Dental Professional Response to Oral Conditions and Domestic Violence, Abuse, and Neglect

As dental hygienists, it is important to assess whether violence, abuse, or neglect is related to the conditions that are seen every day. Untreated decay, facial pain, lesions in the mouth, new and old facial bruises, or facial lacerations are routinely seen in dental practices. At times, these conditions can be related to violence, abuse, or neglect; assessing whether there is a connection is important. More than 65% of violence and abuse occurs in the head and neck region, including perioral tissues.¹

This article defines various kinds of domestic violence, key identifiers for past or current history of domestic violence, and what can be done to assess violence in the dental office. Ways to understand the evidence for determining the best tools to assess domestic violence for dental patients is discussed, then the correct strategy can be chosen for each dental practice.

What Is the Definition of Domestic Violence?

When discussing domestic violence, a number of definitions are useful.

• Domestic violence is a broad term for any type of physical, sexual, emotional, economic, or psychological actions or threats of actions that influence another person within a familial relationship. This includes any behaviors that intimidate, manipulate, humiliate, isolate, frighten, terrorize, coerce, threaten, blame, hurt, injure, or wound someone.¹
• Intimate partner violence is defined as actual or threatened physical, sexual, psychological, emotional, or stalking abuse of an intimate partner. An intimate partner can be a current or former spouse or non-marital partners, such as a boyfriend, girlfriend, or dating partner.¹
• Sexual violence includes non-consensual completed or attempted penetration of the vagina or anus, nonconsensual completed or attempted oral sex, non-consensual intentional touching of a sexual nature, or non-consensual, non-contact acts of a sexual nature, such as voyeurism and verbal or behavioral sexual harassment. Sexual violence can be perpetrated by a friend or acquaintance, a current or former spouse/partner, a family member, or a stranger.²
• Child maltreatment is a term applied to parents and caretakers of children under 18 years of age or someone who is not an emancipated minor. It refers to child abuse or neglect by a parent or caretaker that results in harm, potential for harm, or threat of harm. Child abuse is an act of commission, such as words or actions that cause harm, potential harm or threat of harm to a child that are deliberate and intentional. This includes physical, sexual, or psychological abuse.^2,3
• Neglect is an act of omission, a term defined as, "the failure to provide for a child's basic physical, emotional, or educational needs or to protect a child from harm or potential harm." This can include medical or dental neglect.²
• Medical or dental neglect is a term that encompasses a parent or guardian's denial of or delay in seeking needed healthcare for a person, whether a child or elder.⁴

 

How Common Is Domestic Violence?
Child Abuse and Neglect

Over 2.5 million cases of child abuse and neglect are reported each year, according to the American Academy of Pediatrics.⁵ In 2006, of about 900,000 children analyzed by type of abuse or neglect, 65.3% suffered neglect, 16% were physically abused, 8.8% were sexually abused, 6.6% were emotionally or psychologically maltreated, and 2.2% were medically neglected. In addition, 15.1% of victims experienced other types of maltreatment, such as abandonment, threats of harm, and congenital drug addiction. These national figures vary by state. State-by-state assessments for 2006 can be accessed from the US Dept of Health and Human Services Administration for Children and Families at: www.acf.hhs.gov/programs/cb/pubs/cm06/table3_6.htm.⁶

Women and Men

Every year, 4.8 million women become victims of domestic violence, a type of family violence occurring between people in an intimate relationship. An estimated 2.9 million men are victims of intimate partner violence. In addition to the physical, mental, and emotional toll of this violence, the estimated cost was more than $8.3 billion in 2003.⁷

Elders

As the population ages, many elderly adults are becoming dependent on others to meet their basic needs. Estimates vary widely about rates of elderly abuse and neglect. However, the National Center on Elder Abuse reported that abuse occurs in about 3% to 5% of people over 55 years of age, while the Senate Special Committee on Aging reported that as many as 5 million elderly people are abused each year. According to one survey, older women are far more likely than older men to suffer from abuse or neglect. In 2003, two out of every three (65.7%) elder abuse victims were women (15 states reporting).⁸

