Q&A: Oral injuries could be signs of abuse, neglect
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Key takeaways:
- Providers should report any suspicion of abuse; they do not need proof to make a report.
- Medical professionals can collaborate with dentists to consult on cases and refer patients for treatment.
Roughly half of child abuse cases involve injuries to the mouth, head or neck, but oral injuries may be missed by physicians who do not know what to look for, according to a report published in Pediatrics.
To improve awareness of oral and dental signs of abuse and neglect, Anupama Rao Tate, DMD, MPH, pediatric dentist, director of Dental Advocacy at Children’s National Hospital and associate professor of pediatrics at George Washington School of Medicine and Health Sciences, and colleagues wrote a guide for pediatricians, dental professionals and other medical providers.
Healio spoke with Tate about what physicians should look for and how to respond to suspected signs of abuse or neglect.
Healio: How common are oral injuries in cases of abuse?
Tate: We do not have numbers for specifically just oral injuries, but craniofacial, head, face, neck and oral injuries are present in about half of child abuse cases. Of those areas, the lips are the most common. When you think of physical abuse, it often is places that are hidden on the body or places that are quick to get to, like hands, ears, head, face, and mouth.
Healio: Why might physicians overlook oral injuries?
Tate: Pediatricians overlook these injuries because they are small. The mouth is a dark place, which can be hard to examine, and some of the injuries are very subtle. For example, a tear in the gum tissue that may or may not be bleeding right now, or it might be just a scar from a previous injury. Or, to assess that a tooth is loose, you sometimes have to touch it.
Another reason is because they may not be thinking of nonaccidental trauma. One of the things that we always talk about is the story and the presentation matching. If you have not seen a lot of oral injury related to trauma, you may not differentiate the difference in these kinds of cases of physical abuse.
For these reasons, I think working with a dentist can be helpful, because we are familiar with normal healing stages and have seen a lot of trauma cases that were both accidental and nonaccidental.
Healio: What type of injuries should pediatricians be looking for?
Tate: Issues with the jaw, like difficulty with opening and closing or moving the jaw from side to side, might indicate an injury to the mandible or lower jaw. When you look in the mouth, any kind of tears, hematoma or rips on the gum tissue, loose teeth or displaced teeth, difficulty closing together or eating. If a gag has been used, you can see scars or bruising on the corners of the mouth. You may also see torn frenum. It may not bleed for a long time, so you might just lift up the lip and see that it has been torn, but not necessarily see a massive injury.
When you see multiple injuries in different stages of healing, like loose teeth in one area, but teeth that have turned gray (or bruised) on the inside somewhere else, that might raise concern.
Healio: How can providers discern injuries that are accidental from those related to abuse?
It goes back to the history of what happened. For example, if you see an injury on multiple sides of the face, and the caregiver reported a fall off the bed, that might raise suspicion because it is unlikely that you would fall and then fall again on the other side of the face. Any tears of the soft tissue or trauma in an infant who is not mobile yet would not make sense. We have seen stories where there is a laceration to the tongue, and people have said, “Oh, the child bit themselves,” but they did not even have teeth in that area yet. If there has been a significant delay in treatment, something has been broken or displaced for what looks like a number of days without seeking care. Anything where the history or the timing does not make sense could be signs of abuse.
Healio: What should providers do if they suspect an injury or trauma is due to abuse?
Tate: Reporting is the number one step. As mandated reporters, we do not need to prove anything. We just need to have a suspicion of it. You can always probe and ask clarifying questions. You can ask for more details or see if there is someone else who witnessed the injury who you can talk to. But if you have the suspicion, then I think the next step would be to report to Child Protective Services in accordance with your state and local requirements.
In addition, if there are oral injuries that would require suturing or a tooth to be repositioned, reimplanted or extracted, find a provider who can work with the family holistically to not only manage the dental problem, but to give the appropriate anticipatory guidance in a patient-centered way.
Healio: What are some signs of dental neglect?
Tate: Dental neglect is very tricky because there are so many barriers — systemic barriers, family-based barriers and cultural barriers — that could make treatment more challenging to complete. Dental neglect is failure to seek proper dental care when these factors — such as finances, transportation, parental lack of knowledge or lack of perceived value in oral health care — have all been addressed.
Things that you would look for is multiple teeth that are decayed, any type of gross infection or abscess, pain that has been long-standing. Look out for facial swelling, or signs of systemic infection, like being unable to open their jaw, or their eyes are swollen closed. Pediatricians can play a role in helping families understand the risk-benefit to address maybe some of the access issues they may have. Parents themselves have dental fears, so you have to help them find a provider that can get them over that hump.
Healio: What can providers do if they see signs of dental neglect?
Tate: Getting families access is important. You can always visit the AAP Dentistry website, which has a provider locator anyone can use. If your family is using Medicaid, knowing some of the providers in your community would be very helpful for families. Using social workers to bridge that gap and get families access to care would be very helpful as well.
But again, if you truly feel that it is dental neglect and not just a lack of access, then I think it is important to report. I do not think any report of neglect is implying that the family does not care deeply about the patient. It may be that they need help in overcoming barriers we might not be aware of.
Healio: Anything else?
Tate: I think the other message from this is the value of medical-dental collaboration, not just on abuse or neglect kind of cases, but even for routine care, especially for medically complex kids or kids that are very young, where parents have to balance differing opinions from providers about the risks of sedation, or whether to do it in a dental office, or a medical office, or a hospital. The more that pediatricians and dentists can communicate with each other, advocate for families, and develop relationships and friendships, the better our communities will be.
References:
- AAPD. Find a pediatric dentist. https://www.aapd.org/publications/find-a-pd/. Accessed Aug. 30, 2024.
- AAPD. Health policies and recommendations (The reference manual of pediatric dentistry). https://www.aapd.org/research/oral-health-policies--recommendations/. Accessed Aug. 30, 2024.
- Tate AR, et al. Pediatrics. 2024;doi:10.1542/peds.2024-068024.
For more information:
Anupama Rao Tate, DMD, MPH, can be reached at anutate@gmail.com.
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