COMPASSION, COMMUNICATION AND CRANIOFACIAL

OBSERVATIONS

HAROLD C. SLAVKIN, D.D.S.

COMPASSION, COMMUNICATION AND CRANIOFACIAL ORODENTAL TRAUMA: OPPORTUNITIES ABOUND

A friend of mine recently vis-

ited her primary care physician for the second time since switching physicians. Like her first visit, this one was an annual routine office visit. Much to her pleasant surprise, the physician remembered where she worked, her job title and that she was engaged to be married. Certainly, well-placed notes in her chart gave the physician this information; still, it made quite a difference. To have a health care provider ask about work and other non–health-related areas of her life made her feel at ease. As a result, she was more comfortable answering and asking health-centered questions that could affect her future. A recent New York Times Magazine article on the effectiveness of placebos touched on this theme,1 which has echoed through health care corridors for more than a decade: time spent with a patient may be a key factor in patient recovery and wellness. Health care providers who can express compassion, empathy and concern for their patients—without checking their watches or being distracted by thoughts of paperwork—practice good dentistry or medicine without writing a single prescription or wielding a surgical tool. “The secret of the care of the patient is in caring for the

patient,” quoted the New York Times Magazine from an essay by Francis W. Peabody, M.D.2 The magazine article also mentioned a 1987 British study that supports this axiom. In the study, patients visiting one physician complained of feeling generally “under the weather.” 3 The physician gave one-half of the patients a definite diagnosis and said they would feel better in a few days; he told the other patients that he didn’t know what was wrong or when they might feel better. After two weeks, 64 percent of the patients who received a diagnosis had gotten better, compared with 39 percent in the other group. For all too many of our dental patients, we are perceived as a profession that focuses on procedures for the teeth. Why should a dental hygienist talk to a patient about nutrition, wearing seat belts in automobiles or asking new parents whether they have made their homes childproof? Why would a dentist ask a teen-ager if she drinks low-fat milk and exercises on a daily basis? Why should dental practitioners, hygienists, assistants and receptionists all engage in a communication that fosters understanding and reduces anxiety and stress? Patients may not expect dental professionals to show interest, compassion, empathy

and curiosity or ask questions beyond those related to dental procedures. But they should because the discussion that ensues after the questions have been asked gives dental professionals the opportunity to educate patients. The consequences of an adult not wearing a seat belt, an infant not being properly placed and restrained in an infant seat, a bicycle accident, a sports injury or domestic abuse leave hundreds of thousands of patients with craniofacial orodental trauma. Craniofacial orodental trauma affects people of all ages, sexes and cultures. This type of trauma often is unintentional and is caused by auto accidents, sports injuries, falls or other accidents at work or in the home. In addition, violence, including domestic and child abuse, produces thousands of craniofacial orodental injuries each year. Dental professionals are part of the prevention of these unintentional and intentional injuries and are part of the treatment of craniofacial orodental injuries. UNINTENTIONAL TRAUMA: ACCIDENTS

By the time children reach age 16 years, 35 percent will have sustain dental trauma at least once. Boys are twice as likely as girls to report dental trauma

JADA, Vol. 131, April 2000 Copyright ©1998-2001 American Dental Association. All rights reserved.

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SLAVKIN

FOR FURTHER INFORMATION National Highway Traffic Safety Administration U.S. Department of Transportation 400 Seventh St., SW Washington, D.C. 20590 General number: 1-202366-0123 Auto safety hotline: 1-800424-9393 Child safety seat information: 1-202-366-2696 Seat belt information: 1-202-366-9294 Air bag information: 1-202366-0910 “http://www.nhtsa.dot.gov/” National Center for Injury Prevention and Control 4770 Buford Highway NE Chamblee, Ga. 30334 Automated information line: 1-770-488-4677 Division of Unintentional Injury Prevention: 1-770488-4652 Division of Violence Prevention: 1-770-488-4352 “http://www.cdc.gov/ncipc/ ncipchm.htm” National Institute of Child Health and Human Development Building 31, Room 2A32, MSC 2425 31 Center Drive Bethesda, Md. 20892-2425 1-800-370-2943 “http://www.nichd.nih.gov/” National Clearinghouse on Child Abuse and Neglect Information P.O. Box 1182 Washington, D.C. 20013 1-703-385-7565 “http://www.calib.com/ nccanch”

