic odontologist to analyze and determine if
the history of the injury and the location of the marks match
o Impressions and bite registration are taken from the suspect and caregiver
o 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:
o Dentists
o Dental hygienists
o 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

DOCUMENTATION

 Purposes of Thorough and Accurate Documentation:

 For future reference and comparison
 To provide authorities meticulous 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
 Content of the Record:
 Obtain thorough histories of the injury from both the caregiver and the 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 examples

Which of the following are reasons for Abuse and Neglect?

 Oral care low priority/Lack of education of

 Limited finances
 Religious beliefs
 All the above

ABUSE OR NEGLECT CAN CONTRIBUTE TO PERIODONTITIS.

 True/False

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

 For future reference and comparison

 To take up time during the appointment
 To provide authorities meticulous information to support an investigation
 To protect the abused patient from harmful circumstances or even death