What a Child's Mouth Can Reveal About Abuse or Neglect

Susan A. Fisher-Owens, MD, MPH

Disclosures

September 18, 2017

The Mouth—A Focus of Abuse and Neglect

The physical or sexual abuse of a child frequently involves the mouth; more than 50% of abused children suffer injuries to the head or neck. In addition to oral trauma, maltreated children are more likely to show evidence of dental neglect, including gingivitis, caries, and other oral health problems.

Examination findings that should raise suspicion of abuse or neglect are outlined in a new clinical report, "Oral and Dental Aspects of Child Abuse and Neglect," published in Pediatrics.[1] Medscape spoke with lead author Susan Fisher-Owens, MD, MPH, about key points in the report for clinicians involved in the care of children and teens.

Medscape: The report is an update of the 2005 report[2] on the same topic. Did anything in particular prompt you to revisit these issues now?

Dr Fisher-Owens: There were some advances in laboratory testing for sexually transmitted infections and more general awareness of how clinicians should respond to evidence of dental neglect. But the biggest changes in the updated report are new sections on bullying and human trafficking, both of which have increased since the previous report. We thought it was an opportune time to highlight the role of medical and dental providers with respect to the oral and dental problems that result from abuse and neglect.

Physical and Sexual Abuse

Medscape: The report, which covers all ages from newborn to adolescent, is divided into six areas, the first being physical abuse. What evidence of physical abuse can be found in and around the mouths of children?

Dr Fisher-Owens: The lips are the most common site for oral injuries of abuse, followed by the oral mucosa, teeth, gingiva, and tongue. One of the most suspicious signs to be seen in a newborn is a torn lingual frenulum. The frenulum can be ripped when a caregiver aggressively forces a bottle into a baby's mouth or strikes the baby with another object. The frenulum is not typically torn during normal activity, unless a child falls with an object in the mouth. A torn frenulum should raise the index of suspicion for abuse (Figure 1).

Figure 1. A torn frenulum. Courtesy of Dr Anupama Tate.

More information can be found in the American Academy of Pediatrics' (AAP's) guidance, "The Evaluation of Suspected Child Physical Abuse."

Medscape: What might tip off the clinician to possible sexual abuse involving the oral cavity?

Dr Fisher-Owens: Even though the oral cavity is a frequent site of sexual abuse in children, visible signs of injury or sexually transmitted infections are rare. In some cases, we may see physical signs of forced genital-oral contact, such as injuries to the oral mucosa. Certain evidence of injury, such as a torn frenulum or petechiae at the junction of the hard and soft palates, should raise concern about forced oral sex. More often, however, the hint of sexual abuse comes up in a discussion or in a child's behavior, rather than from an overt physical sign.

The report provides details about testing for sexually transmitted infections. Timing is critical. The evidence is most likely to produce a result if collected within 24 hours of exposure for prepubertal children or within 72 hours of exposure for older adolescents.[3,4] This type of collection can't be done in every setting, so it makes sense that when sexual abuse is suspected, the clinician should contact child protective services so that further investigation (eg, forensic exam and history) can take place in a setting where they are accustomed to conducting these evaluations, in as timely a way as possible. More information on this topic can be found in the AAP policy, "The Evaluation of Children in the Primary Care Setting When Sexual Abuse is Suspected."

Medscape: In the section on bite marks, the report addresses not only the oral cavity of the abused but also that of the abuser. How should clinicians evaluate bite marks?

Dr Fisher-Owens: The most important lesson for the general provider is to know the difference in shape between a human bite and an animal bite. Parents or caregivers may explain away a mark on the skin as being from an animal, but the shape of an animal bite is quite different from that of a human bite. The next point is to take photographs to document the bite mark. Finally, if the skin is actually open, the clinician can take a swab of the skin for DNA in the saliva (appropriately collected, documented, and labeled, maintaining the chain of custody). A forensic odontologist may be able to make a mold from the bite mark that can be used to identify an abuser (Figure 2).

Figure 2. A human bite mark. Courtesy of Dr Anupama Tate.

Dental Aspects of Child Trafficking

Medscape: How does the oral and dental examination provide clues about human and child sex trafficking?

Dr Fisher-Owens: Sadly, human trafficking is becoming more common. We don't have firm numbers, but more than 100,000 children annually are victims of prostitution, and the average age of these children is about 12 years. Some of the increase is the result of clinicians having greater awareness of children in their practices who may be at higher risk for trafficking (children who have been in and out of foster care, homeless children, runaways, and those who have been incarcerated). In a separate clinical report, "Child Sex Trafficking and Commercial Sexual Exploitation: Health Care Needs of Victims," the AAP covers this topic in greater detail.

The dental problems of trafficked children may be due to a lack of preventive dental care, poor nutrition, slow growth of the teeth and poorly formed teeth, or physical abuse. Children of any age may also present with dental caries, infections, and broken or missing teeth. In some cases, trafficked children are brought in for cosmetic dental care to improve their appearance, which is important to their value as trafficked individuals.

It's also critical for healthcare providers to be aware that this problem isn't limited to females; males can be victims of human trafficking as well.

Dental Neglect

Medscape: What are the key issues related to dental neglect that you'd like clinicians to know? Is this considered a form of abuse, or is it a lack of awareness?

Dr Fisher-Owens: A lot of dental neglect comes from ignorance. Rates of dental problems are higher among people with low socioeconomic status to the point at which families have a fatalistic view that, of course, they will lose their teeth in adulthood. It's a sad fact that every year, kids die from almost completely preventable dental disease.