Symptoms of Domestic Violence

Regardless of age, gender, or health status, abuse and neglect are serious issues. The dental team has an important role in assessing, identifying, and recording incidents and properly referring for abuse and neglect. There are many common symptoms of domestic violence or abuse and neglect. Violence, abuse, or neglect can present in the oral cavity or perioral areas in a variety of ways. Any oral lesion or tooth or soft-tissue injury could be caused by violence. As part of the oral examination, dental healthcare practitioners may notice facial trauma or a history of facial trauma, including¹⁰:

• Untreated or rampant decay
• Missing or avulsed teeth
• Unexplained oral trauma
• Bruises, especially both old and new injuries
• Lacerations in the mouth or around the face
• Neck trauma, including marks or bruises continuing education
• Evidence of trauma or scarring in the perioral area
• Lesions in the mouth
• Unexplained orofacial pain

 

How to Identify Domestic Violence in the Dental Practice

1. Assess

Make sure that patients have a safe environment to discuss issues with a staff member when taking their medical history. This includes privacy and confidentiality. Simple, direct questions may be useful. The Family Violence Prevention Fund¹⁰ suggests starting by stating that, "Because violence is so common, our practice is asking all its patients about it routinely," and then following up with questions, such as:

• Are you in a relationship with a person who physically hurts or threatens you?
• Did someone cause these injuries? Who?
• Have you had ever any injuries like this in the past? How often?

 

Answers should be noted in the patient chart.

Common Assessment Tools and Programs for Domestic Violence in Dental Practice In 2007, the US Centers for Disease Control and Prevention (CDC) published a comprehensive inventory of currently available assessment instruments for intimate partner violence and sexual violence victims for use in healthcare settings.11 The document includes information on the characteristics of the various assessments and whether they are appropriate for use with a given population. Various instruments are used to assess domestic violence, and these tools are used for detailed questions about physical partner or date abuse, or other types of physical abuse. These assessments have in common the following characteristics¹¹:

• Ask about the violence very directly
• Ask who did this to the patient
• Convey to the patient confidentiality and safety
• Assess any physical, emotional, psychological, and other abusive behaviors
• Take detailed photographs of the patient
• Refer to the emergency room, if necessary
• Ask whether they are in a relationship that threatens or harms them
• Look for behavioral clues, such as evasive behaviors or physical clues, like old injuries or a history of unexplained past injuries
• Assess the frequency of physical, emotional, or psychological abuse
• Assess sexual abuse, if any
• Determine a detailed plan for immediate and follow-up care

 

The CDC document also describes whether the assessment is used with men or women and specific racial or ethnic groups. The document may also be used to help the dental team make appropriate referrals for both victims and perpetrators.¹¹

Information on the use of assessments for identification of dental and facial injury by dental professionals is limited. At least one review by the Cochrane Collaboration performed in 2004 and updated for 2008 identified no eligible randomized controlled trials (RCTs) to assess whether dental offices that used assessments were better at detecting domestic violence than those that did not.¹² RCTs are the highest level of evidence for assessing the effectiveness of various interventions, and they are rare for any prevention practice in dentistry, except for community water fluoridation. With the evidence used by the Cochrane Collaboration through 2004, no evidence either supported or refuted that screening for domestic violence among adults was either beneficial or harmful.¹² This does not mean lack of effectiveness, just lack of evidence.

While more scientific evidence is needed with a RCT of dental professionals using different instruments in dental practice, the current CDC evaluation could assist in determining what tools to use for various patients. The front of the document contains a list of assessment tools and various populations that may be useful for selection of the right tool for each practice.¹¹ Dental healthcare workers may wish to evaluate this document periodically, such as in conjunction with routine OSHA training.

