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PEDIATRICS Vol. 104 No. 2 August 1999, pp. 348-350
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ABSTRACT |
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Top
Abstract
Conclusion
References
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In all states, physicians and dentists recognize their responsibility to report suspected cases of abuse and neglect. The purpose of this statement is to review the oral and dental aspects of physical and sexual abuse and dental neglect and the role of physicians and dentists in evaluating such conditions. This statement also addresses the oral manifestations of sexually transmitted diseases and bite marks, including the collection of evidence and laboratory documentation of these injuries.
In all 50 states, physicians and dentists are required to
report suspected cases of child abuse and neglect to social service or
law enforcement agencies.1-4 Physicians receive minimal
training in oral health and dental injury and disease and thus may not
detect dental aspects of abuse or neglect as readily as they do child
abuse and neglect involving other areas of the body. Therefore,
physicians and dentists should collaborate to increase the prevention,
detection, and treatment of these conditions.
Craniofacial, head, face, and neck injuries occur in more than
half of the cases of child abuse.5-14 Careful intraoral
and perioral examination is necessary in all cases of suspected abuse.
Some authorities believe that the oral cavity may be a central focus
for physical abuse because of its significance in communication and
nutrition.15 The injuries most commonly are inflicted with
blunt trauma with an instrument, eating utensils, hands, or fingers or
by scalding liquids or caustic substances. The abuse may result in
contusions; lacerations of the tongue, buccal mucosa, palate (soft and
hard), gingiva alveolar mucosa or frenum; fractured, displaced, or
avulsed teeth; facial bone and jaw fractures; burns; or other injuries.
These injuries, including a lacerated frenum, also can result from
unintentional trauma. Discolored teeth, indicating pulpal necrosis, may
result from previous trauma.16,17 Gags applied to the
mouth may leave bruises, lichenification, or scarring at the corners of
the mouth.18 Multiple injuries, injuries in different
stages of healing, injuries inappropriate for the child's stage of
development, or a discrepant history should arouse suspicion of abuse.
Age-appropriate nonabusive injuries to the mouth are common and must be
distinguished from abuse based on history, the circumstances of the
injury and pattern of trauma, and the behavior of the child, caregiver,
or both. Consultation with or referral to a pediatric dentist is
appropriate.
The oral cavity is a frequent site of sexual abuse in
children.19 The presence of oral and perioral gonorrhea or syphilis in prepubertal children is pathognomonic of sexual
abuse.20 When gonorrhea or syphilis is diagnosed in a
child, the case must be reported to public health authorities for
investigation of the source and other contacts. A multidisciplinary
child abuse evaluation for the child and family should be
initiated.21 Pharyngeal gonorrhea is frequently
asymptomatic. Therefore, when a diagnosis of gonorrhea is suspected,
lesions should be sought in the oral cavity, and appropriate cultures
should be obtained even if no lesions are detected.22-26
When obtaining oral or pharyngeal cultures for Neisseria
gonorrhoeae, the physician must specifically ask for culture media that will grow and differentiate this organism from Neisseria meningitidis, which normally inhabits the mouth and throat.
Gonococci will not grow in routine throat cultures.27 Even
when selective media is used, nonpathogenic Neisseria
species can be confused with N gonorrhoeae. Laboratory
confirmation using two different types of tests is needed to
properly identify N gonorrhoeae. Detection of semen in the
oral cavity is possible for several days after exposure. Therefore,
during examination of a child who is suspected of experiencing forced
oral sex, cotton swabs should be used to swab the buccal mucosa and
tongue, with the swabs preserved appropriately for laboratory analysis
of the presence of semen.
Unexplained erythema or petechiae of the palate, particularly at the
junction of the hard and soft palate, may be evidence of forced oral
sex.28,29 Although cases of syphilis are rare in the
sexually abused child, oral lesions also should be sought and
dark-field examinations performed. Oral or perioral condylomata
acuminata, although probably most frequently caused by sexual contact,
may be the result of contact with verruca vulgaris or
self-inoculation.30
Bite marks are lesions that may indicate abuse. Dentists trained
as forensic odontologists may be of special help to physicians for the
detection and evaluation of bite marks related to physical and sexual
abuse.31 Bite marks should be suspected when ecchymoses,
abrasions, or lacerations are found in an elliptical or ovoid pattern.
Bite marks may have a central area of ecchymoses (contusion) caused by
two possible phenomena: 1) positive pressure from the closing of
the teeth with disruption of small vessels or 2) negative pressure
caused by suction and tongue thrusting. The normal distance between the
maxillary canine teeth in adult humans is 2.5 to 4.0 cm, and the canine
marks in a bite will be the most prominent or deep parts of the bite.
Bites produced by dogs and other carnivorous animals tend to tear
flesh, whereas human bites compress flesh and can cause abrasions,
contusions, and lacerations but rarely avulsions of tissue. If the
intercanine distance is <2.5 cm, the bite may have been caused
by a child. If the intercanine distance is 2.5 to 3.0 cm, the bite was
probably produced by a child or a small adult; if the distance is
>3.0 cm, the bite was probably by an adult. The pattern, size,
contour, and color(s) of the bite mark should be evaluated by a
forensic odontologist or a forensic pathologist if an odontologist is
not available. If neither specialist is available, a pediatrician or
pediatric dentist experienced in the patterns of child abuse injuries
should observe and document the bite mark characteristics photographically with an identification tag and scale marker in the
photograph. The photograph should be taken at a right angle (perpendicular) to the bite. A special photographic scale was developed
by the American Board of Forensic Odontology (ABFO) for this purpose,
as well as for documenting other patterned injuries and should be
obtained in advance from the vendor (ABFO No. 2 reference scale.
