Dental Trauma and Child Abuse

Dental Trauma and Child Abuse

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Description: Traumatic Dental Injuries(TDI), Causes of TDI, General principles of prevention of TDI, High Risk Individuals for TDI, Raise Pubic Awareness, Protective Devices, Mouth-formed Mouth Guards, Custom Mouthguards, Custom Mouthguards Criteria for Proper Action, Custom Mouthguards Fabrication, Positive Pressure Machines, Sports and Mouthguards.

 
Author: Dr. Suhad al-Jundi (Fellow) | Visits: 1634 | Page Views: 2156
Domain:  Medicine Category: Implants Subcategory: Dental 
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Contents:
Dr. Suhad al-Jundi

Traumatic dental injuries (TDI)
TDIs are very common and currently considered a public health problem all over the world In Jordan studies showed that TDI affect % of year old children

Causes of TDI
Most commonly reported causes of TDI include:
Falls Collision Contact sports Road traffic accidents Child abuse

Recently human behavior and environmental factors have been implemented in TDI causes

General principles of prevention of TDI
Target risk group population Raise public awareness of emergency management and prevention Promote use of protective devices during sports Promote use of seat belts Improve playground and school environment

High risk individuals for TDI
High risk groups should be specifically targeted in preventive strategies, they include:
Children with increased overjet: perform ortho tx Children who already sustained previous trauma: are at . times higher risk if truama occurred before age yrs Children with risk taking behavior Deprived children: Improve School and playground environment

Raise pubic awareness
Educate children about st aid when TDI occur using simple posters and simple information such as
Avulsion: replace avulsed permanent teeth immediately or store in milk Fracture: Look for tooth fragments Educate people who care for children including parents, school teachers, sports coaches

Protective devices
principle: these devices act by either prevention of the impact from reaching the tissues or by absorbing the energy of the impact (cushioning), or by restraining the individual such as seat belts to prevent the impact from reaching the oral and maxillofacial area. Types:
faceguards Helmets mouthguards

Faceguards
Cage of metal or composite attached to a helmet either prefabricated or custom made It protects the face and the teeth but cant protect the teeth if the hit is below the chin particularly useful in protection while playing hokey

Helmets
Helmets are encouraged during bicycle and motor cycle sports.

Mouthguards
Mouthguards are specially useful in contact sports Their function is as follows
Prevent tooth injury by absorbing and deflecting blows to teeth Sheilding the lips, tongue, gingiva from laceration Prevent opposing teeth from coming into violant contact Provide mandible with support preventing fracture of angle or condyle Effect on prevention of concussion and neck injuries is controversial The thicker the better protection up to mm The thicker the less the athlete comfort

Mouthguards \Types
Stock (prefabricated) Mouth formed Custom made

Stock mourhguard
Material: plastic or rubber Available in three sizes Disadvantages:
Loose fit Limited modification possible Uncomfortable Obstruct speech and breathing

Advantages:
Inexpensive Readily available if need replacement

Lowest protection of all types

Mouth-formed mouthguards
Tow types; first type: Consists of outer hard layer and an inner soft liner, the outer layer is made of vinyl, the inner layer is self curing methyl methacrylate or sillicone rubber Construction: Adapt outer layer to mouth and trim around frena and sulcus, fill it with liner material and seat in the mouth, wait for setting, trim excess and adjust. Second type is made of PVA or PVC that is softened in hot water and adapted to the mouth Disadvantages: Bulky and may be rough Advantages: better fit, inexpensive, available

Custom Mouthguards
More comfortable than other mouthguards More costy No evidence that they protect better than other types of mouthguards Most common material for fabrication is ethylene vinyl acetate (EVA) copolymer EVA is elastomeric soft and flexible so easily processed EVA has good clarity, gloss, low temperature toughness, stress crack resistance, little odor. EVA mouthguards should be replaced regularly since its protective properties will be reduced

Custom Mouthguards criteria for proper action
The mouthguard must be fabricated from reseliant material It should have adequate retention Should absorb and desperse the energy of the impactby :
Covering the whole maxillary arch Allow mouthbreathing Protect soft tissues Reproduce occusal relationship

Should be made on an impression of the athletes teeth

Custom mouthguards Fabrication
Take impression of maxillary and madibular arches with a wax bite especially the alveolus and vestibule. Impression of maxillary arch may be enough Two basic methods of fabrication:
Traditional vacuum Positive pressure machine

Traditional palate of the model to ensure good vacuum Drill a hole in the
suction. Pre heat the EVA plate to adapt well to the cast. Apply suction Leave to cool in place Trim the mouthguard when completely cool. Flame the edges with a torch and smooth it with wet fingers Gently heat the occlusal surface and ask athlete to bite on the mouthguard.

