Evaluation of the Orofacial Features in the Victims of Abuse and Neglect of 5-16-Year-old Age Children.

BACKGROUND: Oral cavity may be considered a pivotal focal point in physical assault or abuse because of its implication in communication and nutrition. Dentists trained in a child abuse curriculum can provide valuable information and assistance to physicians about oral and dental aspects of child abuse and neglect. The present study was conducted to evaluate the orofacial features of children between the age group of 5-16 years suspected to be victims of child abuse/neglect.
MATERIALS AND METHODS: This study was conducted on 250 children ranging between 5 and 16 years were enrolled in the study. All the participants were suspected to be victims of child abuse/neglect. The orofacial features were carefully examined by a well-trained dentist.
RESULTS: Two hundred and fifty children were enrolled in the study. Seventy-two children (30%) presented with laceration of various sites including lip (n = 13), frenum (n = 8), buccal mucosa (n = 26), palate (n = 16), and floor of the mouth (n = 9). Twenty-nine participants exhibited the features of avulsion (11.6%). Eighteen children revealed dento-alveolar fractures, 104 presented with dental caries (41.6%), 19 presented with missing teeth (7.6%), all the candidates presented with deposits (100%).
CONCLUSION: Careful intraoral and perioral examination of the participants victimized to abuse and/neglect is necessary as the oral cavity is a central focus for physical abuse, which may be allied to its importance in communication and nutrition. Physicians and dentists should work together to increase the prevention, detection, and treatment of these conditions. Copyright:

INTRODUCTION

Child abuse, malocclusion, and dental caries are believed to be the most prevalent issues affecting children globally. Child abuse may be defined as any act of commission that imperils or impairs a child's physical, sexual or emotional health, and development.[1] Violence may be defined as an act or omission by parents, relatives, guardians, society resulting in physical, sexual, and emotional damage to victims.[2]

Child maltreatment has been defined as “all forms of physical and emotional ill-treatment, sexual abuse, neglect, and exploitation that results in actual or potential harm to the child's health, development or dignity.” by the World Health Organization. Abuse may broadly be classified into four types, namely neglect, physical abuse, psychological abuse, and sexual abuse. Maltreatment of children is one of the most powerful risk factors for contemporaneous psychopathology, morbidity, and retarded development.[3]

Indian subpopulation has been reported to have world's highest number of working children along with world's largest number of children subject to sexual or physical abuse. The incidence of children subjected to abuse reported for hospitalization is usually 2%–10%; however, it may vary as it is concealed both by the perpetrators and the victims. A clinical condition, considered as a frequent cause of permanent disability or death is the “battered-child syndrome” characterized by evidence of fracture of any bone, subdural hematoma, failure to thrive, soft-tissue swellings or skin bruising, in a child who dies unexpectedly, or where the degree of injury is at dissent with the trauma history. This condition was coined by Dr Henry Kempe in 1962.[4]

Studies have consistently reported that at least 50% of physically abused children show signs of orofacial abuse, including abrasions or bruising of tongue, lips, oral mucosa, hard and soft palate, gingiva, alveolar mucosa, frenum; dento-alveolar injuries, avulsions, jaw fractures, burns, and “tattoo” injuries. Neglected children may also report with signs of poor oral hygiene such as halitosis, untreated dental caries with progression, odontogenic infections, plaque and calculus deposits, aphthous ulcers as a result of a nutritional deficiency.[5] These detrimental outcomes may adversely affect learning, communication, normal growth, and development of these children.

Oral cavity may be considered a pivotal focal point in physical assault or abuse because of its implication in communication and nutrition. Lips may exhibit lacerations, hematoma/ecchymosis, burns caused by hot food or cigarettes. Abrasions or lacerations of the frenum, gingiva, tongue, palate, and floor of the mouth may be caused by food or burning utensil. Teeth may exhibit pulpal necrosis, fractures, dislocations, avulsions, or mobility. Jaw fractures may be characterized by fracture of the condyle, mandibular ascending ramus, mandibular symphysis, nasal bone, zygomatico-maxillary complex, orbit, etc.[6]

Dentists trained in a child abuse curriculum can provide valuable information and assistance to physicians about oral and dental aspects of child abuse and neglect.

