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Child abuse and dentistry: orofacial trauma and its recognition by dentists
O ro fa cia l traum a was fo u n d in 4 9 % o f 2 6 0 d o cu m e n ted ca se s o f ch ild a b u s e s e e n d u rin g a fiv e -y e a r p e r io d at the C h ild re n ’s Hospital M e d ic a l C en ter, Boston. A n additional 16% o f the ca ses in v o lv ed h e a d tra u m a ; the total p e r c e n t a g e o f h e a d a n d fa c ia l traum a w as 65%. H e a d or fa c ia l traum a was the p rin c ip a l rea so n f o r adm ission to the hospital in 4 5 % o f th e ca ses. A su rv ey o f 5 3 7 dentists in M assachusetts sh o w ed that the m ajority w e re u n a w a re o f th eir le g a l a n d so cia l resp o n sibilities to re p o rt s u s p e cted ca ses o f c h ild a b u se. E le v e n p e r c e n t o f all dentists s u rv e y e d saw o ro fa cia l traum a ca ses that w ere o f a suspicious n a tu re, but only 22 co n firm e d ca ses o f ch ild a b u s e w e re n o ted b y th e dentists. O f th ese, only fo u r w e r e re p o r te d to social a g en cies . In g e n e ra l, oral s u rg eo n s a n d ped odontists sa w a h ig h e r p e r c e n t a g e o f th ese ca ses a n d w e r e m o re a w a re o f th eir resp o n sibilities than w ere g e n e r a l pra ctitio n ers.
Child abuse and dentistry: orofacial trauma and its recognition by dentists David Belf Becker, DMD, MPH Howard L. Needleman, DMD Milton Kotelchuck, PhD, MPH, Boston
Q
t J o c i e t y is becom ing increasingly aware of ch ild abuse. Much has been w ritten about its causes, sequelae, and current concepts of treat m en t.1'3 The dental profession appears less aware than other medical professionals in the detection and treatm ent of suspected cases of child abuse. There are very few reports about child abuse in the dental literature, yet trauma to the head and face appear to be commonly associated with child abuse. In the limited number of case studies that document the location of the injury, the frequency of injuries of the head and face ranges from approxim ately30% 4,s to 50% 6,7The methods used in these studies vary greatly and all had small sample sizes. Nonetheless, the data 24 ■ JADA, Vol. 97, July 1978
suggest that dental professionals may be in con tact with a significant number of abused ch il dren. As annual estim ates in the United States range from 200 ,0 0 0 to 1,000,000 reportable cases a year,8,9 it is im probable that dentists have not seen this problem. The reasons for dentists’ reluctance to ac knowledge child abuse are probably the same as those for private physicians and others. Silver and others10 and San d ers11 suggest a num ber of possible reasons for this hesitancy, including lack of adequate histories, lack of knowledge about the problem of child abuse and their role and responsibilities in reporting it, concern about the effects on their practices if they report cases, and fear of confronting the parents. These
concerns m ay also account for the lack of litera ture about dentists’ experiences with cases of child abuse. In this study, head and intraoral trauma found in abused children who required hospitaliza tion in a large, urban children’s hospital and the extent of dentists’ knowledge about and experi ence with child abuse in the state of Mas sachusetts were documented.