Positive pressure machines
The EVA plate is adapted to the cast by pressure from above rather than being drawn down onto the cast by negative pressure. With this system it is possible to add mare than one layer unlike the traditional vacuum method It is possible to insert name or brand between layers

Care of mouthguards
Should be washed with water and soap after each use Should be dried thoroughly and stored in a box Should be rinsed in mouthwash or mild antiseptic before wear. Should be inspected regularly to check its fit Replace regularly.

Sports and mouthguards
Mouthguard should be worn for the following sports:
American football Baseball Basketball Boxing Field and ice hokey Horseback riding Rugby Soccer Team hanball

Prevention of child abuse

Prevention of child abuse
The key to prevention of child abuse is Recognition Raising awareness of public Reinforcing laws that mandate reporting Reinforcing laws that punish perpetrators

Recognition
There is clear evidence that child abuse is a global problem. It occurs in a variety of forms and is deeply rooted in cultural, economic and social practices. Child abuse has been neglected for long time by both society and medicine, but now it is a focus of public attention. Nowadays cases of suspected maltreatment are featured in the news media and argued in the courts.

Vijay John, child abuse And Dentistry:A Study Of Knowledge And Attitudes Among Dentists In Victoria, Australia. Australian Dental Journal, 1999. 44:(4):259-26.

Definition
Child abuse is defined as the NA commission of any act by a care-taker upon a child under the age of 18 years which causes risk of serious physical or emotional injury, or which constitutes a sexual offense (such as rape or molestation). A caretaker may be a child's parent, stepparent, guardian, or any person entrusted with the responsibility for a child's health or welfare.
Spencer, D.E., Child Abuse: Dentists' Recognition And Involvement. CDA Journal, 2004. Vol.32 No.4.

Definition
Child abuse is the physical or psychological/emotional mistreatment of children. In the United States, the CDC define child maltreatment as any act or series of acts of commission or omission by a parent or other caregiver that results in harm, potential for harm, or threat of harm to a child. Most child abuse occurs in a child's home, schools or communities the child interacts with.
Spencer, D.E., Child Abuse: Dentists' Recognition And Involvement. CDA Journal, 2004. Vol.32 No.4.

The situationregional taboo about the discussion In Jordan, Breaking a in Jordan
of child abuse, the Jordan River Foundation, whose chairperson is her majesty queen Rania, launched the child safety program in 1997. Working with children, families, teachers, policy makers and partner organizations, the child safety program has put the prevention of child abuse on the national agenda.

Unicef, Unicef Eminent Advocate For Children, Queen Rania Of Jordan, Speaks Out On Abuse. Unicef 2008.

Queen Rania
Under the direction of queen Rania, it has opened the first centre for abused children in the Arab world( Dar al Amman). Dar al-Amman, which has been operational since 2002, offers psychological, medical, social and educational services for abused children and their families. In an effort to reverse the trend, the government, with assistance from UNICEF, is developing a plan to establish child-protection committees in 10 hospitals countrywide in order to guarantee that proper procedures are followed in cases of suspected Abuse.
Plett, B., Jordan Acts On Child Abuse. BBC News, 2001.

In Jordan
Statistics reveal that only 1% of child abuse cases are reported by doctors, as compared to 75 % by police, 10% by relatives, 9% by government ministries and 5% by schools.

Plett, B., Jordan Acts On Child Abuse. BBC News, 2001.

Child abuse in Jordan

Year
2003 2004 2005 2006 2007 2008

Physical Abuse
(males, females) 157 183 133 79 109 93

Child abuse in Jordan
Year
2003 2004 2005 2006 2007 2008

Sexual abuse
(males, females) 530 578 640 553 567 695

Aetiology of child abuse
NAI found to be more common in the following situations: Lower socio-economic groups; Young parents; Unwanted pregnancy; Parents of lower intelligence; Marital instability; History of NAI of the parents themselves when they were children; Poor tolerance and impulse control; Psychiatric history or personality disorder. Handicapped or mentally retarded child;
Welbur, A.C.A.R., The Role Of The Dental Team in Child Protection- A Review. Scottish Medical Journal, 2009. 54(2). Curzon, M.E.J., Handbook Of Dental Trauma. 2001. Ch. 14.

