Child Abuse: Oral & Dental Aspects PDF

11-13-2023 Child Abuse Oral & Dental Aspects Your text Dr. Yasmin Alayyoubi here DMD, DMSc, MSD, CAGS  Outline 1. Introduction 2. Incidence 3. Etiology 4. Contributing factors 5. Types of abuse 6. The dentist's role 7. Legal & l...

11-13-2023 Child Abuse Oral & Dental Aspects Your text Dr. Yasmin Alayyoubi here DMD, DMSc, MSD, CAGS  Outline 1. Introduction 2. Incidence 3. Etiology 4. Contributing factors 5. Types of abuse 6. The dentist's role 7. Legal & liability issues 8. Assessment 9. How to take action 10. Clinical cases  Introduction Child Abuse and Neglect As many as 1,500 children a year die from abuse (this data may be under-reported by 50%) Major problem that pervades in all socioeconomic segments of our society  Introduction Massachusetts has one of the highest rates of abused and neglected children Injuries to the head and neck occur in 65%-75% of cases of physically abused children. Children with special health care needs are more vulnerable to abuse  Introduction There has been a dramatic 25% increase in incidence of abuse over the past 20 years. Confirmed cases of abused or neglected children in MA: 31,089: 2015 94,410: 2017 97,731: 2018 84,399: 2021  Purpose of the study: To assess injuries Increased proportion of physical abuse secondary to physical child abuse treated at a injuries at level I Level 1 Pediatric Trauma and Burn Center pediatric trauma (John Hopkins Children’s Center, Maryland) center during the Covid- 19 pandemic (Kovler,et al. Science Direct Vol 116, Part 2, Methods: Retrospective study reviewing June 2021) patients admitted over the period of 2018 to 2020 treated for physical child abuse Subjects: Infants to < 15 years old Increased proportion of physical abuse injuries at level I pediatric trauma Results: center during the Covid- 19 pandemic (Kovler,et al. Science Direct Vol 116, Part 2, Covid 19 period: Physical abuse injuries June 2021) comprised 13% of total trauma patients  Increase in physical child abuse attributed to: Increased proportion of physical abuse Increased exposure to perpetrators in home injuries at level I pediatric trauma center during the Restricted access to safe alternative childcare Covid- 19 pandemic (Kovler,et al. Science arrangements Direct Vol 116, Part 2, June 2021) Limited contact with educational personnel, social service staff and medical personnel during the pandemic, who initially recognized and previously reported more than two- thirds of cases of child abuse and neglect  Victim Demographics (MA) Incidence 01 Of the 80% of deaths 82% of these 43% of these were estimated children were less than a 1 year were caused by 1,520 children one or more of the younger than 4 old, and died from that died from victim’s parents years old maltreatment child abuse: (National Children’s Allegiance) Children in the first year of life: highest rate of victimization of 23.1 per 1000 children in the national population of the same age 13  Etiology Most episodes of child abuse and neglect take place within a dysfunctional family Approximately 80% of abusers are parents Abusive parents: Young, emotionally immature adults, usually between 20- 30 years of age with very poorly controlled aggressive tendencies Past history of child abuse May have a present or past history of substance abuse Compete with the child for attention Abused Children: Possess characteristics that tend to evoke negative responses from parents May be physically or developmentally disabled Product of an unwanted pregnancy Youngest in a large family Contributing Factors: Lack of parenting skills 01 02 Lower social economic status, stress Past history of child 03 Child 04 Addiction or abuse Abuse substance abuse Unrealistic expectations 05 06 Mental health of caregivers problems Types of Abuse Physical Abuse Intentional bodily injury, e.g. kicking, slapping, pinching, biting, choking, showing, or physical restraint Physical Abuse Sexual Abuse Any sexual behavior or activity with a child or exploitation of a minor Physical Abuse Sexual Abuse Emotional Abuse Any behavior intended to control, manipulate, threaten, or belittle another person Physical Abuse Sexual Abuse Emotional Abuse Dental Neglect The “willful failure of parent or guardian, despite adequate access to care, 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” Physical Abuse Sexual Abuse Emotional Abuse Dental Neglect Munchausen Syndrome Fabrication or induction of signs/symptoms of a disease by a caretaker to their child Physical Abuse Oral injuries may be inflicted with instruments such as eating utensils or a bottle during forced feedings, hands, fingers, (American Academy of scalding liquids, or caustic substances Pediatric Dentistry Reference Manual.pp278- This form of abuse may result in contusions; burns or 283) lacerations of the tongue, lips, buccal mucosa, palate (soft and hard), gingiva, alveolar mucosa, or frenum; fractured, displaced, or avulsed teeth; or facial bone and jaw fractures Some studies cited lips as the most common site for inflicted oral injuries (54%) followed by the oral