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Oral injuries in victims involving intimate partner violence
Forensic Science International 221 (2012) 102–105
Contents lists available at SciVerse ScienceDirect
Forensic Science International journal homepage: www.elsevier.com/locate/forsciint
Oral injuries in victims involving intimate partner violence Ineˆs Morais Caldas a,b,*, Ana Clara Grams b,c,d, Ame´rico Afonso a,b, Teresa Magalha˜es b,c,d,e a
Faculdade de Medicina Denta´ria da Universidade do Porto, Rua Dr. Manuel Pereira da Silva, 4200-393 Porto, Portugal CENCIFOR – Center of Forensic Sciences, Largo da Se´ Nova, 3030-213 Coimbra, Portugal c Instituto Nacional de Medicina Legal – Delegac¸a˜o do Norte, Jardim Carrilho Videira 40150-167 Porto, Portugal d Faculdade de Medicina da Universidade do Porto, Alameda Prof. Hernaˆni Monteiro, 4200-319 Porto, Portugal e Instituto de Cieˆncias Biome´dicas ‘‘Abel Salazar’’ da Universidade do Porto, Largo Prof. Abel Salazar, 2, 4099-003 Porto, Portugal b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 9 January 2012 Received in revised form 29 March 2012 Accepted 14 April 2012 Available online 6 May 2012
Introduction: Current literature states that dental medicine can have an important role in diagnosing situations of domestic violence, namely cases of intimate partner violence, since many of the injuries that occur in this context concern the head and neck areas. The aim of this study was to characterize oral injuries in these cases in a Portuguese population, and to determine the kind of permanent consequences that they might represent. Material and methods: 332 forensic reports of domestic violence survivors were analysed. The reports concerned examinations performed in the North Branch of the National Institute of Legal Medicine of Portugal in 2007. Reports were assessed in order to obtain data regarding victim and offender demographic characteristics, and to characterize the nature and number of sustained injuries and their permanent consequences. Main results: Most victims were females with a mean age of 33.7 years; the most frequent offender was the spouse; the majority of oral injuries affected soft tissues; permanent body consequences were found mainly in the teeth and periodontal tissues; permanent functional consequences were described as chewing difficulties, feeling pain or soft tissue mobility changes; permanent consequences for life activities referred mostly to social life aspects. Conclusions: Oral injuries and their consequences were observed in 13.4% of intimate partner violence cases, and though being suggestive of this kind of violence, oral injuries alone are insufficient to identify this kind of abuse, and additional diagnostic criteria and evidence should be used. ß 2012 Elsevier Ireland Ltd. All rights reserved.
Keywords: Intimate partner violence Oral injuries Forensic evaluation Dental medicine
1. Background Intimate partner violence (IPV) implies any type of behaviour within an intimate relationship that causes harm to one or both parties [1]; it refers to a broad pattern of coercive or violent tactics used by one partner to establish, maintain power and control over the other. These tactics can include physical, sexual, psychological, and economic abuse in an intimate partnership (any present or previous intimate relationship, with or without sexual involvement). IPV can occur between spouses, former spouses, or unmarried intimate partners [2]. The term IPV has been used interchangeably with domestic violence (DV) [3]. However, in more recent years, DV has developed a broader meaning and now includes abuse that occurs
* Corresponding author at: Faculdade de Medicina Denta´ria da Universidade do Porto, Rua Dr. Manuel Pereira da Silva, 4200-393 Porto, Portugal. Tel.: +351 220901100; fax: +351 220901101. E-mail address: [email protected] (I.M. Caldas). 0379-0738/$ – see front matter ß 2012 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.forsciint.2012.04.010
in any relationship within a household, including that against children, the elderly, or siblings [1]. IPV is a serious health problem that affects, in the USA, up to 26% of adult women and 16% of adult men [4]. An analysis of 48 population-based studies by the World Health Organization indicated that from 10% to 69% of women had been physically assaulted by an intimate partner at some point in their lives. The high prevalence of this phenomenon has given rise to an increasing number of publications on DV and IPV, regarding the signs, symptoms, diagnosis [5–7] and even the medical-professional role in the treatment and guidance of the survivors [8]. IPV has profound health consequences: abused women are more likely to have physical and psychological problems, including reproductive problems, depression, psychosomatic disorders, and limitations in social functioning [9]. In addition, IPV is also associated with loss of productivity and increased use of health care and social services, even long after the end of the violent episodes [10]. Head and neck areas have been reported as the most frequently affected site in DV [11–13]; therefore oral health care professionals may be the first to identify a person who is being abuse and to
I.M. Caldas et al. / Forensic Science International 221 (2012) 102–105
intervene [14]. In 1996, the American Dental Association enacted a policy to encourage efforts to educate oral health professionals in the identification of abuse and neglect of adults [15]. The aim of the present study was to determine the incidence of oral injuries in IPV in the Portuguese population.
