**3.4 Oro-facial trauma that may be indicative of abuse or neglect**

Various reports indicate that injuries related to child abuse predominantly occur in the head and neck region, particularly the face [18, 27–29] as it is easily accessible and a psychologically important target area for abuse [18]. As school-age children commonly sustain accidental dental injuries [29], dental practitioners must have a heightened index of suspicion and practice vigilance in the examination of maxillofacial injuries in children to distinguish between abuse and non-abuse related injuries.

Physical abuse is more prevalent in younger males while sexual abuse is more common in younger females [18]. It is however important to also consider the possibility of outliers of these groups to ensure that no abused child is overlooked.

Dependent on the nature and the site of abuse, there may be a multitude of clinical manifestations of abuse that are encountered as described below. It is important to note that although these signs may alert the dental practitioner to the possibility of abuse, they should not be considered in isolation, but rather contextually [29].

## *3.4.1 Early childhood caries and neglect*

Dental neglect is a subtype of physical neglect that is least likely to be considered during a dental consultation [30]. Dental neglect should be suspected in the presence of the following:


Early childhood caries, although one of the main signs to neglect may be present as a of sequelae of environmental and social confounders such as drinking water, breast feeding habits, poor economic situations or unemployment of parents and lack of education [28, 31]. Furthermore, depending on the geographic region and socio-economic environment, early childhood caries may be commonly encountered in some parts of the world within the dental environment [31]. Untreated symptoms and a lack of continuity of care although considered to be negligent, may sometimes occur in the setting of caregivers who are unaware or unknowledgeable. This provides a challenge for the clinician who, whilst conducting a consultation and examination, must also deduce whether the failure of treatment is due to lack of knowledge, socio-economic difficulties such as access to health care and poverty, or is in fact due to a conscious failure to provide a child with adequate health care [14].

The presence of early childhood caries should therefore elicit a higher index of suspicion from the dental practitioner [28] followed up with a thorough investigation for external signs related to behavior, dressing and appearance; but also other intra-oral signs such as early childhood caries in the setting of untreated or chronic oro-facial pain, a high bleeding index and poor or no plaque control may alert neglect and where appropriate dental care has not been sought despite previous advice received [29]. Under these circumstances, the caries must be contextualized and suspicion for abuse interrogated.

#### *3.4.2 Injury to the soft tissues of the mouth*

The most common abusive injury to the mouth is to the lips resulting in laceration, bruising or swelling of the lips [32, 33]. Intraorally, bruising is the most common form of injury, with lacerations being the third most common [18].

#### *3.4.2.1 Lacerations, bruises and contusions to the soft tissues of the mouth*

Lacerations presenting in the oral cavity and related to physical and sexual abuse may present as tears, penetrating mucosal wounds, cuts through the mucosa and bite marks.

The location of the injury is often the clue and may assist a dental practitioner to distinguish suspicious cases of abuse from the mundane.

Lacerations of the mucosa in the vicinity of the commissure of the mouth could result from gagging with a rope or cloth [34], suggestive of injuries that are often related to forms of physical and sexual abuse. Lacerations to the tongue are also commonly reported [18]. Penetrating injuries to the vestibule, floor of the mouth and more common and less commonly the palate can occur with forcible insertion of objects such as feeding utensils or pacifiers in the mouths of young infants [35].

Laceration may also occur in the form of bite marks with recorded cases of adult bite marks on a child's tongue [36]. A bite mark pattern, generally appearing as a central area of hemorrhage found between markings of the upper and lower dental arches is suggestive of physical or sexual abuse. In the context of the head and neck region, these are rarely reported intraorally but commonly reported on the cheeks of abused children [37].

Lacerations to the upper labial frenum with a tear of the frenum from the inner aspect of the upper lip is an injury that is often quoted as an intraoral injury pathognomonic of abuse based on historical cases reported [13]. Whilst a torn frenum may result from forced feeding, gagging, violent rubbing or a direct blow, recent literature does not support a diagnosis of abuse from the presence of a torn labial frenum

#### *Signs of Child Abuse and Neglect: A Practical Guide for Dental Professionals DOI: http://dx.doi.org/10.5772/intechopen.101564*

in isolation [29]. Contextualizing the situation to discern a suspected case of abuse from that of a non-abuse, such as in the case of a regular bump to the mouth or fall during the years that a child is learning to walk, is important. For instance, a frenal tear in a non-ambulatory neonate (< 1 year), or an older, more stable child (> 2 years) should raise one's suspicion as to the possibility of the injury being nonaccidental [13] and to proceed with a full oral examination to screen for any further potential signs of abuse [32].

Intraoral contusions, ecchymoses and petechiae are commonly found in abuse cases. The location of the bruising, ecchymoses or petechiae may also allude to the presence and nature of abuse. An unexplained erythema, petechiae or ecchymoses at the junction of the hard and soft palate or elsewhere on the palatal mucosa potentially may be as a result of forced oral sex [14]. This bruising is usually nonulcerated and may be a single lesion or be bilateral extending across the midline [38]. There have also been reports of ecchymoses on the alveolar mucosa in conjunction with avulsed teeth [33].

#### *3.4.2.2 Burns*

Burn injuries may be due to electrical, thermal and chemical sources and may represent any of the forms of abuse; being physical and sexual abuse as well as neglect [39]. Damage to the skin usually occurs in temperatures in excess of approximately 49°C and over a sufficient contact time, thereby resulting in mechanisms of cellular damage. It can be extrapolated, that due to the structure of oral mucosa, these burns may be easier to inflict on mucosal surfaces.

In general, injury sustained by burns can be scalds which are thermal contact burns from hot objects or fluids and flame burns. Burns may be inflicted by hot utensils or cigarettes as a sign of abuse and by hot food as a sign of neglect.

Electric burns from cables are also common injuries of infants but a dental practitioner should consider neglect if an electric burn is found in conjunction with any of the other signs mentioned in this chapter.
