Forensic Science International 159S (2006) S121S125

www.elsevier.com/locate/forsciint

Short communication

Domestic violence: A complex health care issue for dentistry today

John P. Kenney *
DuPage County Illinois Coroners Office, 101 S. Washington, Park Ridge 60068-4290, IL, USA
Available online 20 March 2006

Abstract
As a natural outgrowth of the dental professionals role in recognizing and reporting child abuse the topic has been broadened in recent years to
domestic violence, that is child, spouse/intimate partner, disabled and elder abuse. Forty years ago in the US there were 662 cases of child abuse
reported to authorities. Today that reported number is in excess of 3 million per year [D. Wiese, D. Daro, Current trends in reporting and fatalities;
the results of the 1994 annual 50 state survey, National Committee to Prevent Child Abuse, Working Paper 808, 1995]. The dirty secret of
spousal/intimate partner violence is believed to affect 34 million individuals per year in the US. Studies have also found that between 50 and 70%
of these perpetrators also abuse their children or those of their intimate partner [J. Kessman, Domestic violence, identifying the deadly silence,
Texas Dent. J. (2000) 43].
Just as child abuse is most often manifested in the head or neck regions, likewise the evidence of physical violence to intimate partners and the
elderly can be seen in the head or neck regions. The insidious part of partner and elder abuse is that often the largest component of these behaviors is
psychological, emotional and indirect neglect, which leave no physical evidence [M. Bowers, Forensic Dental Evidence: An Investigators
Handbook, Elesevier, San Diego, CA, 2004, p. 119].
# 2006 Elsevier Ireland Ltd. All rights reserved.
Keywords: Domestic violence; Child abuse; Intimate partner abuse; Elder abuse; Disabled abuse

1. Introduction
The abusive party will use any means necessary to obtain the
control he or she seeks in a given situation. That may be
psychological threats such as harm to children, pets or personal
possessions with a significant intrinsic meaning to the victim.
Humiliation, ridicule, withholding of affection and belittling
are all types of emotional abuse. Financial dependence,
exploitation or isolationprohibition from working in order
to preclude independence from the abuser are also part of a
pattern of control. Social isolation from family or friends, or
monitoring of telephone calls are prevalent. Physical and sexual
abuse includes hitting, slapping, choking, beating, restraining
or forced intimate contact in painful or degrading ways.
The parallels between the various categories of abuse are
always there, and crossover from one victim type to another is
common. Domestic violence is a learned behavior. Just as we
parent the way we were parented, we treat our spouse or elders
the way we saw it happen in our own lives be it as perpetrator or

* Tel.: +1 847 698 2088; fax: +1 847 698 2091.

E-mail address: frnscdds@aol.com.
0379-0738/$ see front matter # 2006 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.forsciint.2006.02.025

accepting adult or child victim. The serial predator perpetrators

of intimate partner violence often seek out the weak and
vulnerable as their partner, because they know they can easily
control, intimidate and exploit the situation. Being partner
abusive when there are vulnerable children also present will
lead to their abuse and exploitation as well. How often we see in
abuse cases, the perpetrator is the paramour.
This paper will present an overview of these types of abuse,
their recognition by the dental health professional and what we
need to do to protect and assist these patients.
2. Domestic or intimate partner violence
It is estimated that between 20 and 30% of women and 7.5%
of men have been physically and/or sexually abused by an
intimate partner at some point in their lives [4]. This is a cycle
that will beget future violence as it becomes a norm for the
children growing up in this setting. Fifty percent of all female
homicides are the result of intimate partner violence [5].
Chronic but often non-specific problems are often reported by
the adult victim. They include headaches, sleep disorders, GI
discomfort and bowel problems, depression, fatigue, anxiety
and post traumatic stress disorder (PTSD). Neurological

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J.P. Kenney / Forensic Science International 159S (2006) S121S125

symptoms can include headache, numbness or tingling.