The present study was conducted to evaluate the orofacial features of children between the age group of 5–16 years suspected to be victims of child abuse/neglect in the Indian population.

MATERIALS AND METHODS

This study was conducted on 250 children who attended the outpatient department. Two hundred and fifty patients ranging between 5 and 16 years were enrolled in the study. All the participants were suspected to be victims of child abuse/neglect. The orofacial features were carefully examined by a well-trained dentist. The following features were evaluated: laceration, avulsion, dento-alveolar fractures, decayed, missing teeth, and deposits. The study was approved by the Research Ethics Committee and a signed consent was obtained from every participant's parent/guardian or witness.

All the data were recorded in a master chart; mean, frequencies, standard deviations, and medians were calculated. The numbers of injuries in conjunction with other orofacial features were cross-referenced using Chi-squared test or Fisher's test. SPSS software SPSS 22; SPSS Inc., Chicago, IL, USA was used for the analysis.

RESULTS

The present study was conducted on 250 children ranging between 5 and 16 years of age group. All the children were subjected to abuse or neglect. One hundred and thirty-one out of 250 (52.4%) were boys, whereas 119 (47.6%) were girls. Seventy-two children (30%) presented with laceration of various sites including lip (n = 13), frenum (n = 8), buccal mucosa (n = 26), palate (n = 16), and floor of mouth (n = 9). The mean, median, and standard deviation of laceration for children between 5 and 10 years of age group were 2.26, 8, and 0.9096, respectively. The mean, median and standard deviation of laceration for children between 11 and 16 years of age group was 2.25, 8.1, and 0.7808, respectively.

Twenty-nine participants exhibited the features of avulsion (11.6%). The mean, median, and standard deviation of avulsion for children between 5 and 10 years of age group was 1.002, 8, and 0.7473, respectively. The mean, median, and standard deviation of avulsion for children between 11 and 16 years of age group were 0.96, 8.8, and 0.6381, respectively.

Eighteen children revealed dento-alveolar fractures. The mean, median, and standard deviation of dento-alveolar fractures for children between 5 and 10 years of age group were 0.872, 8.3, and 0.5999, respectively. The mean, median, and standard deviation of dento-alveolar fractures for children between 11 and 16 years of age group were 0.336, 8.6, and 0.3741, respectively.

One hundred and four presented with dental caries (41.6%). The mean, median, and standard deviation of dental caries for children between 5 and 10 years of age group were 3.24, 8.1, and 1.3568, respectively. The mean, median, and standard deviation of dental caries for children between 11 and 16 years of age group were 3.76, 8.15, and 1.6874, respectively.

Nineteen presented with missing teeth (7.6%). The mean, median, and standard deviation of missing teeth for children between 5 and 10 years of age group were 0.546, 7.4, and 1.0513, respectively. The mean, median, and standard deviation of missing teeth for children between 11 and 16 years of age group were 0.84, 7.2, and 1.3494, respectively.

All the candidates presented with deposits (100%). The mean, median, and standard deviation of plaque deposits for children between 5 and 10 years of age group were 7.927, 8, and 0.7811, respectively. The mean, median, and standard deviation of plaque deposits for children between 11 and 16 years of age group were 8.02, 7.9, and 0.2965, respectively [Tables 1 and 2].

Table 1

Pathological conditions in children aged 5-10 years (n=124)

	Laceration	Avulsion	Dento-alveolar fracture	Decayed teeth	Missing teeth	Plaque deposits
Mean	2.26	1.002	0.872	3.24	0.546	7.927
Median	8	8	8.3	8.1	7.4	8
SD	0.9096	0.7473	0.5999	1.3568	1.0513	0.7811
Variance	0.8273	0.5584	0.3588	1.8237	1.1078	0.6102
t-test	0.0743	−0.334	0.5086	1.1641	0.4121	−0.3449
P	0.66

SD: Standard deviation

Table 2

Pathological conditions in children aged 11-16 years (n=126)