2. Chart

It is critically important to document all interactions associated with possible abuse or neglect. Depending on the state's reporting requirements and the practice's office manual, specifics for documentation may need to be adapted. However, all practices can start with these pointers for charting, adapted from the Family Violence Prevention Fund⁹:

• Document the patient's exact words in response to questions. Be sure to document patient's responses to questions and any nonconsensual activities, such as oral trauma or forced oral sexual violence.
• Note the exact location of all current injuries, as well as any previous evidence of abuse or neglect.
• Document the entire head and neck, specifying locations. For example, chart the interior of the mouth using clock directions to specify the location of injuries (eg, at 3 o'clock in the midbuccal area, there is a large purple lesion about 3 cm in size with a focal area of 2 mm in the center that is darker in color).
• Use both radiography and photography for recordkeeping. Today, digital photography, as well as radiography, is used for diagnosis, referral, and recordkeeping.
• Document the referral and any follow-up for reporting purposes. Put a copy of any reports in the record.

 

There are a number of intervention programs designed for dental professionals for the prevention of domestic violence. While none have been found to be effective with RCTs among dental professionals, they still can be evaluated for use in the practice, if appropriate. The Department of Justice has a free program for dental professionals called Family Violence for Dental Professionals, which can be accessed at the Department of Justice Web site: www.ojp.usdoj.gov/ovc/publications/bulletins/dentalproviders/welcome.html.

Another popular program is the Prevent Abuse and Neglect through Dental Awareness (PANDA) Program, which is available through Dr. Lynn Mouden of the Arkansas Department of Health in Little Rock, Arkansas (501-661-2595 or lmouden@arkansas.gov).

Other program resources include those housed at the National Resource Center on Domestic Violence (888-Rx-ABUSE or www.endabuse.org). These resources also can be evaluated. Oral healthcare practitioners also should research emerging science about the role and need for training among dental professionals on violence and abuse prevention.

3. Referrals

Suggested protocols for referring patients and reporting violence may vary from state to state, and in some cases by local jurisdiction. Confidentiality and assuring safety for the patient should be maintained at all times. Your state board of dentistry should assist you in getting a copy of any requirements for dentistry, as well as specific requirements for Medicaid patients or any social service agency in your area. In addition, the local health department may assist you in maintaining a list of local shelters or safe havens for potential victims of domestic violence.

Contact your state dental licensing board and local legal entities to find out what the dental team's obligation is to identify and report domestic violence. Keep a current list of local resources and reporting requirements in the office procedure manual that include local emergency response information. Local resources could include¹³:

 

• Office and hospital personnel with special training
• Law enforcement (police, lawyers, advocates)
• Shelters (housing, support groups, advocates)
• Local hotlines
• Child protective services

 

Common obligations for reporting of suspected violence for many states include the following:

• A detailed report of bruise sites, or injuries noted on the chart
• Pictures of the injury and any history in the form
• Any evidence of use of an object or manual force
• History as stated by the patient, in the patient's words, if possible
• Follow-up and course of care
• Any referral, such as to an emergency room or law enforcement or social services

 

The Cochrane Collaboration noted that "owing to lack of training, dentists and oral and maxillofacial surgeons may not be the best persons to give advice to someone experiencing domestic violence."¹² The dental team may need to research local and state resources and even develop a script to address patients who may be experiencing domestic violence. Another option is to talk to local physicians who are addressing domestic violence.

Some tips on what an oral healthcare practitioner might consider in developing a script based on reporting requirements and restrictions include:

1. We are now asking all of our patients about violence because it has become so common. Are you now in a relationship where you are threatened physically, emotionally, psychologically, or in which love and attention are withheld?

2. If yes, I want to thank you for telling me. I want you to know that you are not to blame. You are not alone, and you do not deserve to be treated this way. We are here to help you. We can provide you with nearby resources to help you.

3. Are you safe to go home? Have you been threatened with knives or guns? Do you have a safe place to go? Can I help you with police assistance?

Violence is a serious, even life-threatening situation, as is abuse and neglect. Should an dental healthcare worker believe that violence, abuse, or neglect is a factor in an oral condition, the patient should be encouraged to seek a safe place and care. There are many community and state resources for supporting victims of domestic violence. Some hotlines also may be useful (see sidebar).