2. Methods IPV event reports concerning forensic examinations performed in the North Branch of the National Institute of Legal Medicine of Portugal in 2007 were analysed (n = 2489). Of these, a selection was made according to the following inclusion criteria: (1) suspected case of IPV; (2) victims (of both genders) older than 16 presenting oral injuries. Oral injuries were defined as those involving the following areas: (a) teeth and the surrounding supportive tissues (periodontium); (b) oral mucosa including the gums, the alveolar mucosa in the edentulous patient, palate, and the buccal mucosa; (c) jaw bones (upper and lower); (d) lips (mucosa and skin); (e) tongue; (f) perioral soft tissues (extraoral tissues that surround the mouth and cover upper and lower jaw). Selected cases (n = 332) were studied for data regarding victim and offender demographic characteristics, the nature and number of sustained injuries and their permanent consequences. To analyse oral injuries, the anatomic location and nature of the injury were identified; if the same area sustained more than one kind of injury, only the most severe was registered. Injury severity was assessed using the severity scale presented routinely in Portuguese legal medicine research [16–19]: grade 0, no injuries suffered; grade 1, mild severity injuries such as scratches, bruises, ecchymoses and cuts; grade 2, medium severity injuries, such as skin lacerations, fractures and other injuries that do not require open treatment; grade 3, major severity injuries, but which are not considered life threatening, although require open treatment; grade 4, very important severity injuries, corresponding to high severity and potential lethal injuries. Permanent consequences were assessed according to the individual’s body, functional and situational impact, using the ‘‘Bodily Damage Assessment Inventory’’ [16]. Body consequences refer to the organic aspects (e.g., scars, prosthetic devices), the functional impact which refers to the incapacities (e.g., the inability to chew or swallow), and the situational consequences which refer to the impact in an individual’s life activities (e.g., the inability to eat in a restaurant, the avoidance of intimate contact, the inability to perform one’s professional work). Findings were recorded in a database developed in a prior study [19], and studied using SPSS (Statistical Package for Social Science – SPSS INC, Chicago, Illinois, USA), version 16.0, for Windows. Descriptive statistics was performed using frequency analysis for categorical variables and descriptive analysis for continuous variables.
103
3. Results Amongst 2489 reports of IPV events, 332 (13.4%) referred to oral trauma. Most victims were females (69.3%) presenting a mean age of 33.7 years (SD = 11.4; minimum = 16; maximum = 92), mostly married or single (46.9% and 39.2%, respectively); 12.1% were divorced and 1.8% were widows. The majority worked in personal or domestic services or were unemployed (32.5% and 19.3%, respectively); 14.4% had jobs linked to commercial or industrial activities, 11.4% had scientific, technical, administrative or similar professions, 9.6% were students and 4.8% had received social security benefits, 5.4% were retired and 2.6% had jobs that do not fit any of the described groups. The most frequent offender was the spouse (58.4%), followed by the boyfriend (21.7%), ex-spouse (17.5%) and others (2.4%). The injuries were reported as being the first occurrence in 19.9% of the cases. Slapping or punching was the main aggression mechanism in 44.6% of the cases, followed by kicking (15.1%), being pushed against something (12.7%), or trauma with a blunt instrument (12.0%). The other cases involved trauma with a sharp object, finger nails, bites, fire arms and hot water (6.6%, 6.6%, 1.2%, 0.6% and 0.6%, respectively). The total number of oral injuries was 438. Oral injuries were the only type of trauma in 27.7% of the victims. Overall, perioral soft tissues were the main site of injury, affecting 80.1% of all survivors (Table 1). Permanent body consequences were present in 11.4% of the victims with the main site being teeth and periodontal tissues, which affected 6.6% of the victims (Table 2). Permanent functional consequences were present in 10.3%. This implied chewing difficulties, feeling pain or soft tissue mobility changes (Table 3). Permanent situational consequences were present in 3.6%, and were mild in terms of severity, and referred mostly to patterns of social behaviour (Table 4).