Specific physical injuries such as dental trauma and head or
neck injuries of any kind without adequate explanation,
defensive injuries on the forearms, presence of multiple injury
sites, especially bilaterally, bruises in various stages of healing,
all point to physical abuse. The victim will often dress in
inappropriate attire such as long sleeved dresses and pants in
hot weather, and oversized dark sunglasses even when it is
overcast. The author has personal experience in his practice
where the mother of a child patient was being badly abused.
They lived in an upper middle class suburb and had a second
home on an island in a resort area about 150 miles away where
the woman would go after a beating to await the bruising to
disappear. It was so well concealed that only after the local
police became involved when a neighbor witnessed an event,
did those who knew the family find out.
The victim of the abuse may not be willing to articulate what
happened, or will offer an explanation inconsistent with the
actual injury. I am clumsy and fell. A tip-off here would be
self denigrating terminology to describe how the injury
occurred. This choice of words might be due to the emotional
abuse such as belittling, or ridicule that accompanies the
physical abuse. The victim has a feeling of hopelessness, that
she and her children, if any, are trapped in the situation. Shame,
embarrassment or guilt can also trigger a responsibility
response for the abuse (I deserved it for being . . .). Religious
beliefs where women are second class, social or immigration
status all can contribute to the problem. Economics also drives
the situation, i.e. if the abuser is prominent in the business or
political community and there is concern that they could
possibly influence the court system. The victims are fearful
of physical retribution from the abuser or their threats, even of
reporting to immigration authorities in the case of illegal aliens,
thus they will often lie or mislead practitioners. The abusive
partner will often beg forgiveness, or offer a gift or attention to
keep the spouse dependent.
In 1996 the American Dental Association enacted a policy to
encourage efforts to educate the dental health professional in
identification of abuse and neglect of adults. In 2001 the US
Department of Justice reported that 85% of intimate partner
violence victims are women, however males in heterosexual
relationships as well as members of the gay, lesbian, bisexual
and transsexual relationship communities have been affected.
In domestic violence, 94% of the victims will show an injury
in the head or neck region [6]. The head and neck area is readily
visible during a dental examination.
What do we look for as symptoms? A presenting history that
conflicts with the clinical appearance of the injury, a history that
is inconsistent, contradictory or vague, the patient who has a
history of repeated accidents or uses a vague/rare illness or
disease process as their explanation. The victim may act
unusually aggressive or withdrawn or exhibit a sudden behavior
change. They will bear signs of previous injuries or have
multiple injuries in various stages of healing. They may recoil
back from a simple touch as part of the examination process.
These victims will come from all educational and socioeconomic levels. Just because you practice in a middle or upper

middle class area does not mean that the dirty little secret of
domestic violence/partner, child or elder abuse does not occur!
A good way of screening patients for domestic violence is
found in the acronym RADAR developed by the Massachusetts
Medical Society and made into a laminated hand out card by the
Illinois Violence Prevention Authority (Table 1): routinely
screen female patients; ask direct questions; document your
findings; assess the patients safety; review options and referrals
for the victim.
The American Dental Association amended its code of
ethics in 1993 to state that dentists shall be obliged to become
familiar with the signs of abuse and neglect and to report
suspected cases to the proper authorities consistent with state
laws In 1996 the ADA enacted a policy to increase efforts to
education dental professionals on how to identify abuse and
neglect of adults [7].
Once the victim has disclosed, and the office has done its
part to inform the patient about what options are available or to
at least provide the telephone number of a shelter or counseling
center for abused individuals (never identify what the phone
number is on the card or piece of paper), they can also be
supportive of the victim by providing free or reduced cost
Table 1
RADAR: screening patients for domestic violence
Routinely screen
Interview patient alone
No partner/relative present
Female assistant in room if male DDS
Simple direct questions
Non-judgmental attitude
Ask direct questions
State that because violence is common in womens
lives we now ask about it routinely
Are you in an abusive relationship?
Ever been hit, kicked, punched by your partner?
I notice you have a number of bruises, did someone do that to you?
Document your findings
Record statement in patients own words
Use assailants name in record if offered
Record pertinent physical findings
Body diagram to document evidence
Photography if indicated and consented
Preserve physical evidence
Document an opinion, i.e. patients statement is consistent/
inconsistent with injuries
Assess patient safety
Is she afraid to go home
Increase in severity/frequency lately of the abuse
Threats of homicide/suicide
Threats to the children
Is there a firearm in the household
Review options and referrals
If in imminent danger, is there a friend or relative who has safe harbor
Need immediate access to a shelter
Have hotline/resource numbers available
Do not force literature on victim; that could become
a trigger for the abusive party
Phone numbers of hotlines in stalls of womens restrooms
Follow up appointment necessary