Methods First, the m edical records of all abused children hospitalized at the Children’s Hospital Medical Center, Boston, Mass, from 1970 through 1975 were reviewed. Children with a physical injury that was diagnosed as caused by abuse were classified as abused children. Any cases of ne glect or “failure to thrive” without physical in juries were not included in the study. A total of 260 cases was reviewed by the senior author and included in this study. Only injuries found during the initial physi cal exam ination by the attending physician were noted, and their location on the body was recorded. Body, head, facial, and intraoral trauma were distinguished, as was the type of injury. For the purposes of this study, “body injury” was defined as all injuries below the neck, including injuries of internal organs. “Head traum a” was defined as skull fractures, subdural hematomas, and contusions, abra sions, and lacerations to the scalp. “Facial in juries” consisted of facial fractures, abrasions and lacerations, contusions and ecchym oses, burns, and bites. “Intraoral traum a” included abrasions and lacerations, contusions and ec chymoses, and injury to the teeth. “Orofacial traum a” is used to describe facial and intraoral injuries. No efforts were made to record the ex tent of the injuries, although it was noted whether the injury was the cause or was inci dental to the admission. Second, a questionnaire was mailed to a third of all general dentists in Massachusetts, who were selected at random. In addition, all oral surgeons and pedodontists in Massachusetts were surveyed. A total of 1,332 questionnaires was sent— 130 to oral surgeons, 68 to pedodon tists, and 1,134 to general practitioners and other specialists. All names were obtained from the state dental society. The questionnaire was on one page. A cover letter explained the purposes of the study, that
the respondents’ answers would be confidential and anonymous, and that the approval of the state dental society had been obtained. The questionnaire solicited information about the dentists’ awareness of legal and practical re sponsibilities in reporting cases of child abuse, the number of cases of traum atic orofacial in juries seen in the past year, the number of cases that were of a suspicious nature, the number of cases that were definitely caused by abuse, the number of cases that were reported to state agencies, and the reasons for not reporting. Background information also was obtained about the types of practice, the general eco nomic status of the patients, and the number of patient-visits conducted each year.
Results Facial and intraoral trauma was part of the phys ical findings in 128 (49%) of the 260 docu mented cases of child abuse that were reviewed. An additional 16% of the cases involved skull fractures, subdural hematomas, and contusions and lacerations of the scalp; head, face, and intraoral trauma occurred in 65% of the patients. Table 1 illustrates the type and location of injuries sustained by abused children at the Children’s Hospital Medical Center from 1970 through 1975. Patients usually had more than one type of injury, and different parts of the body were affected at the same time; thus, there was a larger number of types of injuries (386) than cases (260). Analysis of the types of injuries that dentists may see showed that 33% were head injuries, 61% were facial injuries, and 6% were intraoral injuries. More specifically, 43% of the head in juries were fractures, 30% were subdural hematomas, 8% were abrasions and lacerations, 18% were contusions and ecchym oses, and 1% were miscellaneous injuries. Of the facial in juries, 2% were fractures, 28% were abrasions and lacerations, 66% were contusions and ec chymoses, 3% were burns, and 1% were bites. Of the 14 intraoral injuries, 28.5% were abrasions and lacerations, 43% were contusions and ec chymoses, and 28.5% were dental trauma. Of the injuries involving the rest of the body (in cluding internal organs), 25% were fractures, 13% were abrasions and lacerations, 35% were contusions and ecchym oses, 17% were burns, 4% were bites, and the others were m iscellane ous (such as a result of sexual m olestation and attempted drowning). Beck er—N eedlem an-Kotelchuck: CHILD A BU SE AND D EN TISTRY ■ 25
Head or facial trauma was the actual reason for adm ission in 118 (45%) of the 260 cases. Intraoral injuries were the cause of adm ission in only two of the cases.