and are much more likely to experience such trauma more than once. Boys sustain their injuries most frequently at age 4 years and between ages 8 and 11 years; girls, at ages 4 and 9 years.4 Certain subpopulations of children are in more danger than are others. Toddlers and young adolescents have the highest injury rates. Studies by the National Institute of Child Health and Human Development have found that children of 508

single adult households have a 40 percent increased risk of accidental injury compared with other children. Interestingly, children in child-care facilities were not at increased risk of injury, compared with children cared for by a parent or guardian. Children younger than 2 years of age whose mothers had fewer than 12 years of education and who were cared for at more than one child-care facilities, however, had a fivefold increased risk of injury.5 In young children, craniofacial, oral and dental trauma is mainly caused through falls. A German survey of more than 1,300 children younger than 19 years of age with facial trauma found that 68 percent had softtissue injuries and 24 percent had dental trauma.6 A hospital in Missouri found that the frequency of dental trauma in children peaked in the 1- to 2-year-old age group, and that the most predominant injury was laceration of the lip. The leading cause of trauma in this study was falls, which accounted for more than onehalf of oral injuries.7 Besides falls, young children, as well as adults, can be injured in bicycle and automobile accidents, two etiologies that can produce much more serious injuries. The advent of bicycle helmets has aided prevention; in Washington state, for example, helmets reduced the risk of injuries to the upper and middle face by more than 60 percent.8 Still, each year more than 150,000 children are treated for bicyclerelated craniofacial orodental injuries in emergency departments across the country.9 Currently, 15 states have some form of bicycle helmet legislation that covers children,

but the Centers for Disease Control and Prevention, or CDC, estimates that 75 percent of bicycle-related fatalities among children could be prevented if all children on bicycles wore helmets. The CDC also projects that the universal use of bicycle helmets by children 4 through 15 years of age would prevent up to 45,000 craniofacial injuries and 55,000 maxillary and mandibular injuries annually.9 Mountain biking—either on wide dirt paths or single-track trails—has become a popular sport over the last decade. Unfortunately, it also is a dangerous one. Mountain bikers registered at the Department of Oral and Maxillofacial Surgery at the University of Innsbruck, Austria, had more severe injury profiles than did road bicyclists. Fifty-five percent of the mountain bikers had facial fractures, compared with 35 percent of road cyclists. Zygomatic fractures were more common in road cyclists, whereas mountain bikers were more likely to sustain Le Fort I, II and III fractures.10 By the time children reach adolescence, they are more likely to sustain craniofacial orodental trauma through auto accidents, sports injuries or violence, which also are common causes of such trauma in adults. Motor vehicle crashes are the leading cause of death for people 5 to 27 years of age and tend to be the primary cause of most midface fractures and lacerations, due to the face striking a dashboard, windshield, steering wheel or the back of the front seat.11 Seat belt use can drastically reduce the incidence and severity of these injuries.12 Although 16

JADA, Vol. 131, April 2000 Copyright ©1998-2001 American Dental Association. All rights reserved.

SLAVKIN states—plus the District of Columbia and Puerto Rico— have mandatory seat belt laws, enforcement varies. The National Highway Traffic Safety Administration estimates that if all states had standard enforcement of seat belt laws, more than 49,000 injuries could be prevented, and $3.4 billion would be saved annually.13 The largest proportion of adolescent injuries—not just craniofacial orodental injuries but all types—is due to motor vehicle crashes. Adolescents are far less likely to use seat belts than any other age group and are more likely than adults to have accidents at night or while under the influence of alcohol.14 Among older children and young adults, sports such as biking, skiing, and soccer and other contact sports can result in a significant proportion of craniofacial orodental trauma. A British survey of maxillofacial sports injuries found that such injuries were much more likely in males—more than 80 percent of injured patients were male. Most injuries were lacerations, but 10 percent of patients had dentoalveolar fractures, and 8 percent had facial fractures.15 INTENTIONAL TRAUMA: VIOLENCE