Table 1 Total number of sustained oral injuries (n = 438). Anatomic level
n
%
Type
n
%
Perioral soft tissues
266
80.1
Lips
98
29.5
Gingival and oral mucosa
40
12.1
Teeth, prosthetic devices and periodontal tissues
24
7.2
Tongue
6
1.8
Jaws
4
1.2
Contusion Laceration Burn Contusion Laceration Contusion Laceration Tooth fracture Tooth luxation Tooth avulsion Prosthetic device fracture Contusion Laceration Temporo-mandibular joint contusion
236 24 6 56 42 4 36 10 4 5 5 2 4 4
88.7 9.0 2.3 57.1 42.9 10.0 90.0 41.6 16.8 20.8 20.8 33.3 66.7 100
Table 2 Body permanent consequences (n = 74). Body
n
% Victims presenting this body consequence (n = 332)
Type
n
%
Perioral soft tissues Lips Gingival and oral mucosa Teeth, prosthetic devices and periodontal tissues
18 20 12 22
5.4 6.0 3.6 6.6
2 0
0.6 0
Scar Scar Scar Tooth structure loss Tooth mobility Scar No. sequelae
18 20 12 18 4 2 0
100 100 100 81.8 18.2 100 100
Tongue Jaws
I.M. Caldas et al. / Forensic Science International 221 (2012) 102–105
104 Table 3 Functional permanent consequences (n = 12). Functions
n
% of victims presenting this functional permanent consequence (n = 332)
Type
n
%
Chewing Feeling pain
4 4
1.2 1.2
Mobility changes
4
1.2
Difficulty Face Teeth Unilateral
4 2 2 4
100 50 50 100
n
%
Table 4 Situational permanent consequences (n = 16). Situations
Daily life Professional life Social life
n
% of victims presenting this situational permanent consequence (n = 332)
Type
2 2
0.6 0.6
Mild modifications Mild modifications
2 2
100 100
12
3.6
Mild modifications
12
100
4. Discussion In the present investigation, oral trauma was found in 13.4% of all cases. In previous studies conducted in Portugal, oral injuries were present in 11.6% (n = 513) of the cases involving violence [17], and in 15.6% (n = 108) of road traffic accidents (RTA) [19] (Table 5). Regarding victim profiles, some important differences were found. In IPV events, most victims were females (69.3%), whereas in aggressions and RTA the majority was male (61.6% and 69.4%, respectively); mean age was also different for IPV, aggressions and RTA victims (33.7, 35.4 and 32.4 years old, respectively). With regards to oral trauma presentation in IPV events, perioral soft tissues were the main site of injury (80.1% of all victims), followed by lips, gingival and oral mucosa injuries, teeth, prosthetic devices and periodontal injuries, tongue and jaw injuries (Table 1). There are important differences in these injuries considering the type of event (Table 6). In aggressions, the two main sites of injuries are the same, although in reverse order, implying that as far as location is concerned, no IVP characteristics of oral trauma differ from other types of oral trauma produced in aggression contexts. In RTA, as in IPV events, trauma to the perioral soft tissues is the most frequent oral injury. Therefore, one can infer that the aetiology of oral trauma does not greatly affect the
Table 5 Comparison between IPV, aggressions and RTA consequences (%). Event
Injuries
IPV Aggression RTA
13.4 11.6 15.6
Permanent consequences Body
Functions
Situations
11.4 25.3 92.6
10.3 7.4 30.6
3.6 16.8 64.8
Table 6 Comparison between IPV, aggressions and RTA injuries (%). Anatomic level
IPV
Aggressions
RTA
Perioral soft tissues Lips Gingival and oral mucosa Teeth, prosthetic devices and periodontal tissues Tongue Jaws
80.1 29.5 12.1 7.2
35.9 57.7 29.2 17.5
37.7 15.9 2.4 22.7
0 0
3.4 17.9
1.8 1.2
location of the oral injuries produced. Permanent consequences of oral trauma were, however, very different (Table 5); for instance, almost all RTA victims had permanent body consequences (92.6%), whereas in the other cases they were much lesser. Important differences were also found at the functional and situational levels. These data may reflect the greater severity of oral injuries in RTA. Other studies regarding IPV events demonstrated similar victim and perpetrator profiles. As Hendler and Sutherland [20] stated, one cannot describe a typical profile of DV victims, as they are represented in all major racial and ethnic groups, age groups, marital status, education, employment and income levels although, some characteristics may act as markers. Our study found women to be more frequent victims than men; this tendency agrees with other studies [11,20–22] in which females accounted for 85–100% of all victims of DV. These findings suggest that clinicians should consider the possibility of IPV any time a woman presents head, neck, facial, or oral injuries in absence of a specific known cause or explanation, when observed in the emergency service [23]. Victims described in the present study had a mean age (33.7 years) consistent with that presented by other authors [10,12,18,23]. However, there are other series with different results; Love et al. [21] found a mean age of 28.5 and McKenzie et al. [7] of 