An important point that has arisen in the past decade is the fact that dental neglect is more than the lack of dental care. Rather, dental neglect occurs after parents have been educated about appropriate dental care and provided with resources to access care, yet the parents still fail to access it for their children. Several stories have been in the news about people who were charged with dental neglect but who claimed that no one would take their insurance, or they had no transportation to the dental provider. These are some of the barriers that must be addressed before a charge of dental neglect is made or the family is reported to child protective services.

In the healthcare field, particularly in medicine, we need to educate our colleagues about the importance of paying attention to a child's dental health and not just saying, "Oh, it's just a toothache," or, "It's only a baby tooth, so it doesn't matter." If children have cavities in their baby teeth, they are not only more likely to have them as an adult, but they are also less likely to graduate from high school or to find a job that pays as well as someone who has a full set of teeth. Problems with teeth that start in childhood can have long-term effects. That's why we're trying to take more of an interprofessional approach to helping keep kids healthy.

Dental Aspects of Bullying

Medscape: Also new in this report is the section on bullying. The report explains that orofacial or dental abnormalities, including malocclusion, can expose the affected child to bullying. Can you discuss aspects of the mouth and teeth that might play a role in bullying?

Dr Fisher-Owens: One third of children in middle school have been bullied or have bullied someone else. And it's true that children with certain orofacial abnormalities or who have problems with teeth alignment (an under- or overbite) or other dental problems are more likely to be bullied. A cycle occurs, in which children who are bullied are more vulnerable to abuse and trafficking, which is deleterious to self-esteem. These children are less likely to take care of themselves, which in turn adversely affects their teeth.

However, frankly, at this point, all children should be screened for bullying. Clinicians need to start conversations by saying, "I'm finding that a lot of my patients are having problems with being bullied," or, "Many of my patients see other kids being bullied." This can make the child more comfortable talking about experiences with bullying. I often have asked a child about bullying, only to have the child answer in the affirmative, and the child's parents had no idea. Being able to open that discussion in the clinic allows it to be opened within the family, as well.

I'd also like to remind healthcare providers of the importance of their role in communities and in being thought leaders. Communities need to have healthcare providers talking about the importance of antibullying programs. Healthcare providers can influence how people approach bullying in schools.

The Role of Dental Providers

Medscape: The report emphasizes, right up front, that it is aimed not only at clinicians in medical settings but also at oral healthcare providers. What do you see as the role of dentists in the initial identification of an oral issue that might be related to abuse or neglect?

Dr Fisher-Owens: Dental providers are moving towards being involved with the child as a whole, and this is another area that we want to encourage dental providers to move into. The dental team often spends more time with the patient in the chair than a medical team spends with a patient in the office. Thus, the dental team may be able to explore how school is going, who the child's friends are, and so forth, and perhaps tease out whether something more might be going on in the child's life. Something that surprised me in the development of the report was finding that the caregivers of children who are being mistreated are likely to doctor-shop, but they tend to stick with the same dentist. So, although each new medical provider who sees the patient may not be aware of frequent injuries, for example, the dental provider might be in a position to pick up on this. It's one reason we think it's so important for dentists and their teams to be more aware of potential abuse or neglect.

Medscape: Do dentists, like other healthcare providers, have a role in reporting abuse and neglect?

Dr Fisher-Owens: All healthcare providers, whether dental, medical, or nursing, are mandatory reporters of abuse. If they have any concern, they are required to report it to child protective services. In general, medical providers for children are more accustomed to making these reports when they have a concern and not waiting for certainty of abuse or waiting for someone else to do it. We can help our dental colleagues become more comfortable with this process. It's not about an accusation; it's about concern for keeping the child safe and healthy. Making a report to child protective services doesn't require any specific training. The people who work in child protective services do this every day, and they can guide providers through the process.

Documentation and Photography

Medscape: With respect to any of these areas of potential abuse—physical, sexual, bite marks—what do you recommend in terms of documentation?

Dr Fisher-Owens: Taking photographs is incredibly helpful because clinicians who are observing these injuries might not fully understand what they're seeing. The photograph, particularly when it is taken with a ruler or other item to establish scale, allows those who evaluate the case later on to see what the clinician saw. Bruises and bite marks fade over time, so a photograph is very helpful.

Figure 3. Dermal melanocytosis can be mistaken for a bruise. Courtesy of American University of Beirut Medical Center.

It's also important for providers to routinely document findings that are normal but could be mistaken for evidence of injury. A great example of this is dermal melanocytosis (formerly called "Mongolian spots")—an area of skin darkening that looks like a bruise. If no one has documented this skin finding at birth or on the first routine examination of the infant, then later on, someone might think it's possible evidence of abuse. It's in the child's best interest to document normal findings that could later be misconstrued (Figure 3).

Medscape: What else would you like clinicians to know about the oral and dental aspects of child abuse and neglect?

Dr Fisher-Owens: Often, these kids come in to a medical provider with somatic complaints—trouble sleeping, stomach pains—but the clinician doesn't find anything upon examination. That should be a tip off that something more might be going on in the family or in the school setting. Kids who keep showing up with these nonspecific complaints may actually be victims of bullying and are afraid to go to school. Or they may be victims of abuse and are silently calling out for help that they can't ask for directly. Being sensitive to the unspoken agenda for a child can be very helpful.

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