The dental treatment of patients who have experienced domestic violence
By Gold Obi, RDH, Adrienne Thuston, RDH, Mandana Talebi, RDH, and Amy Coplen, RDH, EPDH, MS
You could call Loretta a coffee addict. Every day for five years, she grabbed a low-fat, double-shot caramel latte on her way to work. But one morning was different from the others. She was on her way out of the coffee shop when suddenly a deep voice called out to her.
"You forgot your wallet," he said in a British accent-but she was lost for words.
"I'm sorry. Is it not yours?" he continued, trying to catch her attention. She smiled and reached out to grab her wallet.
"I am Mark," he said. "Would you like to sit and keep me company?" His accent and the depth of his voice were appealing. Every word he uttered seem charged with authority. Without hesitation, she sat, and for the next two hours, they talked and laughed. When it was time for her to go to work, she thought the day might be the beginning of her "happily ever after."
Fast-forward a total of four years, past three months of dating, followed by their wedding and the birth of a beautiful baby girl: Loretta is now living in a shelter. Mark started hitting her not long into their marriage. One fateful night, Loretta had had enough of the intimidation and beating. That night, the argument got heated, but Mark was quick to call the police and lie about the situation at home. Mark's lie resulted in Loretta being put in jail and admitted to a psych ward. By the time she returned home, Mark had removed everything from the house, emptied her account, and disappeared with the baby.
After the emotional and physical trauma, Loretta was ready to get her life back together, starting with her health. The first thing she did was schedule appointments with a doctor and a dentist.
The signs of violence
This is where you come in: Imagine that Loretta has entered your office, requesting dental care. As soon as you start a friendly conversation with her, you notice she is timid and shy. Her replies to your questions are short and simple, like she is trying to hide something. She tells you that her last dental cleaning was 10 years ago and that she usually sees a dentist only when she is in pain. Her medical history reveals that her last visit to the doctor was for treatment of a broken finger; her daily medications include an antidepressant and an antipsychotic. She explains that her main concern is pain in her lower jaw and sensitivity to cold.
In performing an extraoral examination, you notice some slight yellow and purple bruising on the lower left side of her face and under her ears. She is hesitant to open her mouth and reports pain upon opening and closing and pain while she is eating. When asked if she has experienced any sort of accident or trauma, she quickly looks away-breaking eye contact-and says that she dropped a box while moving it from a high shelf.
The intraoral exam reveals light purple irregular spots present on her left buccal mucosa, a chipped tooth, and petechiae on the palate. Further inspection reveals that teeth Nos. 18 and 19 have small fractures on the facial surfaces.
While domestic violence can happen to individuals of any gender, one of four women in the United States has experienced severe physical violence by an intimate partner in her lifetime.1 Loretta happens to be one of those women. As Loretta's extraoral and intraoral exams have demonstrated, most physical injuries resulting from domestic violence are found on areas of the head and neck that can be visible to clinicians during dental examinations.2
Common injuries associated with domestic violence include chipped or cracked teeth, poor dental hygiene, a broken jaw, a black eye, a broken nose, bruises on the earlobes or chin, and finger marks on the neck, upper arms, or wrists. While these are common, dental professionals might observe a number of different physical injuries on patients who experience domestic violence.3 With the majority of injuries from domestic violence occurring in the head and neck areas, dental professionals are presented with a prime opportunity to examine patients through assessments. Screening for signs of domestic violence should be as quick and easy as performing a standard, complete extraoral and intraoral exam.
Following the exam, you ask Loretta questions in hopes of getting a history of the injuries. She is unwilling to dispose such vulnerable information and replies, "I'm not sure-maybe." Studies show that individuals who have experienced some form of domestic violence are likely to display low self-esteem.3 Like Loretta, they might avoid maintaining eye contact, make statements of uncertainty, or put the blame on themselves. But sometimes, compassionate care can help (see sidebar).
