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Current Pediatric Research

Child abuse presented as orofacial injury

Author(s): Afshan Bey, Nazia Ashfaq and Syed S. Ahmed

Vol. 15, No. 2 (2011-07 - 2011-12)

Afshan Bey(1), Nazia Ashfaq(2) and Syed S.Ahmed(3)

(1)Department of Periodontics and Community Dentistry,
(2)Department of Periodontics and Community Dentistry,
(3)Department of Oral and Maxillofacial Surgery, Dr. Z. A. Dental College, Aligarh Muslim University, Aligarh, India

Abstract

Child abuse is the term used to describe the manhandling or torturing a child. It is a com-mon phenomenon in every class of society of the world. The children are manhandled due to one or the other reason leading to physical and psychological trauma. Although it is a commonly observed phenomenon, but it has been least reported in the literature. It is the responsibility of every citizen to protect and prevent the child from abuse. Identification of the abuse is the responsibility of health professionals. Psychologists and psychotherapist should also be involved for counseling of child and the parents in such cases. We are report-ing a case of child abuse for documentation in the literature.

Key words. Child abuse, Maltreatment, Bruise
Accepted April 14 2011

Introduction

Maltreatment of children is a major social problem which has been given a scientific term of child abuse. It is a state of emotional, physical, economic and sexual maltreatment given to a person below the age of eighteen. In India, like in other countries, there has been no well defined extent or magnitude of the problem. The growing complexities of life and the changes brought about by socio-economic transitions in India have played a major role in increasing the vulnerability of children to various forms of abuse. Thus, it not only includes maltreatment, but involves ex-ploitation and neglect as well.

Child abuse and the society

Child abuse is a globally prevalent phenomenon and is spreading as an epidemic. However, owing to various cultural, social and ethnic conditions, child abuse is be-coming a major problem in India and other developing countries. There is a need to deal it with caution and de-termination for protection of children and betterment of society.

Previously it was thought that there were no such happen-ings like child abuse in India, but the fact is, it exists, but due to certain traditional practices ,which amount to child abuse, is ignored by the society.

Preventing child abuse and protecting the child is a chal-lenge. It involves a range of health care professionals, human service disciplines and experts in the area of fam-ily violence. Dentists are also included in this list. Some studies have shown that 50% of all injuries involve the head and neck region, which place the dentists at fore front [1]. Dental care providers are more likely to see evi-dence of physical abuse than are the other health care workers, as it has been reported that oro-facial trauma is present in approximately 50-75% of all reported cases of physical child abuse [2]. Some authors believe that the oral cavity may be a central focus for physical abuse be-cause of its significance in communication and nutrition [3]. Although enough room exists to prevent the child abuse and protect the child, but it is widely believed that the abuse is still being under reported by the health care professionals, including dentists.

Child abuse is defined as any act (non-accidental or trauma) that endangers or impairs a child’s physical or emotional health or development [4]. The American Academy of Pediatric Dentistry defines dental abuse as a neglect aand the willful failure of a parent or guardian to seek and follow through with treatment necessary to en-sure a level of oral health essential for adequate function and freedom from pain and infection [4]. The indicators that may be noticeable to the dental professional include trauma to the teeth and injuries to the mouth, lips, tongue or cheeks that are not consistent with an accident [5]. Other common signs of child abuse include fractures of the maxilla and mandible and oral burns. Injuries to the upper lip and maxillary labial frenum may be a character-istic in severely abused young children [2].

Case report

An 8 year old male child was referred to our department for the management of swollen lips and bleeding gums. It was observed that he had bruises and cuts on his face spe-cially around his mouth and nose. His lips were swollen and the gums were lacerated and bleeding. He had bruised nasal bridge and forehead. The intraoral examination re-vealed Ellis type III fracture in right upper central incisor and Ellis type II fracture in left upper central incisor. The child appeared frightened and disturbed. The father told the child sustained trauma due to fall on the floor while running in the house. However, on repeated questioning, it was found that he was allegedly beaten up by his father and it was a usual happening. The father was called, and then referred to the psychotherapist for counseling. Dur-ing the interaction with the psychotherapist, the father revealed certain acts of his child which irritated him and consequently he beat or tortured the child to relieve his anguish. The acts were excessive use of computers for game and chatting and mobile phone, for calling his friends and gossiping and spending lot of time which he (father) accounted as wastage of time. He was of the opin-ion that the child was ‘wasting’ lot of time on these mod-ern gadgets and believed that computers and mobiles should be used at the time of need only and not to pass the time. Later on the child was sent to pediatric counselor who helped him to alter his behavior which irritated his father. The father was also counseled for his thinking and irresponsible be-havior. During the course of follow up visits, the child enlightened the changes and helpful attitude of father. Now the child was fearless and very confidant. The father was also became a happy man.

Fig1

Figure 1. Extra-oral injuries, with bruised nose and lips. Patient has applied some antiseptic cream on bruised nose.

Fig 2a

2a

Fig 2b

Fig. 2 b
Figure 2. Intraoral photograph showing swelling of lower lip (2a) and fracture of central incisors in an abu-sed child.(2b)

Discussion

Every child patient attending the dental clinics with his-tory of trauma should be evaluated and excluded for the child abuse. The history should be recorded in simple terms and cross questioning should be done to identify the precise cause of trauma. If the child is accompanied by parent or guardian they should be requested to leave the patient alone with the dentist. This is necessary to hear the undistorted history of trauma; usually child may modify the history in the presence of parent or guardian.

