3/16/11 Guideline on Oral and Dental Aspects of Child Abuse and Neglect

Department of Pediatric Dentistry
Resident’s Name:Murphy Program:Lutheran Medical Center - Providence
Article title:Guideline on Oral and Dental Aspects of Child Abuse and Neglect
Journal: AAPD Guidelines
Year. Volume (number). Page #’s: 2010
Major topic: Child ABuse
Minor topic(s): Physical abuse, sexual abuse, bite marks, neglect
Main Purpose: Review the oral and dental aspects of physical and sexual abuse and dental neglect and the role of physicians and dentists in evaluating such conditions.
Overview of method of research: Review

Findings:
In all fifty states physicians and dentists are required to report suspected cases of abuse and neglect to social services or law enforcement. Physicians receive minimal training in OH and dental disease/trauma and therefore may not be able to detect dental signs of abuse and neglect.
Physical Abuse
Craniofacial, head, face, and neck injuries occur in more than half of all childhood abuse cases. Thorough intra and extra oral exam must be completed in all cases. When performing the IOE, any caries, gingivitis, or any other oral health issues should be noted and documented. Authorities believe that the oral cavity is a central focus for abuse because of it’s significance in communication and nutrition.
The lips are the most common site for inflicted oral injuries (54%), followed by the oral mucosa, teeth, gingival and tongue. Gags may cause bruising, lichenification, and scarring at the commisures.
Oral injuries from accidents are extremely common, and must be distinguished from abuse. A good history and exam should help to make the differentiation. Children that have multiple injuries, injuries at different stages of healing, or a discrepant history should arouse suspicion of abuse.

Sexual Abuse
While the OC is a frequent site of sexual abuse, visible oral injuries in kids and infections are rare. Any time oral-genital contact is suspected a referral must be made immediately to a specialized clinic equipped to conduct a comprehensive exam. Oral and periooral gonorrhea in prepubertal children is pathognomonic, but is rarely seen. Pharyngela ghonorrhea is usually asymptomatic. In terms of HPV, the mode of transmission is usually uncertain due the various ways to contract the virus.
Unexplained injury or petechia of the soft palate may be evidence of forced oral sex. Children who present with a recent history to sexual abuse may require specialized forensic testing for semen, etc resulting from the assault. Cotton swabs can be used to collect samples for analysis.

Bite Marks
Acute or healed bitemarks may indicate abuse. Bite marks should be suspected when an elliptical or ovoid pattern is found with ecchymosis, abrasions, or lacerations. Bite marks with a central ecchymoses may be cause by either positive pressure of the teeth closing, or the negative pressure caused by sucking or tongue thrust. Dog bites typically tear flesh, causing lacerations, whereas human bites cause abrasions, contusions, and lacerations by compressing tissue. An intercanine distance of >3cm indicates an adult bite. Pictures should be taken perpendicular to the bite mark. Also, any bite mark with an indentation should have a polyvinyl siloxane impression taken of it. Written observations and photographs should be taken and repeated daily for 3 days to document the bites evolution. Again, swabs should be taken to try to isolate DNA.

Dental Neglect
Dental neglect is the “willful failure of 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.” Caries, perio disease and other oral conditions can lead to pain and infection and loss of function. These can adversely affect learning, communication, nutrition, and growth and development.
After the parent has been properly alerted by a health care professional about the nature and extent of the condition, the tx that is needed is when they may be considered negligent. The clinician must be sure the parent or guardian has been given the necessary information, and had the opportunity to ask questions regarding the condition and required tx. Clinicians should be aware of possible barriers to care, including financial aid, transportation, etc. Before neglect is considered, the clinician must be sure the parent/guardian understand the explanation of the disease, it’s implications, and the tx.

Key points/Summary:
Oral abuse and neglect are extremely serious things that we all need to be aware of and be on the look out for.

Assessment of Article:
Basic guideline put out by the AAPD. We all need to know this stuff cold.