*3.1.4 Injuries at different stages of healing*

Dental professionals need to observe if a pediatric patient presents with any bruises, burns or wounds on the face or body that are at different stages of healing.

The most common presentation on physical abuse that can be observed in children are bruises [11]. Children who have been abused physically tend to experience bruises or injuries on the buttocks, extremities and ears [18, 19], and injuries of soft tissue which do not cover bone [18]. Observations on the face show that the cheeks are indicated to be the most frequently traumatized part in physical abuse [18]. The physically abused child will present with bruises in the shape of a fingertip especially in the neck region which are usually indicative of a "gripping" action [13]. If a child is physically abused with objects such as belts there will be distinctive marks on the skin [12] which can raise suspicions of deliberate injury. A handprint may present as parallel linear spaced marks [11]. Multiple bruises of different colors are indicative of various stages of healing and could be as a result of protracted abuse [12, 20].

**Figure 1** has an illustration of a slap to the cheek. In the drawing one can observe the imprint of one slap to the cheek. The slap forces the blood from the impact site of the fingers and deforms tissues between the fingers [2]. A histamine reaction occurs along the margins [2]. This bruise can last from a few minutes to a few hours or even a day depending on the force of the blow and the resiliency of the child's system [2, 6].

Dental professionals who suspect physical abuse should examine the pediatric patient's head and neck for asymmetry, swelling and bruising; inspect the scalp for signs of hair pulling; check the ears for tears, abnormalities and scars during the extra oral assessment [2, 12]. The dental professional should examine the face for bruises and abrasions that have different colors, which could be an indication of the different stages of healing. The extra oral examination should include observations of any distinctive pattern marks on skin left by objects such as belts, cords, hangers or cigarettes [2, 12]. The dental professional should also observe if there are any bite marks, which could present on the pediatric patient as a result of uncontrollable anger by the adult or another child [12]. Bite marks in areas that cannot be the result of self-inflicted wounds are not usually accidental. The extra oral examination should include assessment of the middle third of the face for bilateral bruising around the eyes, petechiae (small red or purple spots containing blood) in the sclera of the eye, ptosis of the eyelids, or a deviated gaze, a bruised nose, deviated septum or blood clot in the nose [12].

**Figure 2** shows bruises on the skin due to bite marks. In the picture one can observe the distinctive shape of the teeth on the skin with areas of perforation caused by the intensity of the bite being clearly visible.

Physical abuse could also lead to burns as a result of electrical, thermal or chemical substances being used as forms of punishment [11, 20]. In some instances, children could experience accidental burns and it is thus important to determine the age and overall development of the child when analyzing the basis of the injury [11]. Cigarette burns are very unique in appearance [20] and can present as an oval or round lesion 5 mm to 10 mm in diameter [21]. Conversely, other abnormalities such as those triggered by impetigo or varicella could have a comparable form and hence those possibilities should be omitted [11]. A cigarette that has been stubbed out on the body can leave an injury or scar with an uneven outline [21] as demonstrated in the **Figure 3**.

These will most often be explained away as being frequent accidental injuries or accidents. However, it is important to note that certain parts of the body are more

**Figure 1.** *Slap to the cheek.*

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

**Figure 2.** *Bite marks.*

**Figure 3.** *Cigarette burn.*

prone to sustain accidental injuries [21, 22]. These include the knees, elbows, shins, and forehead [22]. It should be noted that protected parts of the body such as the back, thighs, genital area, buttocks, backs of legs, and face, are more common as the sites of non-accidental injury which may constitute physical abuse [22].