While many etiologies of craniofacial orodental trauma are accidental or unintentional injuries, all too many injuries are caused by violence. Fistfights or the use of guns, knives, bottles or other weapons commonly affect the craniofacial orodental complex. In a survey of more than 2,400 violencerelated injuries, nearly 70 percent were craniofacial. The most common weapons

are fists and feet.16 Data from the aforementioned German survey 6 showed that more than 60 percent of craniofacial injuries in teen-agers were due to an assault. Mandibular fractures were most common, with condylar fractures making up 80 percent of all fractures to the jaw.6 While nasal, mandibular and zygomatic fractures are common consequences of assaults using fists and feet,17 penetrating craniofacial trauma caused by guns, knives and other weapons can result in multiple fractures, soft-tissue injuries and intracranial penetration, which have lifelong consequences such as brain damage and blindness. These sequelae are in addition to the obvious cosmetic complications. Of 100 patients treated at a Brooklyn, N.Y., hospital for gunshot wounds to the face, 38 percent had significant neurological injury, and 67 percent sustained bony injury. Ultimately, onefourth of the patients had at least one complication such as osteomyelitis.18 People with assault-related injuries, like those with accident-related craniofacial orodental trauma, are predominantly male; in the study of gunshot wounds to the face, 89 of 100 patients were male.18 Other studies have found that men constitute approximately 80 percent of assault victims who suffer craniofacial orodental trauma.18,19 While men seem to sustain most of the injuries caused by sports and assaults, women suffering from domestic abuse make up a substantial number of craniofacial orodental trauma victims, although domestic violence is a frequently unrecog-

nized cause of such injury. Compared with women injured through other means, these women tend to have injuries to the head, face and neck.20 Of 218 women seen at a California emergency department with injuries from domestic violence, 28 percent had to be admitted as a result of the severity of their injuries. More than 85 percent of the women had been abused previously, and 40 percent had required medical care previously. Ten percent were pregnant at the time of abuse.21 In many cases, domestic partner abuse occurs with child abuse.22 Using data from the 1985 National Family Violence Survey, researchers found that each act of violence toward a partner cumulatively increases the probability of the violent partner also being abusive to the child, particularly for fathers. The most chronically violent husbands (toward their spouses) had a nearly 100 percent probability of also physically abusing their male children, but not their female ones.23 Children also can suffer craniofacial orodental trauma through domestic violence, either through direct abuse or from attempts to intervene during acts of partner abuse. Of children injured in the latter fashion, craniofacial injuries are the most common type of trauma they experience.24 Many injuries that result from domestic abuse are minor ones. However, by dental practitioners inquiring as to the causes of all injuries, it may be possible for them to pinpoint more cases of abuse and facilitate a process in which families seek the help they need. A young mother or child may be unwilling to discuss “private

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SLAVKIN problems” with a health care provider. Then again, the dental health care provider Dr. Slavkin is may represent director, National the one safe Institute of Dental and Craniofacial person whom Research, 31 Center these people Drive, MSC 2290, can turn to, Building 31, Room 2C39, Bethesda, Md. someone 20892-2290. Address knowledgeable reprint requests to Dr. Slavkin. who will listen and maybe help them. The ADA’s Principles of Ethics and Code of Professional Conduct 25 includes a statement that as dentists we have an ethical duty to become familiar with the perioral signs of child abuse and to report all suspected cases to the proper authority. More than 3 million children in the United States were reported to child protective services in 1997 as suspects of being abused. Of these, 1 million cases were substantiated, a 50 percent increase over 1989.26

for health promotion. By reading our patients’ subtle cues or gestures, we truly become and are perceived by our professional colleagues, staff and patients to be a doctor and colleague who really cares. Our communication competencies may be an even larger and more significant dimension of our professionalism than we fully appreciate. By talking with and listening to our patients, while demonstrating compassion and empathy, we can establish relationships with them in which they view us as dental health care professionals with an emphasis on the “care.” 25 Learning how to interpersonally communicate well with and cultivating better relationships with our patients provides us with a wellspring of even more trust from which we may never need to drink. But if we do, it is there and can save lives and promote health. ■

CONCLUSION

The views expressed are those of the author and do not necessarily reflect the opinions or official policies of the American Dental Association.

Communicating with health care professionals and patients is critical to our clinical performance. As health care professionals, we cultivate our capacity to critically observe and listen. Within and beyond the bounds of polite everyday exchanges, we are provided with opportunities to make and record significant and vital observations that may translate into health promotion and disease prevention, as well as gain information that may factor into our diagnosis and prognosis of craniofacial orodental trauma, diseases or other disorders. By being curious and engaged, we can receive answers that may illuminate important avenues

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JADA, Vol. 131, April 2000 Copyright ©1998-2001 American Dental Association. All rights reserved.