Survey of Dentists Of the 1,332 questionnaires, 537 responses were received, yielding a response rate of 40% . The response rate was higher for oral surgeons (56%) and for pedodontists (57%) than for general practitioners and other specialists (38% ). As indicated in Table 2, during 1975, 75% (403 of 537) of all dentists surveyed saw cases of orofacial trauma. There was a higher percentage of oral surgeons (95%) and pedodontists (90%) than of general practitioners and other spe cialists (70%) who saw these cases. More than 8% of all dentists surveyed saw cases of orofa cial traum a that were of a suspicious nature. This percentage was m uch higher for oral sur geons (22% ) and pedodontists (18%) than for general practitioners and other specialists (5%). Actual cases in which there is a certainty of abuse is always much smaller than the number of suspected cases. Only 22 confirmed cases were noted by dentists responding to the survey; as seen in Table 2, these were seen in all spe cialties. Of the 22 cases of child abuse, only four were reported to the Children’s Protective Services. The remaining 18 cases were not reported to agencies because the dentists found it difficult to confirm their suspicions. One dentist added that he did not wish to implicate himself. Fifteen percent of the dentists (83) saw more than 4 0 cases of orofacial traum a in 1975. Den tists who reported seeing a larger number of cases of orofacial trauma also tended to see more suspicious and definite cases of abuse. These same dentists saw 51% (23) of the suspicious cases and 45% (10) of the definite cases of abuse. Only 45% of all dentists responding to the questionnaire were aware of their legal respon sibilities to report suspected cases of child abuse; once again, there appears to be a greater awareness among the oral surgeons (62%) and the pedodontists (77%) compared to other den tists (39% ). A proportionately smaller percent of dentists knew the name of an agency to which cases of child abuse should be reported (28% of all dentists, 36% of the oral surgeons, 54% of the pedodontists, and 24% of the general prac titioners and other specialists). In general, legal 2 6 ■ JADA, Vol. 97, July 1978
awareness is a prerequisite for agency aware ness; hence most dentists who were unaware of their legal responsibilities did not know where to get help or where to report cases. Two issues that might influence the percep tion of cases of abuse are the awareness of legal responsibility and the social class of the pa tients. Table 3 indicates that the number of sus picious cases increased with the dentists’ legal awareness (x2= 7 .816, P < .0 2 1 ), but it is not cor related with confirmed cases or reported cases. Fifty-six percent of those dentists who did not report confirmed abuse cases knew that they had legal obligations to do so. The socioeconom ic class of the populations within a practice was described by each dentist. There was no significant relationship between average econom ic levels of a practice and sus pected, confirmed, or reported cases of child abuse. Cases of child abuse were seen in prac tices with patients from all econom ic levels.
Discussion The finding that 49% of the documented cases of child abuse had orofacial trauma is consistent with the 50% incidence rate noted in some pre vious studies.6,7 The current finding takes on greater significance than that of previous studies as it was found in an unselected popula tion in a large, general pediatric hospital, over a long period, rather than in a limited pediatric practice. This high percentage of orofacial trauma suggests that dentists could be in contact with cases of child abuse and not recognize them. Facial contusions were by far the most com mon type of injury found; they occurred almost tw ice as often as the second most common in jury, contusions to the body or organs. Head and face trauma were also some of the most serious injuries inflicted on the children. One hundred and eighteen, or 45% of all abused children who cam e to the Children’s Hospital, were admitted with a diagnosis of head or face trauma, or both. Only 14 cases of intraoral trauma were seen in the hospital records. This figure may be low since the physicians who performed the initial physical examination might have overlooked intraoral trauma as it is not their specialty. Another possibility is that cases of trauma lim ited to the oral cavity do not com e to the Chil dren’s Hospital emergency room, but might be seen by private dentists and physicians.
It is not clear how many of the cases of either head, facial, or intraoral trauma would have gone to a dentist first; nevertheless, it is a rea sonable assumption that as only the most seri ous cases com e to the Children’s Hospital, a great deal of minor trauma resulting from abuse may be seen by dentists. As a large majority of dentists see orofacial trauma, they are in a posi tion to identify cases of child abuse and to pro vide aid for the children and their families. The rate of response for our questionnaire was 40% . This is about what one would expect for such a questionnaire. According to Kerlinger,12 a good rate of response to unsolicited surveys of professionals is approxim ately 40% . A similar questionnaire on child abuse sent to all physi cians in Massachusetts received only a 28% rate of return.13 There is no way to assess how the question naires that were not returned would compare to the returned questionnaires. It could be argued either that