During assessments, you note that Loretta has moderate calculus, heavy plaque, moderate bleeding, and moderate bone loss. She claims that she is brushing once per day-or when she remembers-and that she does not floss. Emotional distress, such as anxiety, depression, and low self-esteem, can cause a patient to lose interest in self-care, leading to poor oral health.
Individuals experiencing domestic violence are more likely to avoid brushing or flossing and may stop making good nutritional choices, which can mean a more cariogenic diet.3 This can also cause a weaker immune system, which, in turn, can make the patient more susceptible to oral sores and decreased wound healing. Research has shown that significant differences exist between women who reported positive for domestic violence and women who did not in terms of oral hygiene aids used, frequency of tooth brushing, periodontal status, missing teeth, intraoral soft-tissue injuries, and incidence of fracture.3
This is where home-care instruction becomes important.
Providing compassionate care
As dental providers, it is not our job to "solve" a patient's problem. For example, in the state of Oregon, where the authors of this article live, dental providers are-unfortunately-not required to report domestic violence. However, we can provide high-quality, compassionate, and comprehensive care. Providing compassionate care for a patient whose relationship involves domestic violence can feel difficult, but it doesn't have to be.
Eliciting information from a victim
Your goal should be to create a relationship with your patient so that he or she might be comfortable enough to answer your questions with honesty. A survey conducted to find out the needs of this population revealed that 70% of patients who experienced domestic violence would have liked to have been asked about their injuries.2
Simple follow-up questions can help dental providers determine if a patient is in a relationship that involves domestic violence. You could ask:
- "Do you have a partner?"
- "What is one word you would use to describe your relationship?"
- "Does your partner treat you well?"
When asking these questions, pay attention to the patient's body language. Offices should also have a current list of local resources available to give to patients. Providing a list gives the patient options for seeking help.
The key to treatment is recognizing the signs, asking the right questions, and offering quality care, advice, and resources. Documentation is another important factor. Chart notes could be called upon for further review in a court of law, so it is wise to be as thorough as possible and include photos for documentation when applicable. Check your state's mandatory reporting laws to determine what types of abuse require reporting.
Make good use of the time spent with this patient population. Many lack a support system, and some isolate themselves from loved ones, due to guilt, shame, fear, and what they understand to be love. You might have a patient who doesn't have anyone to talk to. Believe it or not, it might be easier for some to talk to a complete stranger than a family member, friend, or acquaintance. Remember, as a health-care provider, your number one duty is to show empathy and compassion through the care you provide. It can't be that hard. After all, the care we give does not hurt and could become a pathway for helping someone exit an abusive relationship.
Gold Obi, RDH, Adrienne Thuston, RDH, and Mandana Talebi, RDH, graduated from Pacific University's dental hygiene program. Obi holds an associate's degree in biology and certification in nursing. During her undergraduate program, she was a distinguished member of Rotary Clubs, an international organization that seeks to bring together professional leaders in order to provide humanitarian services. Thuston holds an associate's degree in general science earned from Mt. Hood Community College. She is a mother of one and is dedicated to upholding her role as a positive role model for her family. Talebi migrated to the United States in 2007 with her family from Iran. Mandana is currently completing her bachelor's degree in dental science. She holds an associate's degree in general science from Portland Community College. Amy Coplen, RDH, EPDH, MS, is an associate professor at Pacific University. She graduated from the University of Michigan. Correspondence can be sent to [email protected].
1. Intimate Partner Violence: Consequences. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Violence Prevention. http://www.cdc.gov/violenceprevention/intimatepartnerviolence/consequences.html. Updated March 3, 2015. Accessed April 20, 2016.
2. Nelms AP, Gutmann ME, Solomon ES, Dewald JP, Campbell PR. What victims of domestic violence need from the dental profession. J Dent Educ. 2009;73(4):490-498.
3. Dourado Sde M, Noronha CV. Visible and invisible marks: Facial injuries suffered by women as the result of acts of domestic violence. Cien Saude Colet. 2015;20(9):2911-2920.