44 years (this last investigation was performed in an urban non-trauma hospital in the USA with a small sample, although some sample bias may exist). In our series, almost half of the victims were married (47%), whereas in other studies the victims were mostly single; again, cultural differences may explain this divergence. Another difference was found in the employment status: our victims were mainly employed, whilst in other investigations, their main status was unemployed [22]. Hendler and Sutherland [20] referred to the aggressor profile stating that 62% of the occurrences were perpetrated by the spouse. This tendency was also observed in our sample, with a similar rate of 58.4%. Regarding the main injury method of abuse, we found that punching was the most common, as was reported in other studies [11,24]. In various studies [3,5,11,24,25], a higher prevalence of head and neck injuries was found. However, most of these studies were performed in hospitals where facial injuries are usually of great concern, so people tend to seek prompt medical care, which might not be the case for other injuries considered to be ‘‘mild’’, which may go undiagnosed. Finally, possible cultural differences should be considered; for instance, Lincoln and Lincoln [26], referred to ‘‘cultural predilections’’ that surely can also contribute to explaining some discrepancies. Abusive trauma to the face is frequently described as including fractured teeth, laceration of soft oral tissues, missing or displaced teeth, fractures of the maxilla and mandible, and bruised or scarred lips [27]. In our study, perioral soft tissues were the main site of injury, affecting 80.1% of all victims, in agreement with those presented by Bach et al. [22], and with those of Saddki et al. [24], but do not correspond with those presented by Nelms et al. [25] that refer to the lip area as the most affected (29%), followed by the face (21%), which may correspond to the perioral soft tissue area described in this study. Other differences are noticed in tongue, tooth, and jaw injuries (5% vs 1%, 20% vs 5%, and 5% vs 1%, in Nelms et al. [25] and in our study, respectively). Some of these differences may be explained by diverse methodologies, particularly in defining the injured areas and what injuries should be considered (for instance, should a contusion be included or not). But it is very clear that there is a huge difference, not only in the frequency of injuries, but also in their nature. In teeth injuries, for example, we have considered several trauma types (such as fracture, luxation,
I.M. Caldas et al. / Forensic Science International 221 (2012) 102–105
avulsion and prosthetic device fracture), whereas Nelms et al. [25] considered only fracture and lost teeth. Even so, their percentage of injuries was four times greater than ours, pointing out that there may be many cases of misdiagnosis. Another important difference concerns the incidence of fractures. Although described as a fairly common injury [22,28], no facial fractures were found in this study; Bach et al. [22] found facial fractures in 30% of DV victims, but Saddki et al. [24], however, described results similar to ours, stating that there were no reported fractures, and only one case of joint dislocation. Permanent consequences of oral injury results were difficult to compare, since most studies focus on the long term-consequences in an anatomical perspective [29]. Our aim, however, was to characterize oral injury consequences in a three-dimensional perspective, as has been previously done with RTA [19] and aggressions [17]. In comparison, oral injuries in IPV were found to cause less permanent consequences than those occurring in the other situations previously mentioned. Despite many authors stating that the presence of head and neck injuries is a marker for IPV situations [3,11,20,25,30], oral injuries have a similar prevalence in other violence-related events and traffic accidents [17,19]. Thus, diagnosing IPV can be challenging, because the condition has no obvious clinical characteristics, and clinical standards for identifying IPV-related injury and other injuries of non-verifiable aetiology is the victim’s self-report [31]. Therefore, the presence of these injuries constitutes an alert factor, and is of great relevance, although the evidence must be evaluated before a diagnosis of IPV is carried out.
[7] [8]
[9]
[10]
[11] [12] [13] [14]
[15] [16]
[17]
[18] [19] [20]
5. Conclusions In the present study, 13.6% of IPV victims presented oral injuries. However, whilst suggesting IPV, oral injuries alone are insufficient to identify this kind of abuse, and additional diagnostic criteria and evidence should be applied.
[21]
[22] [23] [24]
Acknowledgement
[25]
The author’s would like to thank Dr. Fred Grech for all the help preparing this manuscript.