dentists who had no knowledge of child abuse would not want to return the ques tionnaire solely with negative responses, or that dentists who had seen cases, but not reported them, may not have returned the questionnaires for fear of incrimination. However, in the ab sence of any better information, we have as sumed that our returned results are typical of the state’s dentists. The rate of response for pedodontists and oral surgeons, 56% and 57% , respectively, is rela tively high when compared to that of general dentists and other specialists (38% ), and may reflect a greater awareness of the problem of child abuse. Although the issue of child abuse is not widely acknowledged by dentists, 10% of dentists yearly report seeing suspicious cases; this figure rises to approxim ately 20% for oral surgeons and pedodontists. This would be ex pected because of the nature of their practice. Although they comprise only 15% of all dentists surveyed, oral surgeons and pedodontists saw 41% of all suspicious cases and 59% of the defi nite cases of abuse. Although Table 3 shows that the number of suspicious cases increases as the legal aware ness of dentists increases, it does not follow that greater awareness leads to seeing more cases of definite abuse. The com parison of confirmed cases of abuse with legal awareness shows no positive association. Moreover, more abused children were seen by unaware dentists than by knowledgeable ones. Legal awareness, there
fore, does not appear to lead to an exaggeration of case reports. Nor are dentists dispropor tionately attributing abuse to poor families, as is so often the case in the reporting of child abuse.14 No difference was found between the mean incom e levels of the patients and the number of cases reported. The exact incom e level of the confirmed abuse cases, however, was not obtainable. Only 18% (4 of 22) of the cases of child abuse seen were reported. These findings are similar to the numbers of physicians reporting con firmed abuse cases as noted by Silver and others10 and Newberger and others.13 Dentists appear as reluctant as physicians to report cases of child abuse. Neither the general practitioners nor any group of specialists reported even a third of their confirmed cases. This failure to report cases of child abuse violates state report ing laws; not reporting cases may, in effect, allow the continuation of child abuse, and more importantly, prevent both the child and his fam ily from getting the social welfare and medical aid that they may need. Dentists were generally unaware of the agency to which cases of child abuse should be reported (in Massachusetts, the Department of Public Welfare, Division of Fam ily and Chil dren’s Services). The only majority of prac titioners who knew where to turn for help were the pedodontists. Yet, child abuse is seen in all dental practices. As part of recent federal legislation, a stan dardized model child abuse reporting act was proposed to all of the states. The act specifically mandates that dentists, as well as many other professionals, report any suspected or con firmed cases of child abuse. Dentists cannot be sued for the act of reporting as long as it is in good faith. Reporting a case does not mean that a child will be removed from his family; rather it mandates an investigation of the family situa tion. This should result in social aid to the child and the family. Any dentist who treats a child with orofacial trauma of suspicious nature (especially where the history given does not coincide with the nature of the injuries) should not hesitate to take the proper steps for the protection of the child. The dentist should discuss the problem with the parents diplomatically; explain that the law re quires reporting the incident to a child protec tive service and that the agency is prepared to assist children and their parents; notify the B ecker-N eed lem an-K otelchuck: CHILD A BUSE AND D EN TISTRY ■ 27
THE AUTHORS Dr. Becker is clinical assistant and Dr. Needleman is instructor in pediatric dentistry, Harvard School of Dental M edicine, Boston. In addition, Dr. Needleman is senior associate in pedodontics at the Children’s Hospi tal M edical Center in Boston. Dr. Kotelchuck is research director, Fam ily Development Study, Children’s Hospi tal M edical Center, and assistant professor of psychol ogy, University of M assachusetts, Boston. He is also a lecturer in psychology at Harvard M edical School in Boston. Address requests for reprints to Dr. Becker, 6 Bartlett St, Marblehead, Mass 01945.
agency; and, if necessary, seek m edical atten tion for the child.
Conclusions Dentists have generally been unfam iliar with child abuse. T h is report suggests that as orofa cial and head trauma is involved in approxi m ately 65% of all children hospitalized because of abuse and as child abuse is widespread and is found in all social classes, dentists can expect to be in contact w ith children who are abused. Oral surgeons and pedodontists are most likely to see cases of child abuse. In one year, 10% of the dentists surveyed reported seeing suspicious cases. The lack of w idespread legal and agency aw areness of the dentists and the further relu c tance of dentists to becom e involved suggest that we are not helping the abused child ren or their fam ilies to the fullest possible extent. It is im portant that dentists becom e more fam iliar with the problem of ch ild abuse; better social, m edical, and dental health should be the out com e.
