The Duty of a Dentist to Report Abuse

From the Winter 2020 Journal of the Colorado Dental Association

Whether you are a new graduate or have been in practice for decades, you have treated patients who were victims of maltreatment, but you may not have been trained to recognize patients in need or know how to help them. Maltreatment includes both abuse and neglect.

Dentists, dental hygienists and dental assistants are uniquely positioned to offer support to people who may be experiencing abuse or neglect. Individuals who commit abuse may avoid taking their victims to the same physician, but often return to the same dental office.¹

Abuse and neglect can come in many forms and it affects people of all races, ethnicities, classes, sexual orientations, gender identities, religious affiliations, ages, immigration status and abilities. Vulnerable populations for maltreatment include children (up to age 18) and at-risk adults. At-risk adults include any person 70 years or older (at-risk elder) and any person who is 18 years or older with a developmental/physical disability. Anyone can experience maltreatment, which is why dental professionals should know the signs and symptoms and know how to screen and potentially report suspected cases of maltreatment.

Dentists and dental hygienists are mandated by Colorado statute (coloradoaps.com/about-mandatory-reporting.html) to report suspected cases of abuse and neglect in children and at-risk adults. All this said, many of your patients may not fall into categories that require reporting, so it is also important to understand the signs of the most common type of abuse among adults: intimate partner violence.

The term intimate partner violence (IPV) is used to describe physical or sexual violence, stalking or psychological harm such as intimidation or threats by a current or former partner or spouse. Research shows that women who talked to their healthcare provider about experiencing abuse were four times more likely to use an intervention such as advocacy, counseling, protection orders, shelter or other services.² According to the National Coalition Against Domestic Violence one in three women and one in nine men experience severe IPV at some point in their lives. Research suggests IPV rates among people who are transgender are even higher.³ If you are treating a patient experiencing IPV, you may be the only one who can intervene to prevent future extreme harm.

Many people experiencing IPV are fearful no one will believe them; they can feel isolated and alone and don’t know where to turn for help. Asking for help may actually put IPV victims at risk for harm if the abuser learns that they disclosed the IPV. Dental professionals and other healthcare providers may be the only safe access survivors have to get help.

Identifying neglect in patients can be difficult. In addition to verbal and physical signs that a patient is being denied basic needs, including food, safe shelter, social interactions and healthcare, you may observe an appearance indicating neglect. Patients may have ill-fitting and dirty clothes, have infrequent healthcare appointments and failure to hit normal developmental milestones.⁴

 Identifying Abuse

The following are signs of possible abuse that dental practitioners may encounter:

• oral and facial lesions;
• tearing of the labial frenum or mucosal lining of the lip from the gingiva;
• prematurely loosened, fractured or avulsed teeth;
• darkened and/or non-vital teeth; and
• jaw factures or multiple scars about the head and neck.

Additional red flags to watch for when interacting with a patient include:

• multiple injuries, at once or over time;
• extraordinary delay in seeking treatment;
• implausible explanation for the injury; and/or
• reluctance to discuss the circumstances of the injury.

Responding to Intimate Partner Violence in a Dental Setting

Dental professionals can take proactive steps to address IPV by adopting the evidence-based CUES intervention (ipvhealth.org/health-professionals/educate-providers) from Futures Without Violence. The CUES intervention includes: Confidentiality, Universal Education and Empowerment, and Support. In Colorado, healthcare professionals are not mandated to report IPV to law enforcement if the victim is at least 18 years of age and does not wish the injury to be reported. Recently, this exception has changed and does not apply if the injury is from a firearm, knife, ice pick or other sharp object. Those injuries must be reported to law enforcement. If a healthcare professional has reason to believe that an injury resulted from IPV, then, regardless of whether the injury is reported to law enforcement, the healthcare professional should refer the victim to an advocate or provide the victim with information on the services available to help. Learn about the advocacy organizations closest to you by visiting violencefreecolorado.org/find-help/programs-by-county/. You can reach out to your local advocacy organization at any time to build a relationship and learn about their specific services. The exact services will vary by program/site and most have 24-hour crisis intervention, advocacy, counseling, education programs, referrals and other supportive services. Many have emergency shelter or assistance with short-term housing needs.

References:

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4554246/
2. Public Health Rep. 2006 Jul-Aug; 121(4): 435–444. doi: 10.1177/003335490612100412. PMCID: PMC1525344. PMID: 16827445. Assessing Intimate Partner Violence in Health Care Settings Leads to Women’s Receipt of Interventions and Improved Health. Laura A. McCloskey, Ph.D., Erika Lichter, Sc.D., Corrine Williams, M.A., Megan Gerber, M.D., Eve Wittenberg, Ph.D., and Michael Ganz, Ph.D.
3. https://www.all4kids.org/2014/03/04/warning-signs-child-abuse-neglect/

The CDA would like to thank Colorado Department of Human Services Domestic Violence Program Director Brooke Ely-Milen, M.P.A., Colorado Department of Public Health and Environment Dental Director Katya Mauritson, D.M.D., and Colorado Department of Public Health and Environment Child Fatality Prevention System Manager Kate Jankovsky for their contributions to this article.