[26]
References
[27]
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Contents lists available at SciVerse ScienceDirect
Forensic Science International journal homepage: www.elsevier.com/locate/forsciint
Oral injuries in victims involving intimate partner violence Ineˆs Morais Caldas a,b,*, Ana Clara Grams b,c,d, Ame´rico Afonso a,b, Teresa Magalha˜es b,c,d,e a
Faculdade de Medicina Denta´ria da Universidade do Porto, Rua Dr. Manuel Pereira da Silva, 4200-393 Porto, Portugal CENCIFOR – Center of Forensic Sciences, Largo da Se´ Nova, 3030-213 Coimbra, Portugal c Instituto Nacional de Medicina Legal – Delegac¸a˜o do Norte, Jardim Carrilho Videira 40150-167 Porto, Portugal d Faculdade de Medicina da Universidade do Porto, Alameda Prof. Hernaˆni Monteiro, 4200-319 Porto, Portugal e Instituto de Cieˆncias Biome´dicas ‘‘Abel Salazar’’ da Universidade do Porto, Largo Prof. Abel Salazar, 2, 4099-003 Porto, Portugal b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 9 January 2012 Received in revised form 29 March 2012 Accepted 14 April 2012 Available online 6 May 2012
Introduction: Current literature states that dental medicine can have an important role in diagnosing situations of domestic violence, namely cases of intimate partner violence, since many of the injuries that occur in this context concern the head and neck areas. The aim of this study was to characterize oral injuries in these cases in a Portuguese population, and to determine the kind of permanent consequences that they might represent. Material and methods: 332 forensic reports of domestic violence survivors were analysed. The reports concerned examinations performed in the North Branch of the National Institute of Legal Medicine of Portugal in 2007. Reports were assessed in order to obtain data regarding victim and offender demographic characteristics, and to characterize the nature and number of sustained injuries and their permanent consequences. Main results: Most victims were females with a mean age of 33.7 years; the most frequent offender was the spouse; the majority of oral injuries affected soft tissues; permanent body consequences were found mainly in the teeth and periodontal tissues; permanent functional consequences were described as chewing difficulties, feeling pain or soft tissue mobility changes; permanent consequences for life activities referred mostly to social life aspects. Conclusions: Oral injuries and their consequences were observed in 13.4% of intimate partner violence cases, and though being suggestive of this kind of violence, oral injuries alone are insufficient to identify this kind of abuse, and additional diagnostic criteria and evidence should be used. ß 2012 Elsevier Ireland Ltd. All rights reserved.
Keywords: Intimate partner violence Oral injuries Forensic evaluation Dental medicine
1. Background Intimate partner violence (IPV) implies any type of behaviour within an intimate relationship that causes harm to one or both parties [1]; it refers to a broad pattern of coercive or violent tactics used by one partner to establish, maintain power and control over the other. These tactics can include physical, sexual, psychological, and economic abuse in an intimate partnership (any present or previous intimate relationship, with or without sexual involvement). IPV can occur between spouses, former spouses, or unmarried intimate partners [2]. The term IPV has been used interchangeably with domestic violence (DV) [3]. However, in more recent years, DV has developed a broader meaning and now includes abuse that occurs
* Corresponding author at: Faculdade de Medicina Denta´ria da Universidade do Porto, Rua Dr. Manuel Pereira da Silva, 4200-393 Porto, Portugal. Tel.: +351 220901100; fax: +351 220901101. E-mail address: [email protected] (I.M. Caldas). 0379-0738/$ – see front matter ß 2012 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.forsciint.2012.04.010
in any relationship within a household, including that against children, the elderly, or siblings [1]. IPV is a serious health problem that affects, in the USA, up to 26% of adult women and 16% of adult men [4]. An analysis of 48 population-based studies by the World Health Organization indicated that from 10% to 69% of women had been physically assaulted by an intimate partner at some point in their lives. The high prevalence of this phenomenon has given rise to an increasing number of publications on DV and IPV, regarding the signs, symptoms, diagnosis [5–7] and even the medical-professional role in the treatment and guidance of the survivors [8]. IPV has profound health consequences: abused women are more likely to have physical and psychological problems, including reproductive problems, depression, psychosomatic disorders, and limitations in social functioning [9]. In addition, IPV is also associated with loss of productivity and increased use of health care and social services, even long after the end of the violent episodes [10]. Head and neck areas have been reported as the most frequently affected site in DV [11–13]; therefore oral health care professionals may be the first to identify a person who is being abuse and to
I.M. Caldas et al. / Forensic Science International 221 (2012) 102–105
intervene [14]. In 1996, the American Dental Association enacted a policy to encourage efforts to educate oral health professionals in the identification of abuse and neglect of adults [15]. The aim of the present study was to determine the incidence of oral injuries in IPV in the Portuguese population.