Available from Lightening Powder Co, Inc, 1230 Hoyt St SE, Salem, OR
97302-2121). Names and contact information for the ABFO certified
odontologists may be obtained from their Web site (www.abfo.org).
Written observations and photographs should be repeated daily for at
least 3 days to document the evolution and age of the bite. 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.
Blood group substances can be secreted in saliva. DNA is present in
epithelial cells from the mouth and may be deposited in bites. Even if
saliva and cells have dried, they should be collected on a sterile
cotton swab moistened with distilled water, dried, and placed in a
cardboard specimen tube or envelope. A control sample should be
obtained from an uninvolved area of the child's skin. All samples
should be sent to a certified forensic laboratory for prompt
analysis.32 The chain of custody must be maintained on all
samples submitted for forensic analysis. Questions of evidentiary
procedure should be directed to a law enforcement agency.
Dental neglect, as defined by the American Academy of
Pediatric Dentistry,33 is "the willful failure of parent
or guardian 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." Dental caries, periodontal diseases, and other oral conditions, if left untreated, can lead to
pain, infection, and loss of function. These undesirable outcomes can
adversely affect learning, communication, nutrition, and other activities necessary for normal growth and development.33
Failure to seek or obtain proper dental care may result from factors
such as family isolation, lack of finances, parental ignorance, or lack
of perceived value of oral health.34 The point at which to
consider a parent negligent and to begin intervention occurs after the
parent has been properly alerted by a health care professional about
the nature and extent of the child's condition, the specific treatment
needed, and the mechanism of accessing that treatment.35
The physician or dentist should be certain that the caregivers
understand the explanation of the disease and its implications and,
when barriers to the needed care exist, attempt to assist the families
in finding financial aid, transportation, or public facilities for
needed services. Parents should be reassured that appropriate analgesic
and anesthetic procedures will be used to assure the child's comfort
during dental procedures. If, despite these efforts the parents fail to
obtain therapy, the case should be reported to appropriate child
protective services.33,35
When a child has oral injuries or dental neglect is suspected, the
child will benefit from the physician's consultation with a pediatric
dentist or a dentist with formal training in forensic odontology.
Pediatric dentists and oral and maxillofacial surgeons, whose advanced
education programs include a mandated child abuse curriculum, can
provide valuable information and assistance to physicians about oral
and dental aspects of child abuse and neglect. The Prevent Abuse and
Neglect Through Dental Awareness (also known as PANDA) coalitions that
have trained thousands of dentists and dental auxiliaries is another
resource for physicians seeking information on this issue (telephone:
573/751-6247; e-mail: moudeL{at}mail.health.state.mo.us).
Physician members of multidisciplinary child abuse and neglect teams
should identify such dentists in their communities to serve as
consultants for these teams. In addition, physicians with experience or
expertise in child abuse and neglect should make themselves available
to dentists and to dental organizations as consultants and educators.
Such efforts will strengthen our ability to prevent and detect child
abuse and neglect and enhance our ability to care for and protect
children.
COMMITTEE ON CHILD ABUSE AND NEGLECT, 1998-1999
LIAISON REPRESENTATIVES
SECTION LIAISON
CONSULTANT
AMERICAN ACADEMY OF PEDIATRIC DENTISTRY AD HOC WORK GROUP
ON CHILD ABUSE AND NEGLECT
PHYSICAL ABUSE
SEXUAL ABUSE
BITE MARKS
DENTAL NEGLECT
CONCLUSION
Top
Abstract
Conclusion
References
Steven W. Kairys, MD, MPH, Chairperson
Randell C. Alexander, MD, PhD
Robert W. Block, MD
V. Denise Everett, MD
Lt Col Kent P. Hymel, MD
Charles F. Johnson, MD
Larry S. Goldman, MD American Medical Association
Gene Ann Shelley, PhD Centers for Disease Control and Prevention
Karen Dineen Wagner, MD, PhD American Academy of Child and Adolescent
Psychiatry
Carole Jenny, MD Section on Child Abuse and Neglect
Robert A. Kirschner, MD
Stephen M. Blain, DDS, MS
Paul E. Kittle, Jr, DDS
John P. Kenney, DDS, MS
Robert J. Musselman, DDS, MSD
Howard L. Needleman, DMD
Lynn D. Mouden, DDS, MPH (PANDA Consultant)
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FOOTNOTES |
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The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
This statement has been approved by the AAP Child and Adolescent Health Action Group.
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ABBREVIATIONS |
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ABFO, American Board of Forensic Odontology.
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REFERENCES |
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Top
Abstract
Conclusion
References
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The following policy statement is a revision:
This article has been cited by other articles:
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  S. Maguire, B. Hunter, L. Hunter, J. R. Sibert, M. Mann, A. M. Kemp, and for the Welsh Child Protection Systematic Review G Diagnosing abuse: a systematic review of torn frenum and other intra-oral injuries Arch. Dis. Child., December 1, 2007; 92(12): 1113 - 1117. [Abstract] [Full Text] [PDF]
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 A. P. Sirotnak, T. Grigsby, and R. D. Krugman Physical Abuse of Children Pediatr. Rev., August 1, 2004; 25(8): 264 - 277. [Full Text] [PDF]
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 Committee on Child Abuse and Neglect When Inflicted Skin Injuries Constitute Child Abuse Pediatrics, September 1, 2002; 110(3): 644 - 645. [Abstract] [Full Text] [PDF]
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