FYI

If you treat children in your practice, your work puts you firmly on the frontlines of early detection and response to child abuse. More than half of all child abuse injuries involve the head, neck and mouth. You also see children at the age during which the majority of child abuse occurs, and your work places you in regular contact with children and their caregivers together, which gives you a unique perspective on both physical condition and family behavior.

Still, refusal to believe that abuse is happening and fear of dealing with angry patients can be powerful barriers to reporting suspected abuse. Prevention begins with knowing what to look for and what to do when you suspect abuse. To mark National Child Abuse Prevention Month, here is a dentist’s guide to detecting and reporting child abuse.

Your responsibilities

As a dentist, you’re required by law in all 50 states to report suspected cases of abuse and neglect to social service or law enforcement agencies.

The American Dental Association also states that you must familiarize yourself with signs of child abuse and report suspected cases to appropriate authorities consistent with state law. The law protects you from liability and civil retribution for reporting suspected abuse, as long as such reports are made with reasonable grounds and without malice.

What to look for

Although many people have preconceived notions of what an abusive family looks like, child abuse can occur in any community and in any neighborhood, regardless of educational level, cultural background or financial well-being. Screening for abuse and neglect should be an integral part of your clinical examination of every child.

Before examination

Even before examination begins, make a routine habit of observing children for unusual behavior and signs of abuse, including:
 

• Poor hygiene
• Outward signs of improper nourishment or poor general health
• Clothing that’s torn, dirty or inappropriate for the weather
• Wounds or bruises on the child’s face or body
• Aggressive, out-of-control or inappropriately angry behavior
• Sullen, stoic or withdrawn behavior
• Behavior that is inappropriately adult-like (taking care of other children) or inappropriately infantile (rocking, thumb-sucking, throwing tantrums) for the child’s age
• Trouble walking or sitting
• Avoidant behavior towards a caregiver or parent

During extraoral examination

Signs of abuse to watch for include:
 

• Asymmetry, swelling or bruising in the head and neck
• Bruising, hair loss or tenderness in the scalp
• Scars, tears or other abnormalities on or around the ears
• Bruises or abrasions of varying colors, which indicate different stages of healing
• Self-treated injuries
• Distinctive patterns in bruises or abrasions left by objects such as belts, cords or cigarettes
• Bilateral bruising around the eyes
• Petechiae (small red or purple spots) in the sclera of the eye
• Drooping eyelids or a deviated gaze
• Bruised nose, deviated septum or blood clot in the nose
• Bite marks that could not be self-inflicted

During intraoral examination

Signs of abuse to watch out for during examination include:
 

• Burns or bruises at the commissures of the mouth
• Scars or tears on the lips, tongue, palate or lingual frenum
• Untreated or self-treated bleeding or trauma in the orofacial region
• Oral manifestations of sexually transmitted diseases
• Fractured or missing teeth
• Untreated, rampant and visibly apparent caries

How to distinguish normal childhood injuries from abuse

We all know that occasional bumps, scrapes and falls are a normal part of childhood. How then can you as a dentist distinguish ordinary injuries from signs of abuse?

Most injuries from accidental falls are uniplanar (i.e., located on one surface of the body, usually the front). Typical injuries of physical abuse are multiplanar.

You should also routinely question both child and parent about the cause of any observed injuries. If possible, question each separately and have a staff member present as a witness.

When speaking with parents and children about suspected abuse, listen for:
 

• Inconsistent accounts of an injury’s origin
• Explanations that don’t comport with the type of injury observed
• Denial about the existence of an injury
• Inappropriate blame placed on the child for injury
• Description of the child in negative terms (bad, worthless, irresponsible, troublesome, etc.)
   

If, at the end of the office visit, you are still in doubt about whether to submit a report, consult with the patient’s physician, a social worker, a local authority or a colleague with experience in dealing with child abuse to discuss what you observed.

When in doubt, it’s better that you make your concerns known than to remain silent and possibly allow a child to remain unprotected. Remember, it’s ultimately the responsibility of the appropriate authorities to determine if abuse has occurred with the information you provide. 

How to document suspected abuse

Documentation of suspected abuse is not required to make a report, but it is nonetheless useful to create the following documentation:
 

• Photographs and radiographs of the structures involved
• A ruler placed beside the injury in photographs to help record its size
• Detailed written notes in the dental chart with respect to the location, appearance, severity and distribution of injuries

Where to report suspected abuse

Once you decide to report suspected abuse, you may wonder whether to inform the parent about your intentions. Generally, it is recommended that parents should not be informed, as the parent may try to dissuade you, or it’s possible an angry encounter might ensue that could place you, your staff or the child at risk.

To fulfill your legal obligation in reporting suspected abuse:
 

• Call 911 to alert the authorities if you believe the child is in imminent danger of immediate harm.
• Otherwise, you or an employee in your office must report your concerns to your local child protective services agency or police department. For more information about where and how to file a report, call the Childhelp National Child Abuse Hotline (800-4ACHILD) or refer to the following state resource listings about where to call to make a report in your state.
   

The report should be made immediately over the telephone and should be followed up in writing. The agency will have special forms for this purpose that they will ask you to complete. When you complete the report, be prepared to include the following helpful information about the child’s situation:
 

• The names and addresses of the child and the parents
• The child’s age
• The types of injuries or signs of abuse you observed
• Information about other children who are living in the same environment

Your practice and child abuse prevention

Dentists who recognize and report abuse can have a positive impact on their patients’ lives by helping victims move toward safety. Intervention is the key to breaking the cycle of abuse, and as a dentist, you’re uniquely positioned to be among the first (and sometimes only) advocate for victims. By being observant and reporting suspected cases, you can help shield your young patients from violence and neglect.