mucosa, teeth, gingiva, and tongue Physical Abuse Unexplained injuries e.g. bruises, broken bones, burns Signs and symptoms Multiple injuries in different stages of healing Injuries that are not consistent with the characteristics of the injury or the child’s developmental capability  Bite Marks Physical Abuse Animal bite marks tend to tear flesh, whereas human bites compress flesh and can cause abrasions, (American Academy of contusions, and lacerations Pediatric Dentistry Reference Manual.pp278- 283) An inter-canine distance measuring more than 3.0 cm is suspicious for an adult human bite Physical Abuse Analyzing Bite Marks: (American Academy of Pediatric Dentistry Bite marks can be difficult to interpret due to time elapsed Reference Manual.pp278- 283) and distortion presented Ideally, bite marks should be evaluated by a forensic odontologist or forensic pathologist If none are available, a dentist may examine the bite mark Physical Abuse Documenting Bite Marks: (American Academy of 1. Photograph Pediatric Dentistry Reference Manual.pp278- 283) Angle the camera directly over the bite Place a ruler/scale marker next to the bite  Documenting Bite Marks: Physical Abuse 2. Double swab technique (American Academy of Pediatric Dentistry Swab the area with a sterile Reference Manual.pp278- cotton swab moistened with 283) distilled water, followed by swabbing the same area with a second, dry cotton swab, thus absorbing any excess liquid DNA present in epithelial cells from the mouth may be deposited in bites even if saliva and cells have dried  Documenting Bite Marks: Physical Abuse (American Academy of 3. Polyvinyl Siloxane Impression Pediatric Dentistry Reference Manual.pp278- 283) Will help to provide a 3- dimentional model of the bite mark All evidence should be collected, documented, and labeled according to standards with a clear chain of custody and submitted for forensic analysis Because each person has a characteristic bite pattern, a forensic odontologist may be able to match dental models (casts) of a suspected abuser’s teeth with impressions or photographs of the bite (this is the responsibility of law enforcement and not the health care provider)  Other forms of physical abuse: Physical Abuse Hitting Ear pulling Slapping Hair pulling Choking/strangulation  Immersion in scalding liquid “Sock burns” Both feet were immersed in scalding Physical Abuse liquid causing wound borders with very distinct, sharply defined, water lines Immersion burns with a distinct pattern are deliberate “Glove burn” This child’s hand was immersed in scalding liquid Parts of the fingertips are spared from the burn due to the child making a fist during the immersion  Cigarette burns Physical Abuse The lit end of a cigarette is over 500 degrees F At this temperature, it only takes an instant to cause this degree of burn  Bruises Physical Abuse Bruises go through a color change as they heal New bruises present as tender, red, and swollen Older bruises tend to be green, yellow, or brown  Analyzing Bruises The appearance of a bruise differs based on: 1. The amount of trauma/injury incurred Physical Abuse 2. Time lapse between the injury and day of evaluation. ❖ Bruises that result from the same traumatic injury heal at about the same time. ❖ Evaluating the color helps to determine if the bruise coincides with history ❖ Location: bilateral injuries are indicative of abuse  Sexual Abuse Although the oral cavity is a frequent site of sexual (American Academy of abuse in children, visible oral injuries or infections are Pediatric Dentistry Reference Manual.pp278- rare 283) When oral-genital contact is suspected, referral to specialized clinical settings equipped to conduct comprehensive examinations is recommended Sexual Abuse Oral and perioral gonorrhea in prepubertal children (which is diagnosed with appropriate culture techniques and Signs and symptoms confirmatory testing) is pathognomonic of sexual abuse Unexplained injury or petechiae of the palate, particularly at the junction of the hard and soft palate, may result from forced oral sex Unexplained oral lesions such as warts Sexual Abuse Oral Petechiae HPV Lesions Ddx: condyloma acuminatum Oral Gonorrhea  Please note: Not all lesions are indications of sexual abuse Sexual Abuse Primary Herpetic Gingivostomatisis (HSV) Most common viral infection of the mouth Common finding in children Transient condition not related to sexual abuse  Emotional Bullying Abuse 30% of children in the sixth to 10th grades report having been bullied and/or having bullied others (American Academy of Pediatric Dentistry Reference Manual.pp278- Children with orofacial or dental abnormalities (including 283) malocclusion) are frequently subjected to bullying Health care providers (including dental providers) are encouraged to ask their patients about bullying and advocate for antibullying prevention programs in schools and other community settings Dental Neglect Defined by the AAPD as: (American Academy of Pediatric Dentistry The “willful failure of parent or guardian, despite Reference Manual.pp278- adequate access to care, to seek