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dental care. Anterior teeth are often damaged or lost due to

physical abuse. The American Association of Cosmetic
Dentistrys Charitable foundation created a partnership with
the National Coalition Against Domestic Violence for a Give
Back A Smile program that began in 1999. As of late 2004,
280 domestic violence cases had been completed with a value
of over US$ 1 million, and another 167 patients were under
treatment. The Face to Face program conducted by the
American Academy of Facial Plastic and Reconstructive
Surgery began in 1995 to assist victims of domestic violence.
There is a 1 year waiting period after the abusive relationship is
terminated so that the treatment time and effort expended will
not be in vain. There are two exceptions to this program, if the
abuser is deceased or in prison, care can begin immediately
upon acceptance [8].
Statistics vary, but there is a great prevalence of intimate
partner violence. The U.S. Bureau of Justice Statistics
(National Center for Justice 154348) in August of 1995
estimated 1 million women in the US were affected annually.
The American Psychological Association in 1996 put the
number at 4 million in an average 12 month period, and that one
in three adult women experience at least one physical assault by
a partner. Based upon these numbers and the prevalence of this
issue not only in the US but across the world, it is important that
dentistry become aware of this issue, along with the signs and
symptoms.
The Journal of Oral and Maxillofacial Surgery addressed the
issues head on in an article [9] discussing Maxillofacial
Injuries Associated with Domestic Violence. A 5 years
retrospective review was done, covering some 236 emergency
department admissions. According to the study 81% of the
victims presented with maxillofacial injuries. The middle third
of the face was the most frequent target (69%) with soft tissue
injuries making up the most common type (61%). The average
number of mandible fractures per patient was 1.32. Fractures to
the left side of the face were more common (right handed
perpetrators). This data is quite impressive, and again tells us as
dental professionals that we do see this type of injury in our
practice, whether we realize it or not.
3. Elder abuse
It is assumed that elder abuse is at least as prevalent as child
abuse (estimated 3 million cases yearly), however is reported
only half as often. It manifests in all social, educational and
economic groups. The majority of victims are women over the
age of 75 years with one or more physical impairments that
precludes them living alone. Categories of elder abuse are as
follows: passive neglect; psychological abuse; material
(financial) abuse; active neglect; physical abuse.
Passive neglect is where there is an unintentional failure to
fulfill a caretaking obligation. Examples are: failure to provide
food, health related or other services because of the caregivers
infirmity or inadequate skill, knowledge or understanding of the
necessity of prescribed or other essential services.
Psychological abuse is where the caretaker will threaten to
withhold necessary medical appliances such as glasses, walker,

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cane, wheelchair, dentures to intimidate or humiliate their

victim. Also threats or breakage of items very sentimental to the
victim is psychological abuse. Remember that these senior
citizens often have had to drastically downsize their lives into
small apartments or nursing homes, or a bedroom in their
childs home. The few possessions they have kept are very
special to them. Threats of abandonment or precluding medical
care also are psychological abuse.
Material (financial) abuse is the illegal or unethical
exploitation and/or use of funds/property/assets belonging to
the elderly person.
Active neglect is the intentional failure to fulfill a caretaking
obligation. Deliberate denial of food, or health related services,
depriving of dentures or eyeglasses, or deliberate abandonment
all take the psychological abuse to the next level.
Physical abuse is the affliction of physical pain or injury,
physical coercion (confinement against ones will) and/or sexual
abuse.
There are many health conditions in seniors that can be
mistaken for abuse.
They include venous lakes and stasis, or ecchymosis from
medicines. Systemic diseases such as lupus erythematosis or
erythema multiforme, diabetes and peripheral vascular ulcers
or decubitus ulcers (bed sores) all can have legitimate causes.
Malnutrition in seniors is common, and pallor, dehydration and
weight loss are not necessarily an indication of neglect, but may
indicate a tumor or systemic disease.
The types and locations of the physical abuse again seem to
center on the head and neck, as in intimate partner violence. An
interesting point to note is that in situations where the couple
has stayed together in spite of the abuse, often the tables are
turned and the male abuser turns into the victim of the spouse he
abused for years, now that he is dependent and weak.
4. Abuse of the disabled
Another area of concern is abuse of those among us with
mental or physical disabilities. This can make them a
convenient target for not only caregivers but neighbors, and
even fellow students. We recently had an instance in the
Chicago area of a 23-year-old profoundly disabled woman
(cerebral palsy from birth anoxia) who was sexually assaulted
while a resident of a long term care facility. Not only did she
suffer the indignity of the sexual assault, but the pregnancy
went unnoticed by the supervisory staff, even though her
missed menstrual periods and morning vomiting were marked
in her chart and brought to the attention of supervision. It was
not until a staff member felt her stomach move that action was
taken.
In another lesser incident related by the mother of a disabled
patient of this author, another mentally challenged girl of the
same high school was forced into her own locker at school and
locked inside by fellow students who thought it was funny.
Persons with developmental disabilities and other special
needs are abused and neglected at four times the rate within the
general population [10]. The deinstitutionalization of these
individuals away from state run facilities into local community