Conclusion

This article emphasized the critical role of the dental team in identifying cases of potential domestic violence and the need for follow-up activity. The article addressed some key points for evaluating domestic violence programming efforts from published scientific reviews. One of the more widely used programs for assessing domestic violence used in dental practice does not yet meet the criteria for the most rigorous evidence for effectiveness. However, lack of evidence does not mean lack of effectiveness; rather it means that there is insufficient or incomplete evidence. Each practice should develop a plan of action for addressing potential cases of domestic violence. This should include compiling a comprehensive list of contacts for referral to appropriate medical personnel, law enforcement authorities, as well as safe havens for potential victims of domestic violence. The plan should include a possible script and a form that fulfills reporting requirements for filling out the forms. A non-judgmental attitude and method to have the person talk about who is hurting them is very important. Requirements for professional liability insurance reporting should also be included. Finally, the plan should include unanticipated contingencies, such as the need for emergency response or methods to secure the office should a perpetrator seek the victim or information about the victim.

References

1. Saltzman LE, Fanslow JL, McMahon PM, et al. Intimate Partner Violence Surveillance: Uniform Definitions and Recommended Data Elements. Version 1.0. Atlanta, GA:US Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 1999.

2. Basile KC, Saltzman LE. Sexual Violence Surveillance: Uniform Definitions and Recommended Data Elements. Version 1.0 Atlanta, GA: US Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2002.

3. Definitions in federal law: child abuse and neglect. Child Welfare Information Gateway Web site. Available at: http://www.childwelfare.gov/can/defining/federal.cfm. Accessed Jul 1, 2008.

4. DePanfilis D, US Dept of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children's Bureau, Office on Child Abuse and Neglect. Child neglect: a guide for prevention, assessment and intervention. User manual series (2006). Child Welfare Information Gateway Web site. Available at: http://www.childwelfare.gov/pubs/usermanuals/neglect/chaptertwo.cfm. Accessed Jul 1, 2008.

5. American Academy of Pediatrics. Parenting corner Q&A. Available at: http://www.aap.org/publiced/bk0_childabuse.htm. Accessed Jul 21, 2008.

6. US Dept of Health and Human Services, Administration for Children, Youth and Families. Child Maltreatment 2006. Available at: http://www.acf.hhs.gov/programs/cb/pubs/cm06/cm06.pdf. Accessed Jul 1, 2008.

7. US Centers for Disease Control and Prevention. Understanding intimate partner violence: fact sheet 2006. Available at : http://www.cdc.gov/ncipc/dvp/ipv_factsheet.pdf. Accessed Jul 1, 2008.

8. Chair of Senate aging committee backs new bill to stop elder abuse. Senior Journal.com Web site. Available at: http://seniorjournal.com/NEWS/Eldercare/2007/7-03-30-ChairOfSenate.htm. Accessed Jul 1, 2008.

9. Family Violence Prevention Fund. Domestic violence guide for dental professionals. Available at: http://www.endabuse.org/programs/healthcare/files/dental.pdf. Accessed Jul 21, 2008.

10. Basile KC, Hertz MF, Back SE. Intimate Partner Violence and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings; Version 1.0. Atlanta, GA: US Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2007.

11. Coulthard P, Yong S, Adamson L, et al. Domestic violence screening and intervention programmes for adults with dental or facial injury. Cochrane Database Syst Rev. 2004;(2):CD004486.

12. American College of Obstetricians and Gynecologists and US Centers for Disease Control and Prevention Work Group on the Prevention of Violence During Pregnancy. Intimate partner violence during pregnancy, a guide for clinicians: screen show and lecture notes Slides 31-40. Available at: http://www.cdc.gov/reproductivehealth/violence/IntimatePartnerViolence/sld031.htm. Accessed Jul 1, 2008.

Domestic Abuse Hotlines

National Domestic Violence Hotline
800-799-SAFE (7233)
800-787-3224 (TTY)
www.ndvh.org

Rape, Abuse, and Incest National Network (RAINN)
800-656-HOPE (4673)
www.rainn.org

National Sexual Violence Resource Center (NSVRC)
877-739-3895
www.nsvrc.org

National Center for Victims of Crime, Stalking Resource Center
800-394-2255
800-211-7996 (TTY)
www.ncvc.org/src

National Teen Dating Abuse Helpline
866-331-9474
866-331-8453 (TTY)
A trained Peer Advocate is available from 4 PM to 2 AM (CST) daily.
www.loveisrespect.org