The commonest injuries among the children are bruises and burn. Abusive bruises often leave the imprint of the object used for torturing like a rod or similar object or a band being used to tie the hands [5]. When such injuries are observed, the professional should determine that if these injuries are consistent with the history and the child’s age, development and level of activity. Bruises are rare in infants and become common among cruisers and walkers. It has been accepted that soft tissue injury in a child of less than nine months of age indicates possible abuse [6]. While considering a case of child abuse, it must be kept in mind that the bruises in toddlers are located in atypical areas, such as the trunk, hands, or buttocks [7]. The society of every ethnic, social and religious stratum, on one hand, is now fully aware of problem of child abuse [6] and on the other hand the cases of child abuse are on rise globally. However, they are not reported in ratio of occurrence, neither by health professionals nor by den-tists. There are many reasons why dentist fail to report child abuse. Ignorance of the problem and lack of aware-ness are the major barriers. Others reasons include fear of dealing with angry parents, or of getting involved in legal procedures.

Although the laws have been framed to deal with child abuse, but recognition of abuse remains the problem . It is the duty of health professional and dentist to recognize them and to report them. The counseling of victim and offender is an important way of prevention. There are definite clinical signs seen in abused children [8]. Altered behavior, poor hygiene, under-nourishment, poor general health , dirty and weathered clothing with wounds and bruises are common findings. They may act aggressively by showing inappropriate anger and loss of control during interaction or they may be sullen or com-pletely withdrawn.

Proper general examination will help to determine the abuse. Besides external examination of the body and face, inspection of the scalp for signs of hair pulling, and of ear pinna for its stretching should be done because they are among the common abuse. Further, the colour of bruises and abrasions may vary which signify the stages of healing and indicates the time elapsed since traumatic abuse. In such cases it is necessary to check for distinctive pattern marks on skin left by objects such as belts, cords, hangers or cigarettes. In addition examina-tion of the face for bilateral bruising around the eyes, petechiae in the sclera of the eye, ptosis of the eyelids, bruised nose, or blood clot in the nose should also be evaluated5. Bite marks should also be checked thor-oughly, because they may be the result of uncontrollable anger by the adult or another child. Bite marks in areas that cannot be the result of self-inflicted wounds are never accidental.

Intraoral examination is also very necessary to decipher the abuse. Burns or bruises near the commissures of the mouth indicate gagging with a cloth or rope. Scars on the lips, tongue, palate or lingual frenum may indicate forced feeding. A torn labial frenum is an indication of abuse. In such events , consideration of child’s age is very impor-tant since a frenum tear in a young child is not unusual . Oral manifestations of sexually transmitted diseases may indicate sexual abuse. In case there is fractured or miss-ing teeth or jaw fracture is present, the cause of such trauma should be investigated

The involvement of dentists in terms of child protection may be beneficial in two ways: dentists would become aware of their role and they assist would assist in the training of non-dental physicians and other professionals for diagnosing the child abuse and prevention by counsel-ling.

In addition, the dentist cannot only diagnose the abuse but can also facilitate community awareness of child abuse and neglect. This can be done in many ways: by distributing pamphlets regarding child abuse and neglect from NGOs community, by providing them or by display-ing in the waiting lounge of hospitals or clinics, by edu-cating the children in schools, by news papers and putting hoardings at prominent places This may provide valu-able information to everyone and may send a message towards all patients that the office is vigilant about child abuse.

India has started to use institutionalization as a method of providing services to children in difficult circumstances. If we have young children fully aware of their rights, we may expect to have a generation of well protected, confi-dant and enthusiastic children in the society, which will be builders of nation in future.

Conclusion

All children have right to live in safety and dignity in a protective and nurturing environment, both at home and in the community. This is possible by creating awareness of their rights, especially their right to protection, in par-ents and other stakeholders, putting in place laws to pun-ish those who abuse and exploit children and taking ap-propriate action to strengthen accountability on the part of government and non-government agencies and the civil society.

References

  1. Ambrose JB. Orofacial signs of child abuse and neglect : a dental perspective. Pediatrician 1989; 16:188-92.
  2. Sibbal P, Friedman CS. Child abuse: implications for the dental health professionals. J Can Dent association 1993; 59: 909-12.
  3. Vadikas G, Roberts MW, Dilley DC. Child abuse and neglect: ethical issues for dentistry. J Mass dent Soc. 1991; 40: 13-15.
  4. Needleman HL. Orofacial trauma in child abuse types, prevalence, management, and the dental profession’s involvement. Pediatric Dent. 1986; 8(special issue): 71-80
  5. Cavalcanti AL. Child abuse: Oral manifestations and their recognition by dentists. Rev Odontol UNICID 2003; 1: 123-8.
  6. Naidoo S A. Profile of the orofacial injuries in child physical abuse at a children’s hospital. Child abuse Negl 2000; 24: 521-34.
  7. Mc Mahon PG, Grossman W, caffiney M, stanitski C. Soft tissue injury as an indication of child abuse. J Bone Joint Surg Am. 1995; 75: 1179-1183
  8. Naomi F, Sugar MD, james A, Taylor MD, Kenneth W, Feldman MD: bruise in infants and toddlers. Arch Pe-diatr Adolesc Med. 1999; 153: 399-403

Correspondence to:
Syed S Ahmed

Department of Oral and Maxillofacial Surgery
Dr.Z.A. Dental College
Aligarh Muslim University
Aligarh 202002, India

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