Connection Between Dentistry and Family Violence Intervention

Research indicates that most physical injuries resulting from family violence are found on the head and neck, areas that are clearly visible to the dental team during examinations.⁶ For example, dental professionals may observe physical injuries such as chipped or cracked teeth, poor dental hygiene, a broken jaw, a black eye, a broken nose, bruises on the earlobes or chin, and fingermarks on the neck, upper arms, or wrists. Multiple studies confirm that head, face, and neck injuries occur in more than one-half of child abuse cases.⁷ In cases of partner abuse, one study of 218 female domestic violence victims who were examined at a hospital emergency department found that the most common injuries were bruises (70 percent), and the most common location of injury was the face (68 percent).⁸ A similar study found that 94.4 percent of domestic violence victims had head, neck, or facial injuries,⁹ and a third study of 98 battered women found that 58 percent had injuries to the face and head.¹⁰ In elder abuse cases, the types of abuse most frequently reported included bruises and welts, broken dentures, fractured and avulsed teeth, and abrasions and lacerations.¹¹

Given that dental professionals routinely assess the head, face, and neck of patients, they are in a unique position to identify the signs of family violence.¹² In fact, these victims may seek out dental treatment for injuries related to violence. A 1998 national survey revealed that 16.7 percent of women who sought health care for rape injuries visited dentists, and 9.2 percent of women who sought care for physical assault by a partner saw a dentist.¹³ In addition, routine dental visits may alert dental professionals to evidence that patients are being abused and lead to early intervention.

Lack of Recognition and Intervention

Despite the likelihood that dental professionals will interact with a victim of abuse in a clinical setting, few recognize family violence as a problem their patients encounter.¹⁴ One study found that dentists (n=247) and dental hygienists (n=271) were the least likely of all clinicians surveyed to suspect child, spouse, or elder abuse. Close to one-half of the dental professionals surveyed did not view themselves as responsible for dealing with these problems.¹⁵ In a second survey of dentists (n=321), 87 percent said they never screened for domestic violence, and 18 percent did not screen even when patients had visible signs of trauma on their heads or necks.¹⁶ Respondents intervened only minimally to help patients they had identified as victims.¹⁷ A third survey of dentists (n=400) found that 29 percent of them had suspected at least one patient to be a victim of child abuse and 14 percent had reported at least one such case.¹⁸ Only 7 percent had suspected a case of elder abuse, and slightly more than 1 percent had reported at least one such case.¹⁹ About 30 percent of respondents indicated they had suspected at least one case of spouse abuse and 3 percent had reported such a case.²⁰ Less than 1 percent of all child abuse reports nationwide are made by dental professionals even though all 50 states require dentists to report suspected cases of child abuse and neglect, and 41 states require the same of dental hygienists.²¹

Barriers to Reporting

The results of a pretraining survey taken as part of the Family Violence: An Intervention Model for Dental Professionals training program revealed several reasons why dental staff do not proactively intervene in family violence.²² Key factors include limited knowledge of the issue of family violence and lack of practical experience on how to intervene effectively. Close to 60 percent of respondents had received no training on domestic violence. In another survey, 68 percent of responding dentists identified a lack of training as a barrier to screening for domestic violence.²³

Misconceptions about the nature of intervention also discourage dental professionals from getting involved.²⁴ In a study of dental attitudes and practices related to domestic violence, dentists and dental hygienists said they thought of intervention in terms of rescuing a helpless victim such as a child.²⁵ They tended to perceive adult victims of partner abuse as autonomous and having the capacity for selfdefense in abusive situations.²⁶ Though spousal abuse is the most frequently suspected category of abuse noted by dental professionals, it rarely causes them to intervene.²⁷ Dental professionals also cited fear of litigation as another reason for not intervening. Approximately 28 percent of respondents in the Family Violence: An Intervention Model for Dental Professionals pretraining survey said they felt uncomfortable talking about family violence with patients because they feared the legal ramifications of reporting their suspicions.²⁸ Respondents indicated that a lack of referral information and knowledge about how to develop a coordinated referral network were additional reasons they did not intervene.²⁹ Other major obstacles included the presence of a partner or children, concern about offending patients, and the dentists’ own embarrassment about bringing up the topic.³⁰

Critical Need for Education

The likelihood that dentists and dental hygienists will suspect or intervene in family violence appears to depend on the amount of related education they receive.³¹ Of all the clinicians sampled in one survey, dentists and dental hygienists reported the smallest proportion of education in child, spouse, and elder abuse.³² As a group, they also suspected abuse the least often. Another survey found that dentists who received domestic violence education were significantly more likely to screen for domestic violence and intervene as necessary.³³ The study’s authors concluded that education on domestic violence needs to be “standardized and incorporated into dental school and continuing education curricula, thus ‘normalizing’ intervention with victims and making it a standard part of a dentist’s professional responsibility.”³⁴

Family Violence: An Intervention Model for Dental Professionals

Clearly, there is a need to better prepare dental professionals to intervene on behalf of patients who have been abused and neglected. The University of Minnesota’s Family Violence: An Intervention Model for Dental Professionals training program was developed for this purpose.³⁵ It includes a 6-hour curriculum, instructional videos, a training manual, a poster for office display, resource directories, and marketing materials.³⁶

The comprehensive curriculum educates dental professionals about the symptoms and patterns of abuse, methods for creating a safe environment for disclosure, appropriate interventions when abuse is suspected, and patient referrals. The curriculum, which includes overheads, slides, and a template, can be duplicated and integrated into dental school and dental hygiene programs. It can be used in two segments for training students or as an all-day seminar for practicing dental professionals.

To enhance the curriculum, two instructional videos were produced. “Clinical Implications,” which is 6 minutes and 40 seconds in length, provides visual images of abuse injuries on the mouth, lip, ear, neck, and head, and corresponding descriptions of how these injuries would occur. “Healing Voices,” which is 11 minutes and 18 seconds in length, discusses effective intervention strategies for dental professionals. It presents several scenarios in which abuse is suspected and shows how dental professionals can respond in a caring and responsible manner. One scenario explores how a dental team might react if abusive or threatening behavior occurs in the office.

The participant training manual includes an outline of the curriculum, research and training materials, and references. The manual also includes a sample medical and dental history form with specific family violence questions. As part of the training, participants also receive a poster to display in their dental offices. This poster was created to raise awareness that the dentist’s office is a safe place to talk about abuse. Participants in the Minnesota training sessions received a state resource directory, and those attending training sessions in other states received a national resource directory.

To promote the project on a national level, every dental school in the United States, state dental association, and state coalition on sexual assault, child abuse, and domestic violence were sent a project abstract, introductory letter, and marketing brochures. Information in the brochure was intended to be reproduced in group newsletters, as well as used to encourage dental practitioners to participate in training. In addition, an article from the September/October 1997 issue of Northwest Dentistry promoted the project by describing the training model.

In Minnesota, the State Board of Dentistry approved 6 hours of continuing dental education credits for completion of the training program. The training program was successfully implemented at multiple sites in Minnesota and across the Nation from 1998 to 2000. At the University of Minnesota, the training is conducted annually for senior dental hygiene students and freshman dental students. Also, a 15-week, 50-minute course on family violence that builds on the project’s curriculum was developed for dental hygiene students.