and follow 283) through with treatment necessary to ensure a level of oral health essential for adequate function and freedom from pain and infection” Dental Neglect Several factors are necessary for the diagnosis of neglect: (American Academy of 1. A child is harmed or at risk for harm because of lack of Pediatric Dentistry dental health care Reference Manual.pp278- 2. The recommended dental care offers significant net 283) benefit to the child 3. The anticipated benefit of the dental treatment is significantly greater than its morbidity, so parents would choose treatment over nontreatment 4. Access to health care is available but not used 5. The parent understands the dental advice given Dental Neglect Dental Neglect Please be mindful: (American Academy of Caregivers with adequate knowledge and willful failure Pediatric Dentistry Reference Manual.pp278- to seek care must be differentiated from caregivers 283) without knowledge or awareness of their child’s need for dental care when determining the need to report such cases to child protective services Dental Neglect When to report dental neglect: (American Academy of Caregiver understands the explanation of the disease and Pediatric Dentistry its implications Reference Manual.pp278- When barriers exist, family is assisted in finding financial aid 283) and or necessary transport information Risks and benefits of treatment was explained Risks of no treatment is explained If parent/caregiver fails to seek treatment despite these efforts, the case should be reported to the appropriate child protective services agency Is this neglect? Munchausen Defined as a mental illness and form of child abuse Syndrome The caretaker of a child, usually a mother, either makes up fake symptoms, or causes real symptoms to make it appear as though the child is sick, e.g. withholds food so the child does not gain weight adds blood to the child’s urine/stool  Epidermolysis Bullosa Predisposing medical conditions that may Hemophilia mimic symptoms of abuse Staphylococcal scalded skin syndrome (SSSS)  A rare genetic skin condition that causes fragile, blistering skin Blisters appear in response to minor injury such as rubbing, Epidermolysis scratching, or heat Bullosa Mimics burns  An inherited bleeding disorder in which the blood does not properly clot This can result in spontaneous bleeding as well as excessive bleeding following surgery or an injury. Hemophilia Children may also bruise easily Bleeding may appear as bruises in different stages of healing  A rare but serious skin infection that causes peeling skin over large parts of the body Staphylococcal May appear as though the skin has been burned by a hot scalded skin liquid syndrome Triggered by exotoxin release from specific strains of staphylococcus aureus bacteria (SSSS)  Dentists are mandated reporters In all US states, health care providers, including dentists, are mandated to report suspected cases of abuse or neglect to appropriate social service or social service or law enforcement agencies Dentists are found to have reported only 32% of these cases compared to other THE DENTIST’S ROLE IN professionals, although dentists may REPORTING CHILD ABUSE actually be the first to see signs of abuse and neglect  Dentists must be aware of the responsibilities outlined by the ADA to comply with the legal mandate to report: The dentist’s role in reporting child 1. Familiarity with the perioral signs of child abuse and abuse neglect 2. Recording evidence that may be helpful in the case including physical evidence and any comments from questioning on interviews 3. Reporting suspected cases to proper authorities consistent with state laws  The dentist’s role in reporting child abuse In Massachusetts, mandated reporters are protected from any criminal, civil liability or retaliation by employers from reporting in good faith Massachusetts: $1,000 fine for failure to make required oral and written reports of suspected abuse Penalties for failing to report Willful failure to report child abuse and/or neglect that resulted in serious bodily injury or death abuse Fine up to $5,000 Up to 2.5 years in jail Can be reported to the Board of Registration in Dentistry Every state that specifies mandated reporting also has criminal for failure to report suspected cases Massachusetts: Department of Children & Families (DCF) is the state agency that receives all reports of suspected abuse How to report and/or neglect of children under the age of 18 child abuse When you suspect a child is being abused and/or neglected, immediately telephone local DCF Area Office and ask for the screening unit On weekends and holidays, call the Child-At-Risk Hotline 800-792-5200  Report must include: Your name, address, phone number All identifying info you have about the child and Documenting parent/caretaker child abuse Nature and extent of suspected abuse and/or neglect, including evidence & photographs Circumstances under which you first became aware of the child’s maltreatment What action, if any, has been taken to assist the child Any other information you believe might be helpful