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When oral injuries lead to suspicion of abuse or neglect :

July 31, 2017

Could the bitemarks, swollen lips or severely decayed teeth in your patient be related to child abuse or neglect?

A clinical report from the Academy and the American Academy of Pediatric Dentistry aims to help pediatric and dental providers review the signs and symptoms of the multiple kinds of maltreatment that manifest in the mouth.

Craniofacial, head, face and neck injuries make up more than half of child abuse cases, according to the updated report. New in this version are warnings that victims of bullying and human trafficking also can have oral health conditions indicative of abuse.

Oral and Dental Aspects of Child Abuse and Neglect, from the AAP Section on Oral Health and the Committee on Child Abuse and Neglect, is available at and will be published in the August issue of Pediatrics

Examining victims, collaborating with experts

The report recommends collaboration among health care and dental professionals to help prevent, detect and treat cases. Providers need to know how to document suspicious injuries, obtain laboratory evidence and photo documentation, and consult with experts. Pediatric dentists and oral and maxillofacial surgeons can provide assistance, and a pediatric dentist or dentist trained in forensic odontology can help ensure appropriate testing, diagnosis and treatment.

Recommendations call for providers to examine suspected victims, including children in state custody or foster care, for signs of oral trauma, caries, gingivitis and other oral health problems, which are more prevalent in maltreated children.

Dental neglect, which is a form of child abuse, can be difficult to differentiate from lack of access to dental care, said Anupama Rao Tate, D.M.D., M.P.H., a lead author of the report and a pediatric dentist. The clinical report outlines factors to consider when evaluating for neglect.

Some patients with oral/dental evidence of abuse could be victims of human trafficking or bullying. Often, children with orofacial or dental abnormalities are bullied, which may lead to mental health issues. Children who report being bullied or who have been physically or sexually abused also can have poor dental health.

Clinicians have a role to play in asking children and families how things are going at school, etc., providing the opportunity to bring up bullying, Dr. Tate said. “If nothing else,” she said, “it’s a resource for the child and shows support by opening that conversation.”

Signs, symptoms of abuse

Oral injuries can be inflicted with hands, instruments, scalding liquids or other caustic substances. This may result in contusions; burns or lacerations of the tongue, lips, buccal mucosa, palate, gingiva, alveolar mucosa or frenum; fractured or avulsed teeth; or facial bone and jaw fractures. Trauma to the teeth can cause pulpal necrosis, leaving the teeth with a gray discolored appearance. Gags applied to the mouth may leave bruises or scarring at the corners of the mouth. Lacerations to the oral frena in infants who are not yet walking often are signs of abuse.

“Soft tissue injuries that are subtle in nature — and especially in infants — can be sentinel events or precursor events to larger physical abuse issues or escalate to abuse issues that may well present with more definitive clinical findings,” Dr. Tate said.

“It’s the force-feeding with the spoon, the bottle shoved in the mouth that often escalate to abuse issues,” she said.

While the oral cavity is a frequent site of child sexual abuse, it’s rare to notice visible signs of injury or infection, the report points out. However, unexplained injury or petechiae of the palate may be a result of forced oral sex. If oral-genital contact is suspected, refer the patient to a specialized clinical setting for comprehensive examinations. A multidisciplinary child abuse evaluation for the child and family is recommended.

Bitemarks are challenging to interpret because of the distortion presented and the time elapsed between the injury and the analysis. They should be suspected when ecchymoses, abrasions or lacerations are found in an elliptical, horseshoe-shaped or ovoid pattern. However, it is rare to directly link a bitemark to a perpetrator.


  • Physicians and dentists are among those required to report injuries suspicious for child abuse or neglect. Because abusive injuries often involve the face and mouth, dental providers may be first to detect such problems.
  • Sexual abuse may involve the mouth, and health care professionals must know how to conduct a history and document other evidence to support forensic investigations. Be aware of specialists in the area for specialized forensic interviews and specimen collection.
  • Ask patients about bullying, and advocate for prevention programs.
  • Know risk factors for human trafficking to help identify potential victims (female and male).
  • Work with colleagues to link families to support when maltreatment has occurred.
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