28 ■ JADA, Vol. 97, July 1978
BECKER
NEEDLEMAN
KOTELCHUCK
1. Kempe, C.H., and Heifer, R .E ., (eds.). Helping the battered child and his family. Philadelphia, J. B. Lippincott, 1972. 2. Caffey, J. T he parent-infant traumatic stress syndrome; (Caffey-Kempe syndrome), (battered babe syndrome). Am J Roentgenol Radium Ther Nucl Med 114:218 Feb 1972. 3. Elmer, E., and Gregg, G.S. Developmental characteristics of abused children. Pediatrics 40:596 Oct 1967. 4. Holter, J.C., and Friedman, S.B. Child abuse: early case finding in the emergency department. Pediatrics 42:128 July 1968. 5. O’Neill, J., and others. Patterns of injury in the battered child syndrome. Trauma 13:332 April 1973. 6. Skinner, A.E., and Castle, R.L. A retrospective study. London, National Society for Prevention of Cruelty to Children, 1969. 7. Cameron, J.M.; Johnson, H.R.; and Camps, F.E. The battered child syndrome. Med Sci Law, 6:2 Jan 1966. 8. Gil, D. V iolence against children: physical child abuse in the United States. Cambridge, Mass, Harvard University Press, 1970. 9. Light, R. Abuse and neglected children in America: a study of alternative policies. Cambridge, Mass, Harvard Educational Review, 43:556, 1973. 10. Silver, L.B.; Dublin, C.C.; and Laurie, R.S. Child abuse syn drome: the “gray areas” in establishing a diagnosis. Pediatrics 44:594 Oct 1969. 11. Sanders, R.W. Resistance to dealing with parents of battered children. Pediatrics 50:853 Dec 1972. 12. Kerlinger, F.M. Foundations of behavioral research. New York, Holt, Rinehart and Winston, 1965. 13. Newberger, E.H.; Hass, G.; and Mulford, R.M. Child abuse in Massachusetts. Mass Physician 32:31 Jan 1973. 14. Newberger, E.H., and others. Pediatric social illness: toward an etiologic classification. Pediatrics 60:178 Aug 1977.
Child abuse and dentistry: orofacial trauma and its recognition by dentists David Belf Becker, DMD, MPH Howard L. Needleman, DMD Milton Kotelchuck, PhD, MPH, Boston
Q
t J o c i e t y is becom ing increasingly aware of ch ild abuse. Much has been w ritten about its causes, sequelae, and current concepts of treat m en t.1'3 The dental profession appears less aware than other medical professionals in the detection and treatm ent of suspected cases of child abuse. There are very few reports about child abuse in the dental literature, yet trauma to the head and face appear to be commonly associated with child abuse. In the limited number of case studies that document the location of the injury, the frequency of injuries of the head and face ranges from approxim ately30% 4,s to 50% 6,7The methods used in these studies vary greatly and all had small sample sizes. Nonetheless, the data 24 ■ JADA, Vol. 97, July 1978
suggest that dental professionals may be in con tact with a significant number of abused ch il dren. As annual estim ates in the United States range from 200 ,0 0 0 to 1,000,000 reportable cases a year,8,9 it is im probable that dentists have not seen this problem. The reasons for dentists’ reluctance to ac knowledge child abuse are probably the same as those for private physicians and others. Silver and others10 and San d ers11 suggest a num ber of possible reasons for this hesitancy, including lack of adequate histories, lack of knowledge about the problem of child abuse and their role and responsibilities in reporting it, concern about the effects on their practices if they report cases, and fear of confronting the parents. These
concerns m ay also account for the lack of litera ture about dentists’ experiences with cases of child abuse. In this study, head and intraoral trauma found in abused children who required hospitaliza tion in a large, urban children’s hospital and the extent of dentists’ knowledge about and experi ence with child abuse in the state of Mas sachusetts were documented.