Diagnosis of child abuse
History 2. Examination General assessment Intraoral assessment Investigation (radiograph& lab test) 3. Records
1.

Curzon, M.E.J., Handbook Of Dental Trauma. 2001. Ch. 14.

Historycarers are suspected NAI, 1 can be taken If 2 parents/
elsewhere on an excuse for completing a form, while the other is re-questioned on the history in order to cross-check history for consistency. The key points to remember: � Never accuse the parents of lying or being the perpetrators of NAI. � Take the history carefully and in detail. � Complete a trauma form. � Check the history several times in different ways, to ensure consistency of the aetiology.
Curzon, M.E.J., Handbook Of Dental Trauma. 2001. Ch. 14.

History
History should include: Detailed history of pain/injury, detailed account of accident, including records of the parents' explanation, when and where the incident happened, what exactly was the detailed sequence of events, medical history (bleeding disorders/ Osteogenesis imperfecta mimic NAI) finally family and social history.

Curzon, M.E.J., Handbook Of Dental Trauma. 2001. Ch. 14.

History
� Explanation not consistent with injuries or a complete lack of explanation. for example, a story was told of how a child fell off a kitchen table onto their father's bicycle is it usual for a bicycle to be in a kitchen? What was the child doing on the top of a kitchen table? the story seemed unlikely and further investigation revealed a family registered with social services as being under surveillance for possible NAI.

Curzon, M.E.J., Handbook Of Dental Trauma. 2001. Ch. 14.

Examination

General assessment Do they seem to be in pain as they walk into your room or climb into the dental chair? If yes, ribs could be injured or bones fractured. Do they appear uncomfortable as they sit down? if yes, indicate sexual abuse. Check for facial symmetry - are there swellings, bruises or other types of injuries from trauma? Observe their hands. Are there burns from cigarettes, lighters or "glove-like" burns from immersion in a hot liquid?

Kurtz-Weidinger, D., The Dental Team's Responsibility In Reporting Child Abuse And Neglect. Arizona Department Of Health Services, 2004.

Carefully observe the child's head. Are there any swellings of the scalp from trauma or fracture, hair was traumatically removed? Does the child's neck appear to have rope burns or hand marks from choking or strangling? Does the child have several bruises in various stages of resolution? Different colored bruises may indicate chronic abuse over several days or weeks? 0 - 2 days: swollen and tender, 2 - 5 days: red and blue, 5 - 7 days: green, 7 - 9 days: yellow, 9+ days: brown, then clearing
Kurtz-Weidinger, D., The Dental Team's Responsibility In Reporting Child Abuse And Neglect. Arizona Department Of Health Services, 2004.

Are there elliptical or oval ecchymoses, abrasions or lacerations that indicate the child has been bitten? Individual marks where the incisal or occlusal surfaces of the teeth may identify the exact teeth used to bite the child. (impression of bite marks). Are there lesions on their ears that may indicate blows, punching, slapping, pulling, twisting or pinching? Does their nose appear broken or are there blood clots in the nostrils?

Kurtz-Weidinger, D., The Dental Team's Responsibility In Reporting Child Abuse And Neglect. Arizona Department Of Health Services, 2004.

Does the child have a black eye, pupils of unequal size, or scleral hemorrhage from trauma? Does the child appear "overdressed" for the climate, wearing long sleeves, a turtleneck sweater, long pants and other heavy clothing in the heat of the summer? This attempt to hide bruises or injuries on arms or legs. Is the child clean, tidy and apparently well nourished, or dirty, disheveled because of neglect and malnourishment? Does it appear that there was an obvious delay in seeking treatment?

Kurtz-Weidinger, D., The Dental Team's Responsibility In Reporting Child Abuse And Neglect. Arizona Department Of Health Services, 2004.

Fingernail marks on child's cheek.
.

Multiple bruises, abrasions on abused child's face.

Bite Marks of Human Origin

Slap Marks to the Face

Theses photos are adapted, with permission, from Arkansas PANDA Coalition

Human bite mark on child's arm.
Numerous linear bruises on the legs as a result of beating with wooden rod

Bite mark on shoulder of seven week- old child abuse-homicide victim.

Theses photos are adapted, with permission, from Arkansas PANDA Coalition

Physical abuse

Burns

Intraoral assessment
Are there lacerations or scars in the lips from trauma, burns from heated implements, or rope marks in the corners of the mouth? Are there any bruising of the Gums, resulting from an open-Handed slap to the Face or condyloma ( wart) Indicative of sexual Abuse. View the palate, at the junction of hard & soft palate, for unexplained petechia or bruises that may be indicative of sexual abuse.
Kurtz-Weidinger, D., The Dental Team's Responsibility In Reporting Child Abuse And Neglect. Arizona Department Of Health Services, 2004.

