Physical Abuse

Figure 1.

Figure 1.

Child-on-child attack with possible multiple bitemarks sustained at a day care facility.

Physical abuse may result in numerous types of injuries including contusions, ecchymosis, abrasions, lacerations, fractures, burns, bites, hematomas, retinal hemorrhaging, and dental trauma. Head and orofacial injuries for which dentists should be alert include:

• Head Injuries^8-10

  • Scalp and hair – subdural hematomas (cause more serious injuries and deaths than any other form of abuse), traumatic alopecia, subgaleal hematomas, and bruises behind the ears

  • Eyes – retinal hemorrhage, ptosis, and periorbital bruising

  • Ears – bruising of the auricle and tympanic membrane damage

  • Nose – nasal fractures or an injury resulting in clotted nostrils

Figure 2.

Figure 2.

Facial injuries of child abuse victim. These images represent classic signs of abuse that should be explored, documented and reported to child protective services.

Figure 3A.

Figure 3A.

Child abuse homicide victim with facial, oral and peri-oral injuries.

Figure 3B.

Figure 3B.

Same victim in Figure 3A with injuries photographed using 425nm blue light narrow band illumination highlighting the extent of the massive bruising the child sustained before dying.

The oral cavity is thought to be a central focus for physical abuse because of its significance in communication and nutrition. Injuries to the mouth can be inflicted with utensils and bottles from forced feedings. Hands, fingers, scalding liquids, or caustic substances may also be used to cause harm. The following are some examples of orofacial abuse that may be observed.

• Orofacial Injuries^9,11,12

  • Lips – lacerations, burns, abrasions, or bruising

  • Mouth – labial or lingual frenum tears (characteristic of more severely abused children), burns, ecchymosis or lacerations of the gingiva, tongue, palate, or floor of the mouth

  • Maxilla or mandible – past or present fractures to facial bones, condyles, ramus, or symphysis of mandible. Malocclusion or temporomandibular joint limitations may be a result of this type of injury

  • Teeth – pulpal necrosis, fractured, displaced, or avulsed teeth

Figure 4.

Figure 4.

Child abuse homicide victim with burns on the chin and other facial injuries.

Figure 5A.

Figure 5A.

Torn labial frenum on a child abuse homicide victim.

Figure 5B.

Figure 5B.

Torn labial frenum on a child abuse homicide victim.

• Bite marks

  • Many times misdiagnosed as simple childhood bruises but often associated with physical or sexual abuse

  • Typically in an elliptical, horseshoe, or ovoid pattern

  • A central area of hemorrhage, may be found between markings of the upper and lower dental arches, suggesting physical or sexual abuse

  • Animal bites tend to tear flesh, whereas human bites compress tissue

  • Although marks may occur anywhere on a child’s body, the most common sites are the cheeks, back, sides, arms, buttocks, and genitalia

  • In addition to making a mandated report in a case where bite marks are indicative of abuse, the general dentist should include a recommendation for further evaluation by a forensic pathologist or odontologist.^13,14

Figure 6.

Figure 6.

Child-on-child attack at a day care leaving possible pediatric bitemark on victim.

Figure 7.

Figure 7.

Child abuse victim with fracture left arm, facial injuries and a patterned injury on the right shoulder. This child survived the attack.