Methods First, the m edical records of all abused children hospitalized at the Children’s Hospital Medical Center, Boston, Mass, from 1970 through 1975 were reviewed. Children with a physical injury that was diagnosed as caused by abuse were classified as abused children. Any cases of ne glect or “failure to thrive” without physical in juries were not included in the study. A total of 260 cases was reviewed by the senior author and included in this study. Only injuries found during the initial physi cal exam ination by the attending physician were noted, and their location on the body was recorded. Body, head, facial, and intraoral trauma were distinguished, as was the type of injury. For the purposes of this study, “body injury” was defined as all injuries below the neck, including injuries of internal organs. “Head traum a” was defined as skull fractures, subdural hematomas, and contusions, abra sions, and lacerations to the scalp. “Facial in juries” consisted of facial fractures, abrasions and lacerations, contusions and ecchym oses, burns, and bites. “Intraoral traum a” included abrasions and lacerations, contusions and ec chymoses, and injury to the teeth. “Orofacial traum a” is used to describe facial and intraoral injuries. No efforts were made to record the ex tent of the injuries, although it was noted whether the injury was the cause or was inci dental to the admission. Second, a questionnaire was mailed to a third of all general dentists in Massachusetts, who were selected at random. In addition, all oral surgeons and pedodontists in Massachusetts were surveyed. A total of 1,332 questionnaires was sent— 130 to oral surgeons, 68 to pedodon tists, and 1,134 to general practitioners and other specialists. All names were obtained from the state dental society. The questionnaire was on one page. A cover letter explained the purposes of the study, that
the respondents’ answers would be confidential and anonymous, and that the approval of the state dental society had been obtained. The questionnaire solicited information about the dentists’ awareness of legal and practical re sponsibilities in reporting cases of child abuse, the number of cases of traum atic orofacial in juries seen in the past year, the number of cases that were of a suspicious nature, the number of cases that were definitely caused by abuse, the number of cases that were reported to state agencies, and the reasons for not reporting. Background information also was obtained about the types of practice, the general eco nomic status of the patients, and the number of patient-visits conducted each year.
Results Facial and intraoral trauma was part of the phys ical findings in 128 (49%) of the 260 docu mented cases of child abuse that were reviewed. An additional 16% of the cases involved skull fractures, subdural hematomas, and contusions and lacerations of the scalp; head, face, and intraoral trauma occurred in 65% of the patients. Table 1 illustrates the type and location of injuries sustained by abused children at the Children’s Hospital Medical Center from 1970 through 1975. Patients usually had more than one type of injury, and different parts of the body were affected at the same time; thus, there was a larger number of types of injuries (386) than cases (260). Analysis of the types of injuries that dentists may see showed that 33% were head injuries, 61% were facial injuries, and 6% were intraoral injuries. More specifically, 43% of the head in juries were fractures, 30% were subdural hematomas, 8% were abrasions and lacerations, 18% were contusions and ecchym oses, and 1% were miscellaneous injuries. Of the facial in juries, 2% were fractures, 28% were abrasions and lacerations, 66% were contusions and ec chymoses, 3% were burns, and 1% were bites. Of the 14 intraoral injuries, 28.5% were abrasions and lacerations, 43% were contusions and ec chymoses, and 28.5% were dental trauma. Of the injuries involving the rest of the body (in cluding internal organs), 25% were fractures, 13% were abrasions and lacerations, 35% were contusions and ecchym oses, 17% were burns, 4% were bites, and the others were m iscellane ous (such as a result of sexual m olestation and attempted drowning). Beck er—N eedlem an-Kotelchuck: CHILD A BU SE AND D EN TISTRY ■ 25
Head or facial trauma was the actual reason for adm ission in 118 (45%) of the 260 cases. Intraoral injuries were the cause of adm ission in only two of the cases.