2. Methods IPV event reports concerning forensic examinations performed in the North Branch of the National Institute of Legal Medicine of Portugal in 2007 were analysed (n = 2489). Of these, a selection was made according to the following inclusion criteria: (1) suspected case of IPV; (2) victims (of both genders) older than 16 presenting oral injuries. Oral injuries were defined as those involving the following areas: (a) teeth and the surrounding supportive tissues (periodontium); (b) oral mucosa including the gums, the alveolar mucosa in the edentulous patient, palate, and the buccal mucosa; (c) jaw bones (upper and lower); (d) lips (mucosa and skin); (e) tongue; (f) perioral soft tissues (extraoral tissues that surround the mouth and cover upper and lower jaw). Selected cases (n = 332) were studied for data regarding victim and offender demographic characteristics, the nature and number of sustained injuries and their permanent consequences. To analyse oral injuries, the anatomic location and nature of the injury were identified; if the same area sustained more than one kind of injury, only the most severe was registered. Injury severity was assessed using the severity scale presented routinely in Portuguese legal medicine research [16–19]: grade 0, no injuries suffered; grade 1, mild severity injuries such as scratches, bruises, ecchymoses and cuts; grade 2, medium severity injuries, such as skin lacerations, fractures and other injuries that do not require open treatment; grade 3, major severity injuries, but which are not considered life threatening, although require open treatment; grade 4, very important severity injuries, corresponding to high severity and potential lethal injuries. Permanent consequences were assessed according to the individual’s body, functional and situational impact, using the ‘‘Bodily Damage Assessment Inventory’’ [16]. Body consequences refer to the organic aspects (e.g., scars, prosthetic devices), the functional impact which refers to the incapacities (e.g., the inability to chew or swallow), and the situational consequences which refer to the impact in an individual’s life activities (e.g., the inability to eat in a restaurant, the avoidance of intimate contact, the inability to perform one’s professional work). Findings were recorded in a database developed in a prior study [19], and studied using SPSS (Statistical Package for Social Science – SPSS INC, Chicago, Illinois, USA), version 16.0, for Windows. Descriptive statistics was performed using frequency analysis for categorical variables and descriptive analysis for continuous variables.
103
3. Results Amongst 2489 reports of IPV events, 332 (13.4%) referred to oral trauma. Most victims were females (69.3%) presenting a mean age of 33.7 years (SD = 11.4; minimum = 16; maximum = 92), mostly married or single (46.9% and 39.2%, respectively); 12.1% were divorced and 1.8% were widows. The majority worked in personal or domestic services or were unemployed (32.5% and 19.3%, respectively); 14.4% had jobs linked to commercial or industrial activities, 11.4% had scientific, technical, administrative or similar professions, 9.6% were students and 4.8% had received social security benefits, 5.4% were retired and 2.6% had jobs that do not fit any of the described groups. The most frequent offender was the spouse (58.4%), followed by the boyfriend (21.7%), ex-spouse (17.5%) and others (2.4%). The injuries were reported as being the first occurrence in 19.9% of the cases. Slapping or punching was the main aggression mechanism in 44.6% of the cases, followed by kicking (15.1%), being pushed against something (12.7%), or trauma with a blunt instrument (12.0%). The other cases involved trauma with a sharp object, finger nails, bites, fire arms and hot water (6.6%, 6.6%, 1.2%, 0.6% and 0.6%, respectively). The total number of oral injuries was 438. Oral injuries were the only type of trauma in 27.7% of the victims. Overall, perioral soft tissues were the main site of injury, affecting 80.1% of all survivors (Table 1). Permanent body consequences were present in 11.4% of the victims with the main site being teeth and periodontal tissues, which affected 6.6% of the victims (Table 2). Permanent functional consequences were present in 10.3%. This implied chewing difficulties, feeling pain or soft tissue mobility changes (Table 3). Permanent situational consequences were present in 3.6%, and were mild in terms of severity, and referred mostly to patterns of social behaviour (Table 4).
