PANDA Dental Awareness in Colorado

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By Katya Mauritson, D.M.D., M.P.H.(c), Dental Director, Colorado Department of Public Health and Environment,
and Jennifer Goodrum, CDA Director of Government Relations
From the Spring 2015 Journal of the Colorado Dental Association

The Prevent Abuse and Neglect through Dental Awareness (PANDA) program is designed to create awareness in the dental community, to help dental teams recognize and use appropriate interventions, and to ultimately prevent abuse and neglect in all populations.

Dentists, dental hygienists and dental assistants play an important role in identifying abuse and neglect among their patients. Individuals who commit abuse often avoid taking their victims to the same physician, but usually return to the same dental office. Vulnerable populations of maltreatment often include children  and at-risk adults,  which include any person 70 years or older (at-risk elder) as well as any person who is 18 years or older with a developmental/physical disability. No one is immune from maltreatment, which is why any individual who is suspected to be a victim of abuse, neglect, violence, or exploitation should be screened and potentially reported.

Dentists and dental hygienists are mandated by Colorado statute to report suspected cases of abuse in children and at-risk adults. Suspected cases of maltreatment in children and at-risk adults should be reported promptly.  Failure to report known or suspected abuse or neglect may result in legal liability.  A dentist or dental hygienist who in good faith makes a report of known or suspected abuse or neglect against a child or at-risk elder is immune from civil and criminal liability. In addition, a good faith reporter may not be terminated from employment for reporting known or suspected child abuse or neglect (there is currently no similar employment protection for reporting at-risk adults).

General Risk Factors for being a Perpetrator of Abuse and Neglect 
Risk factors may include:
•    history of drug or alcohol abuse within the family;
•    severe stress – economic, lifestyle, or as a result of disasters;
•    lack of support network or isolation (e.g., single parent families, few close friends, no relatives nearby, geographic isolation);
•    other forms of family violence within the home (e.g., spousal or partner abuse, abuse of elders); and
•    history of a parent having been abused as a child.

Identifying Abuse
The majority of child maltreatment is neglect, which is difficult to identify through physical observation. The following are signs of possible abuse  that dental practitioners may encounter:
•    oral and facial lesions, including bruises, lacerations or abrasions;
•    tearing of the labial frenum;
•    tearing of the mucosal lining of the lip from the gingiva;
•    prematurely loosened, fractured or avulsed teeth;
•    teeth that are darkened, non-vital or both; and
•    jaw factures or multiple scars about the head and neck.

Additional red flags to watch for when interacting with a client include:
•    the injury is one of a series noted;
•    there is extraordinary delay in seeking treatment;
•    an implausible explanation is offered for the injury; and/or
•    there is reluctance to discuss the circumstances of the injury.

Dentists are not required to perform a formal diagnosis of non oral health conditions or perform an intervention with the patient and caregiver. However, abuse in children and at-risk adults should be documented and reported according to the guidelines below.

Protocol for Identifying and Reporting Suspected Abuse and Neglect

  1. General physical assessment of the patient. Although general physical examinations may not be appropriate in the dental setting, be aware of obvious physical traits that may indicate abuse or neglect (e.g. difficulty walking or sitting, physical signs that may be consistent with the use of force).
  2. Behavioral assessment. Judge the patient’s behavior against the demeanor of patients of similar maturity in similar situations.
  3. Health histories.  If you suspect child maltreatment, it can be useful to obtain more than one history, one from the child and one separately from the adult.
  4. Orofacial examination. Look for signs of violence, such as multiple injuries or bruises, injuries in different stages of healing, or oral signs of sexually transmitted diseases.
  5. Consultation. If indicated, consult with the patient’s physician about the patient’s needs or your suspicions.

Steps in Reporting Suspected Abuse or Neglect
1.    Documentation.  Carefully document any findings of suspected abuse or neglect in the patient’s record.
2.    Witness. Have another individual witness the examination, note and co-sign the records concerning suspected abuse or neglect.
3.    Reporting: Make the report as soon as possible without compromising the patient’s dental care.
•    Child: Reporting needs to be conducted immediately.
•    Adult: Reporting is urged within the first 24 hours after making the observation or discovery.
•    Elder:  Reporting is required within the first 24 hours from the initial observation or discovery.

To report suspected abuse or neglect in Colorado, contact one of the following:
•    For children, report abuse/neglect to 1-844-CO-4-KIDS (1-844-264-5437);
•    For at-risk adults, contact local law enforcement or the county department of social services where the suspected abuse/neglect is
taking place;
•    If it is after normal business hours or an immediate emergency, call 911.

4.   Information to include in the report for children and at-risk adults:
•    The name, address, age, sex and race of the child/adult;
•    The name and address of the person responsible for the suspected abuse or neglect;
•    For a child:
–    Name and address of parent or legal guardian;
–    Nature and extent of the injuries, including any evidence of previous cases of known or suspected abuse or neglect of the child or
the child’s siblings; and
–    The family composition;
•    For an adult:
–    Name, address and contact information of the adult caretaker; and
–    Nature and extent of the condition and injury (whether physical or financial);
•    The name, address and occupation of the person making the report; and
•    Any other pertinent information.

If you would like more resources on the PANDA program, please contact the Oral Health Program at the Colorado Department of Public Health and Environment at cdphe.information@state.co.us or 303-692-2470.

PANDA Mission: To create an atmosphere of understanding in dentistry and other professional communities that will result in the prevention of abuse and neglect through early identification and appropriate intervention for any individual who is suspected to be a victim of abuse or neglect.

Colorado Data
Abuse and neglect data is limited to reported offenses. The following are Colorado domestic violence and child maltreatment data. The underlying method of domestic violence involves coercion, control, punishment, intimidation or revenge. Child maltreatment includes both neglect and abuse.

Domestic Violence
•    Domestic violence is defined as an act of violence upon a person where the actor is or has been involved in an intimate relationship.
•    In 2012, there were a total of 15,139 domestic violence victims (includes men and women).
–    71% (10,751) of cases were simple assaults
–    13% (1,973) of cases were aggravated assaults

Pregnant Women
•    2.3% of women reported abuse by their husband/partner 12 months before pregnancy
•    2.6% of women reported abuse by their husband/partner during pregnancy

Child Abuse and Neglect
•    In 2011, there were a total of 10,515 confirmed child victims of maltreatment in Colorado, with an overall child abuse rate of 8.3%.

At-risk Adult Abuse
•    In fiscal year 2014, the Department of Human Services received 11,818 total reports for all “at-risk” adults; 64% (or about 7,564) of these complaints involved a person age 65 or older.