*3.4.3 Injuries to the dentition*

Injuries to the dentition related to physical abuse frequently present as fractured or avulsed teeth. This may be in setting of other soft tissue (lacerations, bruising) or hard tissue injuries (dento-alveolar fractures, skeletal fractures) or in isolation. Damage to the primary or permanent teeth can be due to blunt trauma [14, 33, 35]. Due to fractured or avulsed teeth commonly occurring with accidental injury in children, it is important to verify the explanation of the injury between the caregiver and the child, but also to look out for other signs such as other discolored teeth, inappropriately missing teeth and in the setting of any other sign of abuse [28].

#### *3.4.4 Injuries to the facial bones*

The dental practitioner is one who would be the first health professional to detect fractures, dislocations, avulsions or mobility related to teeth or within the jaws that are pathologic [28]. Furthermore, the mandible and maxilla can often show early, or previous fracture signs localized to the condyles, mandibular ascending ramus and mandibular symphysis which should alert to abuse [40]. It is important to screen for any previous fractures of teeth or the jaw bones and evidence of dental malocclusions as a result of a previous trauma.

#### *3.4.5 Pathological lesions*

The dental practitioner may be focused on diagnosing and managing the condition but may overlook the circumstance in which the condition occurs, and in turn overlook a lesion suggesting abuse.

Sexually transmitted infections in children are rare and their oral manifestation may suggest oro-genital contact and alert the practitioner to the suspicion of sexual abuse. Oral and peri-oral gonorrhea in children is pathognomonic of abuse [14] and may present as erythema, pharyngitis or itching but is often asymptomatic [40]. Gonococcal infection is more likely to be suspected and investigated in the setting of the more common manifestations of gonococcal infection such as those that are found in the urogenital or rectal region [40].

Whilst an HPV-induced infection of the oral cavity is transmitted through sexual contact, amongst children at pre-primary school, HPV spread may be due to close contact or sharing of utensils [41]. There are several oral lesions seen namely: Oral squamous cell papilloma, multifocal epithelial hyperplasia, verruca vulgaris and condyloma acuminatum are some of the oral lesions associated with HPV infection [41]. Condyloma acuminatum is spread via sexual contact and when it occurs in children, it alerts to possible sexual abuse [41]. Oral condylomas develop at the site of oro-genital sexual contact and are found commonly on the tongue, gingiva, soft palate and lips. Classically, the lesions present as broad based (sessile) exophytic masses with blunt projections [5, 41]. The other HPV-induced lesions listed above may not be as suggestive, however abuse should always be a consideration in their presence.

Manifestations of syphilis are less prevalent in abuse cases than other sexually transmitted infections such as gonorrhea and HPV-induced lesions, however, transmission of syphilis outside the neonatal period is almost always due to sexual abuse [41]. Syphilis in children manifests the same as it does in adults with presentations in three different phases [41]. The dental practitioner should thus be sensitive to lesions such as syphilitic chancres, mucous patches and condylomata lata that may indicate abuse [42].

#### **3.5 Documentation and record keeping**

Dental professionals should ensure that they document and make notes in patients' files on any deviations from the norm. Detailed information should be recorded in the dental file along with images and x-rays of the injuries [27, 43]. Information gathered in the dental record should include the time and date of the dental data i.e. radiographs and photographs [43]. In order to gauge size for records, a measurement scale ruler should be placed alongside an injury or bite mark when taking photographs [43]. In order to prevent distortion and give a more precise representation of the actual size of the injury, the camera lens should be held directly over the bite and perpendicular to the plane of the bite mark [20, 27]. The site, appearance, phase of healing and severity of the injury should be accurately and comprehensively recorded [13, 19, 20]. Each entry should be dated and signed. Diagrams for recording purposes are also useful [19]. It is important that handwriting on written documents is legible and that no abbreviations are used [19]. Wherever possible, information collated should be in the child, guardian or parent's own words [19].

Finally, it is imperative that consent should be acquired prior to collecting dental records and taking photographs. The pediatric patient has the right to exercise their voluntary participation and refuse photographs be taken and this refusal should be respected [19, 43]. The important factor to be noted is that such a refusal should be documented in the pediatric patient's file [19, 43].

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

In terms of appropriate referrals – this should be immediately done for the management of any injuries or lesions that are outside the scope of the consulting dental practitioner [21]. If child abuse is suspected, referrals should be made before discussing the issue of abuse with the parents. Making referrals after a discussion with parents or caregivers may negatively impact the treatment that the child receives as parents or caregivers may feel threatened [21]. Physicians and dental practitioners are obligated to detect cases of maltreatment or neglect, to meticulously and comprehensively document, to refer for appropriate treatment and to notify the relevant authorities as soon as possible [44].