Intra-oral assessment
Are there fractured or non-vital teeth that appear to be from non-accidental trauma? Are any teeth missing or displaced for which there is no obvious explanation? Is the labial frenum lacerated from forced feeding or from blunt trauma from an instrument or hand

Kurtz-Weidinger, D., The Dental Team's Responsibility In Reporting Child Abuse And Neglect. Arizona Department Of Health Services, 2004.

An Oral Condyloma, a Venereal Wart, Indicative of Sexual Abuse.*

A Tooth Knocked Loose, Lacerations to the Lip, and Bruising of the Gums, Resulting from an OpenHanded Slap to the Face.*

These photos are adapted, with permission, from Arkansas PANDA Coalition

Examination
Investigation Radiographs to exhibit recent and healed fractures? Impression in case of bite &laboratory data for forensic studies performed within 72 hours of acute sexual assault or sexual abuse, cultures to perform serologic tests for sexually transmitted disease.

Kurtz-Weidinger, D., The Dental Team's Responsibility In Reporting Child Abuse And Neglect. Arizona Department Of Health Services, 2004.

Detailed documentation at dental Records is vital, even ifthe time of the hard-pressed examination the dentist is in a busy clinic. As with all cases of trauma, the use of the trauma form is highly recommended. The following details should be recorded names and addresses of all people accompanying the child, Time of arrival, illustrations of the size, position and type of injuries. Photographic documentation is beneficial.

Indicators of child abuse
1. 2. 3. 4. 5.

Behavioral indicators Medical and social history indicators Caretaker indicators Physical indicators Dental indicators

Signs of child abuse
Signs of physical abuse:
1. 2. 3. 4. 5. 6.

Bruising Beating Burns Bite marks Bone injuries Intracranial injuries

Guideline On Oral Dental Aspects Of Child Abuse And Neglect. American Academy Of Pediatrics Dentistry, Refrence Manual 2009.31(6) Guidelines For The Evaluation Of Sexual Abuse Of Children: Subject Review. Pediatrics, 1999. Vol. 103 No. 1.

Behavioral indicators:
Lack of eye contact. Worry of parent or guardian. Fear of touch. Inappropriate language. Overly anxious . Inappropriate clothing for the time of year. Dramatic mood changes. History of suicide attempts. History of running away

Welbur, A.C.A.R., The Role Of The Dental Team in Child Protection- A Review. Scottish Medical Journal, 2009. 54(2).

2. Medical and social history indicators: Low family income. Unexplained or inconsistent injuries. Delay in seeking care. Specific accusation by a child. Child with a chronic illness. Premature child (7times more likely than a term-birth child to be abused). Child living in an extremely isolated area. Child who is viewed as "different." Child with special needs. Child with very strict or overly critical parents. Abused children 8 times more likely to have untreated dental caries than other children.

3. Caretaker indicators: explanation of the injury is inconsistent with the facts. Providing a vague story of the injury, lacking details. Caretaker plays down the "incident." Delays seeking care. Caretaker is a substance/alcohol abuser. Hostile or aggressive attitude. Compulsive behavior. Inflexible attitude. Have unreasonable expectations of the child. Has previously abused a child. Blames a third party. Passive and dependent. Hospital shopper.

4. Physical indicators

Retinal hemorrhage � (shaken baby syndrome. Fractured incisors - repeated trauma. Burns on lips - forced feeding of hot food. Bruises on lips/frenum- forced pacifier/feeding. Oral or perioral syphilis or gonorrhea Venereal warts (condylomata acuminata) Palatal petechiae or erythema - probable sexual abuse. Bite marks - 65% of them are visible while child is clothed. Bruises in various stages of healing - indicative of multiple episodes of abuse.
Welbur, A.C.A.R., The Role Of The Dental Team in Child Protection- A Review. Scottish Medical Journal, 2009. 54(2).

5. Dental indicators Irregular attendance &repeatedly failed appointments; Failure to complete planned treatment; Returning in pain at repeated intervals; Requiring repeated GA for dental extractions.

Where to report abuse in Jordan
Family Protection department Phone number

Laws in Jordan
Corporal punishment is prohibited in schools in Jordan Law / mandates health care providers to report suspected cases of abuse.

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