Survey of Dentists Of the 1,332 questionnaires, 537 responses were received, yielding a response rate of 40% . The response rate was higher for oral surgeons (56%) and for pedodontists (57%) than for general practitioners and other specialists (38% ). As indicated in Table 2, during 1975, 75% (403 of 537) of all dentists surveyed saw cases of orofacial trauma. There was a higher percentage of oral surgeons (95%) and pedodontists (90%) than of general practitioners and other spe cialists (70%) who saw these cases. More than 8% of all dentists surveyed saw cases of orofa cial traum a that were of a suspicious nature. This percentage was m uch higher for oral sur geons (22% ) and pedodontists (18%) than for general practitioners and other specialists (5%). Actual cases in which there is a certainty of abuse is always much smaller than the number of suspected cases. Only 22 confirmed cases were noted by dentists responding to the survey; as seen in Table 2, these were seen in all spe cialties. Of the 22 cases of child abuse, only four were reported to the Children’s Protective Services. The remaining 18 cases were not reported to agencies because the dentists found it difficult to confirm their suspicions. One dentist added that he did not wish to implicate himself. Fifteen percent of the dentists (83) saw more than 4 0 cases of orofacial traum a in 1975. Den tists who reported seeing a larger number of cases of orofacial trauma also tended to see more suspicious and definite cases of abuse. These same dentists saw 51% (23) of the suspicious cases and 45% (10) of the definite cases of abuse. Only 45% of all dentists responding to the questionnaire were aware of their legal respon sibilities to report suspected cases of child abuse; once again, there appears to be a greater awareness among the oral surgeons (62%) and the pedodontists (77%) compared to other den tists (39% ). A proportionately smaller percent of dentists knew the name of an agency to which cases of child abuse should be reported (28% of all dentists, 36% of the oral surgeons, 54% of the pedodontists, and 24% of the general prac titioners and other specialists). In general, legal 2 6 ■ JADA, Vol. 97, July 1978
awareness is a prerequisite for agency aware ness; hence most dentists who were unaware of their legal responsibilities did not know where to get help or where to report cases. Two issues that might influence the percep tion of cases of abuse are the awareness of legal responsibility and the social class of the pa tients. Table 3 indicates that the number of sus picious cases increased with the dentists’ legal awareness (x2= 7 .816, P < .0 2 1 ), but it is not cor related with confirmed cases or reported cases. Fifty-six percent of those dentists who did not report confirmed abuse cases knew that they had legal obligations to do so. The socioeconom ic class of the populations within a practice was described by each dentist. There was no significant relationship between average econom ic levels of a practice and sus pected, confirmed, or reported cases of child abuse. Cases of child abuse were seen in prac tices with patients from all econom ic levels.
Discussion The finding that 49% of the documented cases of child abuse had orofacial trauma is consistent with the 50% incidence rate noted in some pre vious studies.6,7 The current finding takes on greater significance than that of previous studies as it was found in an unselected popula tion in a large, general pediatric hospital, over a long period, rather than in a limited pediatric practice. This high percentage of orofacial trauma suggests that dentists could be in contact with cases of child abuse and not recognize them. Facial contusions were by far the most com mon type of injury found; they occurred almost tw ice as often as the second most common in jury, contusions to the body or organs. Head and face trauma were also some of the most serious injuries inflicted on the children. One hundred and eighteen, or 45% of all abused children who cam e to the Children’s Hospital, were admitted with a diagnosis of head or face trauma, or both. Only 14 cases of intraoral trauma were seen in the hospital records. This figure may be low since the physicians who performed the initial physical examination might have overlooked intraoral trauma as it is not their specialty. Another possibility is that cases of trauma lim ited to the oral cavity do not com e to the Chil dren’s Hospital emergency room, but might be seen by private dentists and physicians.
It is not clear how many of the cases of either head, facial, or intraoral trauma would have gone to a dentist first; nevertheless, it is a rea sonable assumption that as only the most seri ous cases com e to the Children’s Hospital, a great deal of minor trauma resulting from abuse may be seen by dentists. As a large majority of dentists see orofacial trauma, they are in a posi tion to identify cases of child abuse and to pro vide aid for the children and their families. The rate of response for our questionnaire was 40% . This is about what one would expect for such a questionnaire. According to Kerlinger,12 a good rate of response to unsolicited surveys of professionals is approxim ately 40% . A similar questionnaire on child abuse sent to all physi cians in Massachusetts received only a 28% rate of return.13 There is no way to assess how the question naires that were not returned would compare to the returned questionnaires. It could be argued either that dentists who had no knowledge of child abuse would not