Table 1 Total number of sustained oral injuries (n = 438). Anatomic level
n
%
Type
n
%
Perioral soft tissues
266
80.1
Lips
98
29.5
Gingival and oral mucosa
40
12.1
Teeth, prosthetic devices and periodontal tissues
24
7.2
Tongue
6
1.8
Jaws
4
1.2
Contusion Laceration Burn Contusion Laceration Contusion Laceration Tooth fracture Tooth luxation Tooth avulsion Prosthetic device fracture Contusion Laceration Temporo-mandibular joint contusion
236 24 6 56 42 4 36 10 4 5 5 2 4 4
88.7 9.0 2.3 57.1 42.9 10.0 90.0 41.6 16.8 20.8 20.8 33.3 66.7 100
Table 2 Body permanent consequences (n = 74). Body
n
% Victims presenting this body consequence (n = 332)
Type
n
%
Perioral soft tissues Lips Gingival and oral mucosa Teeth, prosthetic devices and periodontal tissues
18 20 12 22
5.4 6.0 3.6 6.6
2 0
0.6 0
Scar Scar Scar Tooth structure loss Tooth mobility Scar No. sequelae
18 20 12 18 4 2 0
100 100 100 81.8 18.2 100 100
Tongue Jaws
I.M. Caldas et al. / Forensic Science International 221 (2012) 102–105
104 Table 3 Functional permanent consequences (n = 12). Functions
n
% of victims presenting this functional permanent consequence (n = 332)
Type
n
%
Chewing Feeling pain
4 4
1.2 1.2
Mobility changes
4
1.2
Difficulty Face Teeth Unilateral
4 2 2 4
100 50 50 100
n
%
Table 4 Situational permanent consequences (n = 16). Situations
Daily life Professional life Social life
n
% of victims presenting this situational permanent consequence (n = 332)
Type
2 2
0.6 0.6
Mild modifications Mild modifications
2 2
100 100
12
3.6
Mild modifications
12
100
4. Discussion In the present investigation, oral trauma was found in 13.4% of all cases. In previous studies conducted in Portugal, oral injuries were present in 11.6% (n = 513) of the cases involving violence [17], and in 15.6% (n = 108) of road traffic accidents (RTA) [19] (Table 5). Regarding victim profiles, some important differences were found. In IPV events, most victims were females (69.3%), whereas in aggressions and RTA the majority was male (61.6% and 69.4%, respectively); mean age was also different for IPV, aggressions and RTA victims (33.7, 35.4 and 32.4 years old, respectively). With regards to oral trauma presentation in IPV events, perioral soft tissues were the main site of injury (80.1% of all victims), followed by lips, gingival and oral mucosa injuries, teeth, prosthetic devices and periodontal injuries, tongue and jaw injuries (Table 1). There are important differences in these injuries considering the type of event (Table 6). In aggressions, the two main sites of injuries are the same, although in reverse order, implying that as far as location is concerned, no IVP characteristics of oral trauma differ from other types of oral trauma produced in aggression contexts. In RTA, as in IPV events, trauma to the perioral soft tissues is the most frequent oral injury. Therefore, one can infer that the aetiology of oral trauma does not greatly affect the
Table 5 Comparison between IPV, aggressions and RTA consequences (%). Event
Injuries
IPV Aggression RTA
13.4 11.6 15.6
Permanent consequences Body
Functions
Situations
11.4 25.3 92.6
10.3 7.4 30.6
3.6 16.8 64.8
Table 6 Comparison between IPV, aggressions and RTA injuries (%). Anatomic level
IPV
Aggressions
RTA
Perioral soft tissues Lips Gingival and oral mucosa Teeth, prosthetic devices and periodontal tissues Tongue Jaws
80.1 29.5 12.1 7.2
35.9 57.7 29.2 17.5
37.7 15.9 2.4 22.7
0 0
3.4 17.9
1.8 1.2
location of the oral injuries produced. Permanent consequences of oral trauma were, however, very different (Table 5); for instance, almost all RTA victims had permanent body consequences (92.6%), whereas in the other cases they were much lesser. Important differences were also found at the functional and situational levels. These data may reflect the greater severity of oral injuries in RTA. Other studies regarding IPV events demonstrated similar victim and perpetrator profiles. As Hendler and Sutherland [20] stated, one cannot describe a typical profile of DV victims, as they are represented in all major racial and ethnic groups, age groups, marital status, education, employment and income levels although, some characteristics may act as markers. Our study found women to be more frequent victims than men; this tendency agrees with other studies [11,20–22] in which females accounted for 85–100% of all victims of DV. These findings suggest that clinicians should consider the possibility of IPV any time a woman presents head, neck, facial, or oral injuries in absence of a specific known cause or explanation, when observed in the emergency service [23]. Victims described in the present study had a mean age (33.7 years) consistent with that presented by other authors [10,12,18,23]. However, there are other series with different results; Love et al. [21] found a mean age of 28.5 and McKenzie et al. [7] of 44 years (this last investigation was performed in an