	Laceration	Avulsion	Dento-alveolar fracture	Decayed teeth	Missing teeth	Plaque deposits
Mean	2.5	0.96	0.336	3.76	0.84	8.02
Median	8.1	8.8	8.6	8.15	7.2	7.9
SD	0.7808	0.6381	0.3741	1.6874	1.3494	0.2965
Variance	0.6096	0.4071	0.1399	0.4725	0.1291	1.6645
t-test	−0.1845	−0.8375	−1.1952	0.3247	−0.3857	−1.5937
P	0.52

SD: Standard deviation

DISCUSSION

The present study was conducted on 250 children ranging between 5 and 16 years of age group. All the participants had a history of being subjected to abuse and or neglect. Oral cavity is alleged to be a central focus for physical abuse, which may be allied to its importance in communication and nutrition. The injuries may by inflicted by the use of a sharp or blunt instrument, utensils, hands or fingers, sweltering, or caustic substances. Face, head, and intraoral sites are commonly affected in the craniofacial region which may occur in the form of ecchymoses, lacerations, and contusions.[7]

Major chunk of population in our study presented with laceration of buccal mucosa followed by palate, lip, floor of mouth, and frenum. Our results were in concordance with a study conducted by Naidoo who conducted a retrospective study to determine the injuries associated with 300 child abuse cases in the Cape Town, South Africa. It was found that head, face, neck, and mouth were the sites of injury in 67% of the 300 cases reviewed. The face was the most frequently injured (41%) part of the body, with the laceration of cheek being the most common site for the injury.[8]

11.6% of the participants presented with tooth avulsion. Dua and Sharma on 880 children in the age group of 7–12 years found the following orofacial features: Enamel fracture in 50% study population followed by crown fracture without pulpal involvement in 20.3%, crown fracture with pulpal involvement in 13.2%, avulsion in only 4.6%, and nonspecific fracture in 11.9%.[9] Tooth avulsion, also referred as exarticulation, is a traumatic injury characterized by complete displacement of the tooth out of its socket. It is frequently seen in the age group of 7–14 years, and permanent maxillary central incisors are the most commonly affected teeth. Avulsion in children subjected to abuse may be seen a result of fall on the anterior maxilla or face allied to push or trauma inflicted by the perpetrators.[10]

7.2% of the study population exhibited dento-alveolar fractures. It is a fracture of the facial bones involving a segment of the alveolus as well as the associated teeth. 41.6% participants presented with the presence of decayed teeth and almost all had the presence of deposits reflecting poor oral hygiene. A literature and narrative review conducted by Melo et al. to determine the knowledge of dentists in reporting child abuse. It was reported that the main orofacial signs found were the presence of caries; increased dental plaque and gingival inflammation scores reflecting the close association between abuse and/or neglect and poor oral hygiene and heath.[11]

Montecchi et al. conducted a study on the dental health of children who were victims of abuse and were referred to the neuropsychiatric unit of the pediatric hospital in Rome. It was demonstrated that the “abused” group had significantly higher dental plaque index, gingival inflammation, and untreated decay than the other groups.[12]

Child neglect is defined as obstinate failure of parents or other people in a position of trust to provide basic child-needed care. The American Academy of Pediatric Dentistry defines dental neglect as failure of caregivers to provide basics of appropriate oral function through seeking dental treatment services necessary to alleviate pain and infection.[13]

The clinical presentation of victims subjected to neglect include untreated caries, aphthous ulcers involving various intraoral sites which could be attributed to nutritional deficiencies, deposits, halitosis or bad breath, and poor oral hygiene in the existence of pathological conditions. These children may suffer difficulty in eating due to pain, infection, loss of oral function, disrupted sleep, malnourishment, poor performance in school, low self-esteem, and impaired quality of life. These may in turn have deleterious effects on nutrition, learning capacity, normal growth, and development.[14]

CONCLUSION

Careful intraoral and perioral examination of the participants victimized to abuse and/neglect is necessary as oral cavity is a central focus for physical abuse, which may be allied to its importance in communication and nutrition. Physicians may not be able to detect orofacial aspects of child abuse/neglect as they receive minimal training in detecting oral disease and dental injury. Dentists trained in a child abuse curriculum can offer important information to physicians about oral and dental aspects of child abuse and neglect. Therefore, physicians and dentists should work together to increase the prevention, detection, and treatment of these conditions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.