e.g. Clinical and behavioral findings, discrepancies between parent and child’s history of trauma A copy of the patient’s chart (considered a legal document) Note: DCF can provide assistance and guidance with filing of the report Documenting Remember: child abuse Dentists only report suspected cases Dentists and dental staff are not responsible for verifying whether abuse and/or neglect occurred  Services Recommend parenting skill classes, or alcohol rendered by and drug rehabilitation courses as needed DCF When necessary, facilitate the removal of the abuser or child from the household Provide prevention services Provides reunification services Assessment Concerned caregivers Realize the urgency of immediate care Accompany the child to see the physician or dentist right away Show concern about the health status of the child Feel guilty for not being able to prevent the injury of the child Possible signs of abuse Parents wait for hours or even days/weeks before seeking medical or dental treatment Parents appear withdrawn, indifferent, unconcerned Have no questions even in life threatening situations Child has unexplained injuries, e.g. bruises, fractures, burns Bruises are at different stages of healing Injuries that don’t match the given explanation Injuries are not compatible with the child’s developmental ability Child has a neglected appearance Parents appear strict and overly critical of their child  Behavioral Child may appear: indicators of Wary of parents child abuse Lack of eye contact and/or neglect Fearful to touch Wanting to run away Dramatic mood changes Overly aggressive Withdrawn History of depression and/or attempted suicide  01 Evaluate If you suspect abuse and/or neglect, look for any physical or behavioral signs of abuse before treatment begins. Document in the patient’s chart. 02 Question the child In cases of suspected abuse, question the child away from the parent 03 Question the parent/caregiver Obtain a history from the parent/caregiver. Look for any inconsistencies in the story. Assess whether there was a history of similar injuries 04 Document How to take action Provide detailed documentation of the incident; include photos and/or radiographs of the affected areas. Record discrepancies in history taking Include your own opinion of why you suspect abuse. Make a clear distinction between facts and your personal opinion  Children may be exposed to maltreatment that manifests in the oral cavity and surrounding tissues As dentists, we can aid in preventing the re-occurrence of abuse and neglect in children Clinical cases Case 1: 4 year old presents to your office with an avulsed #E and extrusion of #F 01 CC: Child lost his tooth while playing at school Trauma was reported immediately 02 at the time of the incident Case of unintentional trauma 03 Case 2: 5 year old presents to your office with an avulsed #E 01CC: None Early loss of maxillary central incisor noted at recall visit, long after the incident 02Parent and child report different histories of how it fell out No emergency visit was noted This should be viewed as a possible case of abuse 03 Case 3: Reported as a tongue bite due to a fall 01 Patient is 4 months old; teeth have not erupted Curvature of bite is in the wrong 02direction Investigation revealed that the child was bitten by someone else 03 Case 4: Reported as a dog bite 01 Patient comes in for dental tx; parent reports that patient got bit by a dog a few days ago Examination: perfect outline of a 02 human adult dentition and not that of a dog; several days have passed and patient was not taken to the ER Investigation: revealed father had inflicted the bite Case 5: Conflicting reports 01 Mother stated “child fell off her bike” Child stated “she fell down the stairs” Inconsistent narration of histories 02 Both did not state what accurately occurred Patient was beaten by her father 03 Case 6: Reported as a bike wreck injury 01 Parents reported that he fell off a bike. Bike was totally wrecked Child examined two weeks later 02Since all injuries occurred at the same time, they all healed at the same time Healing and history reported are consistent This confirms the history of bicycle wreck injury 03 Initial examination 2-week follow up Case 7: Reported as a bike injury 01 CC: None. When asked about the injuries on her face, parents stated that she fell off her bike Injuries occurred bilaterally. 02Injuries that occur bilaterally should be investigated further for child abuse Observe that the bruises above her lip and under her eye are of different colors Investigation revealed that the child was 03 beaten by her father multiple times Oro-facial trauma in child abuse fatalities S Afr Med J 2006; 96: 213- 215.  To raise children in an emotionally nurturing environment that gives them a sense of belonging, protection, and safety A child should be given the privilege to mature in a loving, supportive family environment that promotes GOALS OF IDEAL PARENTING development of the child’s full potential  Thank You Special thanks to Dr. Cristina Baens, DMD, MSc for clinical case material [email protected]