urban non-trauma hospital in the USA with a small sample, although some sample bias may exist). In our series, almost half of the victims were married (47%), whereas in other studies the victims were mostly single; again, cultural differences may explain this divergence. Another difference was found in the employment status: our victims were mainly employed, whilst in other investigations, their main status was unemployed [22]. Hendler and Sutherland [20] referred to the aggressor profile stating that 62% of the occurrences were perpetrated by the spouse. This tendency was also observed in our sample, with a similar rate of 58.4%. Regarding the main injury method of abuse, we found that punching was the most common, as was reported in other studies [11,24]. In various studies [3,5,11,24,25], a higher prevalence of head and neck injuries was found. However, most of these studies were performed in hospitals where facial injuries are usually of great concern, so people tend to seek prompt medical care, which might not be the case for other injuries considered to be ‘‘mild’’, which may go undiagnosed. Finally, possible cultural differences should be considered; for instance, Lincoln and Lincoln [26], referred to ‘‘cultural predilections’’ that surely can also contribute to explaining some discrepancies. Abusive trauma to the face is frequently described as including fractured teeth, laceration of soft oral tissues, missing or displaced teeth, fractures of the maxilla and mandible, and bruised or scarred lips [27]. In our study, perioral soft tissues were the main site of injury, affecting 80.1% of all victims, in agreement with those presented by Bach et al. [22], and with those of Saddki et al. [24], but do not correspond with those presented by Nelms et al. [25] that refer to the lip area as the most affected (29%), followed by the face (21%), which may correspond to the perioral soft tissue area described in this study. Other differences are noticed in tongue, tooth, and jaw injuries (5% vs 1%, 20% vs 5%, and 5% vs 1%, in Nelms et al. [25] and in our study, respectively). Some of these differences may be explained by diverse methodologies, particularly in defining the injured areas and what injuries should be considered (for instance, should a contusion be included or not). But it is very clear that there is a huge difference, not only in the frequency of injuries, but also in their nature. In teeth injuries, for example, we have considered several trauma types (such as fracture, luxation,
I.M. Caldas et al. / Forensic Science International 221 (2012) 102–105
avulsion and prosthetic device fracture), whereas Nelms et al. [25] considered only fracture and lost teeth. Even so, their percentage of injuries was four times greater than ours, pointing out that there may be many cases of misdiagnosis. Another important difference concerns the incidence of fractures. Although described as a fairly common injury [22,28], no facial fractures were found in this study; Bach et al. [22] found facial fractures in 30% of DV victims, but Saddki et al. [24], however, described results similar to ours, stating that there were no reported fractures, and only one case of joint dislocation. Permanent consequences of oral injury results were difficult to compare, since most studies focus on the long term-consequences in an anatomical perspective [29]. Our aim, however, was to characterize oral injury consequences in a three-dimensional perspective, as has been previously done with RTA [19] and aggressions [17]. In comparison, oral injuries in IPV were found to cause less permanent consequences than those occurring in the other situations previously mentioned. Despite many authors stating that the presence of head and neck injuries is a marker for IPV situations [3,11,20,25,30], oral injuries have a similar prevalence in other violence-related events and traffic accidents [17,19]. Thus, diagnosing IPV can be challenging, because the condition has no obvious clinical characteristics, and clinical standards for identifying IPV-related injury and other injuries of non-verifiable aetiology is the victim’s self-report [31]. Therefore, the presence of these injuries constitutes an alert factor, and is of great relevance, although the evidence must be evaluated before a diagnosis of IPV is carried out.
[7] [8]
[9]
[10]
[11] [12] [13] [14]
[15] [16]
[17]
[18] [19] [20]
5. Conclusions In the present study, 13.6% of IPV victims presented oral injuries. However, whilst suggesting IPV, oral injuries alone are insufficient to identify this kind of abuse, and additional diagnostic criteria and evidence should be applied.
[21]
[22] [23] [24]
Acknowledgement
[25]
The author’s would like to thank Dr. Fred Grech for all the help preparing this manuscript.
[26]
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[27]
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