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based residential facilities has increased the presentation for

care in the average dental office. It is also noted that a higher
incidence of oral health problems are present in mentally
challenged individuals. More than 70% of women with
developmental disabilities are sexually assaulted in their
lifetime. The offenders in many of these cases are those
charged with caring for the disabled individual.
In the US there are both federal and state laws that cover
abuse and neglect of senior citizens and disabled adults.
5. Child abuse
Child abuse continues as a prime concern of health care
providers. Research over the past 40 years has shown that at
least half and up to 75.5% of all physical injury occurs in the
head or neck region [1113]. Neglect of oral health needs, and
sexual abuse all can manifest in ways readily apparent to the
dental health professional [14].
The signs of abuse are the same. There is unexplained injury,
injury that conflicts with the history given by the parent/
caretaker, or an inconsistent, contradictory or vague story.
Patient has a history of repeated accidents or the caretaker/
parent ascribes the cause to a vague or rare disease process.
There is a refusal to cooperate with health care provider to care
for the problem or its root cause. There will be a refusal to
consent to diagnostic testing. Hospital or doctor shopping to
avoid detection is a common thread, and there is usually a delay
of 1224 h in seeking treatment, with an explanation that they
thought it was a minor situation that would resolve. The injury
is usually one where a reasonable person would have sought
immediate or nearly immediate care.
Abusive parents/caretakers are usually isolated from family
support, trust no one, are very reluctant to give information
about the childs injuries, either because they caused them or
the other parent/paramour did and the parent presenting with
the child fears retribution. Those responsible for the childs well
being may be overly critical of the child, do not interact in a
normal fashion with their child and fail to return for routine or
follow up care.
Ninety percent of the abusers are related to the child. They
are usually the primary caretaker, and may be lonely, unhappy
or depressed, and under a great deal of stress. As abuse is a
learned behavior, the abuser was often mistreated as a child, so
considers it a normal behavior. Persons from all educational
and economic levels can be abusive. They see Value in
punishment of the child.
In terms of age, 75% abuse occurs above 2 years of age,
but the majority of physical abuse occurs from birth till the
second birthday, because of the very dependent nature of the
infant/toddler. Under a year of age, it is primarily male children
that are abused, about equal from ages 1 to 12 years and then
above 12 years primarily female because of the prevalence of
sexual abuse.
The targeted children will often appear different physically
or have emotional issues. They will often be unduly afraid of an
unrelated person of the same sex as the abuser. They will have a
generally unkempt appearance. The caregiver will often give

them inappropriate food, drink or medications. The child will

bear signs of previous injury, or exhibit a sudden behavior
change. Other contributory factors will include a perception
that the child is different, they may be hyperactive,
physically or mentally handicapped, or have been a premature
birth
The physical signs of abuse include spiral or greenstick
fractures, multiple fractures of varying ages, skull fractures,
hand and digital fractures, or metaphyseal (growth center)
fractures. Bruising again in multiple locations or of varying
ages, repetitive shapes, finger marks on the victims upper arms
or identifiable patterns such as hand prints, leather belts, loop or
U shaped marks, belt buckle marks or human bite marks all
indicate serious physical abuse is taking place [12].
Hot objects or water may be used to burn a child. High water
marks from forcible immersion, especially with a lack of splash
marks, symmetrical injuries with well defined margins, and
patterned burns such as from a stove grid, or heater, or the
circular burns from a cigarette (1/21 cm diameter) all are
highly suspicious [15].
Hot water from the tap can be very dangerous, even as an
accidental injury. At 155 8F, only 1 s is necessary to produce a
full thickness (second or third degree) burn. Two seconds at
150 8F, 5 s at 140 8F and 30 s at 130 8F. Home water systems
should be kept below 120 8F for maximum safety [16].
Other diagnostic injuries include retinal hemorrhage,
subdural hematoma and subgaleal hematoma, which is
frequently caused by hair pulling. Poisoning or munchausen
syndrome by proxy is another subtle abuse process [17].
Orofacial injuries include a torn labial or lingual frenum,
scarring of the lips, maxillary and mandibular fractures,
fractures or avulsion of teeth, and multiple root fractures or an
unusual (likely trauma induced) malocclusion.
Dental neglect such as untreated but previously diagnosed
dental caries, or rampant caries with multiple abscesses are in
many jurisdictions are grounds for neglect charges with the
appropriate authority [18].
Sexual abuse is usually a progressive action over a long
period of time. It can begin with seemingly innocent actions
and proceeds to a more overt form of sexual content. The sexual
abuser is usually someone well known and trusted by the
victim, such as a parent, caregiver, grandparent, stepparent,
brother, sister, neighbor or friend of an older sibling or parent.
Oral manifestations include evidence of sexually transmitted
diseases (gonococcal phayryngitis/oral syphilis/condolomyta
acuminatum, clinical manifestations of AIDS and petechial
palate, which is caused by fellatio) [19]. A child/teen patient
who in the past has been normal and cooperative is suddenly
extremely fearful of a dental examination should be carefully
screened for possible sexual abuse. They may exhibit subtle
signs such as difficulty sitting or walking, or being alone with
adults of a particular sex [20]. Fear of being reclined in the
dental chair in a vulnerable position is also common [21].
Preventing abuse and neglect through dental awareness, or
PANDA is a wonderful acronym and a program that was
developed by Dr. Mouden of the Arkansas State Department of
Health. Originally conceived as a child abuse prevention