want to return the ques tionnaire solely with negative responses, or that dentists who had seen cases, but not reported them, may not have returned the questionnaires for fear of incrimination. However, in the ab sence of any better information, we have as sumed that our returned results are typical of the state’s dentists. The rate of response for pedodontists and oral surgeons, 56% and 57% , respectively, is rela tively high when compared to that of general dentists and other specialists (38% ), and may reflect a greater awareness of the problem of child abuse. Although the issue of child abuse is not widely acknowledged by dentists, 10% of dentists yearly report seeing suspicious cases; this figure rises to approxim ately 20% for oral surgeons and pedodontists. This would be ex pected because of the nature of their practice. Although they comprise only 15% of all dentists surveyed, oral surgeons and pedodontists saw 41% of all suspicious cases and 59% of the defi nite cases of abuse. Although Table 3 shows that the number of suspicious cases increases as the legal aware ness of dentists increases, it does not follow that greater awareness leads to seeing more cases of definite abuse. The com parison of confirmed cases of abuse with legal awareness shows no positive association. Moreover, more abused children were seen by unaware dentists than by knowledgeable ones. Legal awareness, there
fore, does not appear to lead to an exaggeration of case reports. Nor are dentists dispropor tionately attributing abuse to poor families, as is so often the case in the reporting of child abuse.14 No difference was found between the mean incom e levels of the patients and the number of cases reported. The exact incom e level of the confirmed abuse cases, however, was not obtainable. Only 18% (4 of 22) of the cases of child abuse seen were reported. These findings are similar to the numbers of physicians reporting con firmed abuse cases as noted by Silver and others10 and Newberger and others.13 Dentists appear as reluctant as physicians to report cases of child abuse. Neither the general practitioners nor any group of specialists reported even a third of their confirmed cases. This failure to report cases of child abuse violates state report ing laws; not reporting cases may, in effect, allow the continuation of child abuse, and more importantly, prevent both the child and his fam ily from getting the social welfare and medical aid that they may need. Dentists were generally unaware of the agency to which cases of child abuse should be reported (in Massachusetts, the Department of Public Welfare, Division of Fam ily and Chil dren’s Services). The only majority of prac titioners who knew where to turn for help were the pedodontists. Yet, child abuse is seen in all dental practices. As part of recent federal legislation, a stan dardized model child abuse reporting act was proposed to all of the states. The act specifically mandates that dentists, as well as many other professionals, report any suspected or con firmed cases of child abuse. Dentists cannot be sued for the act of reporting as long as it is in good faith. Reporting a case does not mean that a child will be removed from his family; rather it mandates an investigation of the family situa tion. This should result in social aid to the child and the family. Any dentist who treats a child with orofacial trauma of suspicious nature (especially where the history given does not coincide with the nature of the injuries) should not hesitate to take the proper steps for the protection of the child. The dentist should discuss the problem with the parents diplomatically; explain that the law re quires reporting the incident to a child protec tive service and that the agency is prepared to assist children and their parents; notify the B ecker-N eed lem an-K otelchuck: CHILD A BUSE AND D EN TISTRY ■ 27
THE AUTHORS Dr. Becker is clinical assistant and Dr. Needleman is instructor in pediatric dentistry, Harvard School of Dental M edicine, Boston. In addition, Dr. Needleman is senior associate in pedodontics at the Children’s Hospi tal M edical Center in Boston. Dr. Kotelchuck is research director, Fam ily Development Study, Children’s Hospi tal M edical Center, and assistant professor of psychol ogy, University of M assachusetts, Boston. He is also a lecturer in psychology at Harvard M edical School in Boston. Address requests for reprints to Dr. Becker, 6 Bartlett St, Marblehead, Mass 01945.
agency; and, if necessary, seek m edical atten tion for the child.
Conclusions Dentists have generally been unfam iliar with child abuse. T h is report suggests that as orofa cial and head trauma is involved in approxi m ately 65% of all children hospitalized because of abuse and as child abuse is widespread and is found in all social classes, dentists can expect to be in contact w ith children who are abused. Oral surgeons and pedodontists are most likely to see cases of child abuse. In one year, 10% of the dentists surveyed reported seeing suspicious cases. The lack of w idespread legal and agency aw areness of the dentists and the further relu c tance of dentists to becom e involved suggest that we are not helping the abused child ren or their fam ilies to the fullest possible extent. It is im portant that dentists becom e more fam iliar with the problem of ch ild abuse; better social, m edical, and dental health should be the out com e.
28 ■ JADA, Vol. 97, July 1978
BECKER
NEEDLEMAN
KOTELCHUCK
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