An approach to assessment
Abuse or neglect may present to the dental team in a number of different ways:
- through a direct allegation (sometimes termed a ‘disclosure’) made by the child, a parent or some other person
- through signs and symptoms which are suggestive of physical abuse or neglect
- or through observations of child behaviour or parent-child interaction.
Because of the frequency of injuries to areas routinely examined during a dental check-up, the dentist has an important role in intervening on behalf of an abused child.
It is assumed that the dentist will be examining a child who is fully dressed.
In some instances, the diagnosis of child abuse is clear. However, there are occasions when evidence is inconclusive and the diagnosis merely suspected. Members of the dental team are not responsible for making a diagnosis of child abuse or neglect, just for sharing concerns appropriately. If in doubt, you should always take advice.
If, having viewed the information on this site on how to recognise physical, emotional, sexual abuse and neglect, you require additional information please see other relevant texts.21, 2
Orofacial trauma occurs in at least 50% of children diagnosed with physical abuse.14-17
It is always important to remember that a child with one injury may have further injuries that are not visible. Where possible, arrangements should be made for the child to have a comprehensive medical examination.
It is important to state that there are no injuries which are pathognomonic of (that is, only occur in or prove) child abuse although some injuries or patterns of injury will be highly suggestive of it.
The assessment of any physical injury involves three stages:
- evaluating the injury itself, its extent, site and any particular patterns
- taking a history to understand how and why the injury occurred and whether the findings match the story given
- exploring the broader picture (e.g. the child’s behaviour, the parent-child interaction, underlying risk factors or markers of emotional abuse or neglect).
Typical features of accidental injuries
Typical features of non-accidental injuries
Types of injury:
Differential diagnosis of physical abuse
Typical features of accidental injuries
Typical features of non-accidental injuries (injuries that should raise concerns)
Accidental falls rarely cause bruises to the soft tissues of the cheek but instead tend to involve the skin overlying bony prominences such as the forehead or cheekbone. Inflicted bruises may occur at typical sites or fit recognizable patterns. Bruising in babies or children who are not independently mobile are a cause for concern. Multiple bruises in clusters or of uniform shape are suggestive of physical abuse and may occur with older injuries.18 However, the clinical dating of bruises according to colour is inaccurate.19
Bruises on the ear may result from being pinched or pulled by the ear and there may be a matching bruise on its posterior surface. Bruises or cuts on the neck may result from choking or strangling by a human hand, cord or collar. Accidents to this site are rare and should be looked upon with suspicion.
Particular patterns of bruises may be caused by pinching (paired, oval or round bruises - see artists impression belolw). Bizarre-shaped bruises with sharp borders are nearly always deliberately inflicted. If there is a pattern on the inflicting implement, this may be duplicated in the bruise — so-called tattoo bruising.
Abrasions and lacerations
Abrasions and lacerations on the face in abused children may be caused by a variety of objects but are most commonly due to rings or fingernails on the inflicting hand. Such injuries are rarely confined to the orofacial structures. Accidental facial abrasions and lacerations are usually explained by a consistent history, such as falling off a bicycle, and are often associated with injuries at other sites, such as knees and elbows.
Approximately 10% of physical abuse cases involve burns. Burns to the oral mucosa can be the result of forced ingestion of hot or caustic fluids in young children. Burns from hot solid objects applied to the face are usually without blister formation and the shape of the burn often resembles the implement used. Cigarette burns result in circular, punched out lesions of uniform size.
Bite marks (clinical presentation)
Human bite marks are identified by their shape and size. They may appear only as bruising, or as a pattern of abrasions and lacerations. They may be caused by other children, or by adults in assault or as an inappropriate form of punishment. Sexually orientated bite marks occur more frequently in adolescents and adults.
The duration of a bite mark is dependent on the force applied and the extent of tissue damage. Teeth marks that do not break the skin can disappear within 24 hours but may persist for longer. In those cases where the skin is broken, the borders or edges will be apparent for several days depending on the thickness of the tissue. Thinner tissues retain the marks longer. A bite mark presents a unique opportunity to identify the perpetrator20 (see discussion of the forensic aspects of bite mark interpretation).
Periorbital bruising in children is uncommon and should raise suspicions, particularly if bilateral. Ocular damage in child physical abuse includes acute hyphema (bleeding in the anterior chamber of the eye), dislocated lens, traumatic cataract and detached retina. More than half of these injuries result in permanent impairment of vision affecting one or both eyes.
Fractures resulting from abuse may occur in almost any bone including the facial skeleton. They may be single or multiple, clinically obvious or detectable only by radiography. Most fractures in physically abused children occur under the age of 3. In contrast, accidental fractures occur more commonly in children of school age. Facial fractures are relatively uncommon in children.
When abuse is suspected, the presence of any fracture is an indication for a full skeletal radiographic survey . A child who has suffered sustained physical abuse may have multiple fractures at different stages of healing.
Damage to the primary or permanent teeth can be due to blunt trauma. Such injuries are often accompanied by local soft tissue lacerations and bruising. The age of the child and the history of the incident are crucial factors in determining whether the injury was caused by abusive behaviour.
Penetrating injuries to the palate, vestibule and floor of the mouth can occur during forceful feeding of young infants and are usually caused by the feeding utensil.
Bruising and laceration of the upper labial frenum is not uncommon in a young child who falls while learning to walk (generally between 8–18 months) or in older children due to other accidental trauma. However, a frenum tear in a very young non-ambulatory patient (less than 1 year) should arouse suspicion. It may be produced by a direct blow to the mouth. This injury may remain hidden unless the lip is carefully everted. Any accompanying facial bruising or abrasions should also be meticulously noted.
Various diseases can be mistaken for physical abuse:
- impetigo may look similar to cigarette burns
- birthmarks (e.g. haemangiomas, mongolian blue spots) can be mistaken for bruising
- conjunctivitis can be mistaken for trauma
All children who are said to bruise easily and extensively should be screened for bleeding disorders. Unexplained, multiple or frequent fractures may rarely be due to osteogenesis imperfecta (look for a family history, blue sclerae and the signs of dentinogenesis imperfecta).
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