J.P. Kenney / Forensic Science International 159S (2006) S121S125

program, the awareness and emphasis has now evolved to

include all forms of domestic violence [22].
6. Conclusion
Dental practitioners have four Rs of responsibility, they
are recognize, record, report, and refer to protect our patients
and their families from the cycle of violence all to prevalent in
society today.
References
[4] V. Mehra, Culturally competent responses for identifying and responding
to domestic violence in dental care settings, California Dent. Assoc. J. 32
(2004) 387.
[5] B.J. Dattel, R. Chez, Women domestic violence and the obstetrician/
gynecologist, Primary Care Update 3 (1996) 179183.
[6] H.A. Ochs, M.C. Neuenschwander, T.B. Dodson, Are head, neck and
facial injuries markers of domestic violence? J. Am. Dent. Assoc. 127
(1996) 757761.
[7] ADA. 99H-1996. In American Dental Association Transactions, Chicago.
American Dental Association, Chicago, USA, 1996, p. 684.
[8] G. Heintshcel, Give back a smile, AACD charitable foundation. Q&A with
national coalition against domestic violence, J. Cosmetic Dent. 20 (1996)
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[9] B.T. Le, E.J. Dierks, B.A. Ueek, L.D. Homer, B.F. Potter, Maxillofacial
injuries associated with domestic violence, J. Oral Maxillofac. Surg. 59
(1996) 1227.
[10] P. Glassman, C. Miller, R. Ingraham, E. Woolford, The extraordinary
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[11] J.M. Cameron, H.R.M. Johnson, F.E. Camps, The battered child syndrome, Med. Sci. Law 6 (1966) 2.
[12] J.P. Kenney, The incidence and nature of orofacial injuries in child abuse
cases reported by selected hospitals in Cook County, Illinois. Thesis,
Loyola University of Chicago, Chicage, 1977.

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[13] M.A. DeFonseca, R.J. Feigal, R.W. ten Bensel, Dental aspects of 1248
cases of child maltreatment on mile at a major county hospital, Pediatr.
Dent. 14 (1992) 152157.
[14] A.M. Cairns, J.Y.Q. Mok, R.R. Welbury, Injuries to the head, face mouth
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[15] D.H. Clark, J.P. Kenney, Child abuse, in: D.H. Clark (Ed.), Practical
Forensic Odontology, Wright, Oxford, UK, 1992, pp. 139140.
[16] M. Young, Burns Part 1, in: R.A. Alexander, A.P. Giardino (Eds.), Child
Maltreatment, A Comprehensive Photographic Reference Identifying
Potential Child Abuse, GW Medical, St. Louis, 2005, p. 68.
[17] M.D. Feldman, M.S. Sheridan, Muchausen syndrome by proxy, in: R.A.
Alexander, A.P. Giardino (Eds.), Child Maltreatment, A Comprehensive
Photographic Reference Identifying Potential Child Abuse, GW Medical,
St. Louis, 2005, pp. 395397.
[18] L. Mouden, J.P. Kenney, Oral injuries, in: R.A. Alexander, A.P. Giardino
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[19] K. Shanel-Hogan, What is this red mark, Can. Dent. Assoc. J. 32 (2004)
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[20] P. Simon, Oral condlyomata acuminatum as an indicator of sexual abuse:
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[21] C.A. Stalker, D. Carruthers-Russell, E. Teram, C.L. Schachter, Providing
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136 (2005) 12771281.
[22] L. Mouden, The dentists role in detecting and reporting abuse. In current
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Further reading
[1] D. Wiese, D. Daro, Current trends in reporting and fatalities; the results of
the 1994 annual 50 state survey, National Committee to Prevent Child
Abuse, Working Paper 808, 1995.
[2] J. Kessman, Domestic violence, identifying the deadly silence, Texas Dent.
J. (2000) 43.
[3] M. Bowers, Forensic Dental Evidence: An Investigators Handbook, Elesevier, San Diego, CA, 2004, p. 119.