Domestic Violence in Dental Care Settings Oral Health Providers Can Help Victims Through Proper Screening, Support and Identifying Options

CDA Journal Volume 32, Number 5 Journal may 2004

departments 361 The Editor/The New Reality 365 Impressions/USC Oral Health Center Projects Fresh Concepts in Dental Design 434 Dr. Bob/Frill-Free Dentistry … And Don’t Forget Your Own Bur features 375 Making a Difference An introduction to the issue. Kathleen A. Shanel-Hogan, DDS, MA; Jon Roth, MROD, CAE; and Marianne Balin, MPH

379 The Extraordinary Vulnerability of People with Disabilities: Guidelines for Oral Health Professionals Knowing what, where, and how to report suspected cases is essential for every dental practice. Paul Glassman, DDS, MA, MBA; Christine Miller, RDH, MHS, MA; Rick Ingraham; and Emily Woolford, BA

387 Culturally Competent Responses for Identifying and Responding to Domestic Violence in Dental Care Settings Oral health providers can help victims through proper screening, support and identifying options. Prepared by Vibhuti Mehra on behalf of the Family Violence Prevention Fund

399 No Place for a Smile: Domestic Violence By asking a few well-placed questions, dentists can confirm the presence of domestic violence and set the stage for positive intervention. Casey Gwinn, JD; George E. McClane, MD; Kathleen A. Shanel-Hogan, DDS, MA; and Gael B. Strack, JD

410 Forensic Odontology: A Global Activity Observation of a pattern mark or injury should be properly documented and presented to experts for analysis. George A. Gould, DDS

416 Dental Reimbursement: Helping Victims Smile Again Dental care made possible through compensation can help victims begin the healing process. Catherine A. Close, JD The Editor Jack F. Conley, DDS

The New Reality

entistry has come a long way would-be victim and considerable from its beginnings. We are dislike for this dentist who also has immersed in issues such as a somewhat evil facial expression. access, an emphasis on pre- Another portrait in sepia tones vention, and a marvelous in Ring’s text shows one of our array of new technologies to professional predecessors with his utilizeD in the treatment of patients. For this hand extended inside a wide- reason, it is sometimes hard to realize how stretched mouth. The picture has a far the profession has come in erasing from banner-like caption at the bottom memory those parts of our history that proclaiming, “The Tooth Ache or graphically associated pain and discomfort Torment and Torture.” This cap- with a trip to the dentist. tion ably characterizes the attitude However, while uncomfortable states that many in society probably har- of oral health still exist and are responsi- bored toward our predecessors. We ble for bringing some patients to the den- believe such depictions of the dental office only out of necessity, they no tist were probably the rule rather longer predominate the attitude of what than the exception in earlier times. dentistry is, or can be to the average per- Periodically, Hollywood has done its son. Let us explain. part to present profiles of our profession In earlier times, dentists were frequently that among a wide variety of possibilities depicted in art as purveyors of pain and suf- may have provided comic relief or con- fering, contributing to a less than savory veyed evil intent. Many of us have dis- reputation. Sometimes, dentists have also cussed these assaults on the dentist from Reality been the target of humorous parodies in time to time, wondering why our profes- film, perhaps less damaging to the psyche, sion, seemingly more often than others, has television may but nonetheless disturbing to the consum- been forced to bear the brunt of less than play a significant mate professional. flattering characterizations, either of the We recall a caricature in Malvin Ring’s profession itself or of the idiosyncrasies of role in changing excellent volume, Dentistry: An Illustrated individual professionals. Perhaps in con- History, which depicts one of our profession- temporary times it has been of some conso- the decades-old al predecessors in a superior position to a lation that the attorney has been increas- attitudes about seated patient with mouth stretched wide ingly replacing the dentist at the center of open. The dentist has one foot on the societal humor. dentistry. patient’s chest; the other balanced on the In this space from time to time, we have seat of the four-legged chair as he is aggres- discussed the image of the profession. sively leveraging a forceps or a primitive Image deals with respect and reputation instrument around a tooth. A nearby female achieved by the profession and its contri- patient-in-waiting appears to be holding her butions to society. What we are talking swollen jaw, either out of personal discom- about here is somewhat different. It is more fort, or out of sympathy for the unfortunate about attitude than it is about image. And soul in the chair. A contemporary viewer of what we are seeing at the present time, is a this well-drawn artistic rendering might real opportunity for a change in attitude express great sympathy for the “victim” and toward dentistry, courtesy of, you guessed

MAY.2004.VOL.32.NO.5.CDA.JOURNAL 361 The Editor

it, Hollywood! If early interest is any guide, put the patient at far greater ease in their reality television may play a significant role goal-setting decision process. An improved in changing the decades-old attitudes about smile provided by dental treatment may be dentistry we have just described. one of the most noticeable and therefore At the outset, we must offer a dis- most desirable incentives to be attained in claimer. This writer is not a fan or aficiona- a total cosmetic treatment package. do of reality television or the weekly series We believe that this real-life exposure to titled “Extreme Makeover.” However, if any dental treatment as part of an extreme of us has had the opportunity to view even makeover plan could promote a significant one episode of this series that includes a long-term change in societal attitudes dental “makeover,” we should be able to toward dentistry. Because of the improved understand the potential this show has to self-esteem patients will achieve as a result It is about convince the populace that dentistry (and of the effort put forth by the dental profes- treatment dentists) can open exciting new opportuni- sional, we believe dentistry will be accorded ties for even the average person. It is not a higher level of respect in the future. that can about relief of pain or maintaining good The services provided in these oral health. It is about treatment that can “makeovers” shouldn’t be considered bring about bring about a massive change in self-esteem reparative or oral health-centered. Nor are a massive for those who seek it. they purely cosmetic. Many dental col- From what we have been hearing, the leagues may be uncomfortable with the change in dental treatment shown in this series has promotion of this type of dental service. created great interest, despite the severity, However, the value to the individual who self-esteem the cost, or any associated risks of treat- seeks this kind of treatment will transcend for those ment. Many will seek the benefits it offers, the cosmetic label or the allegations of despite the costs or risks. At the same time, commercialism of the practitioner that who seek it. we must remember that in the past, and might be forthcoming from critics within even in the present, there are some individ- the profession. In the past, television uals who will continue to endure oral dis- newsmagazines have featured subjects comfort rather than pursue treatment they unfavorable toward dentistry such as believe may provide a painful experience. It Death in the Dental Chair, The Dangers of is a matter of attitude. Mercury in Dental Amalgam, and The Threat The real-life “makeover” vignettes have of AIDS Transmission in the Dental Office. been showing that an objective of Instead, a national television audience is improved appearance and self-esteem now being exposed to dental treatment becomes far more important than any of considered to be of great value to the self- the associated risks or of the downsides, esteem of those who seek and receive it. such as post-operative discomfort or recov- It is clear those who will have the great- ery. It is also significant that the dental est interest in the benefits to be achieved treatment is only a small part of a treat- from such a treatment plan are women. Not ment plan that does involve more serious coincidentally, women are responsible for medical and surgical procedures. In such a making a majority of dental appointments! situation, the dental treatment may be A simple, reality-based television considered a less risky, less painful compo- program that may help to positively nent. Of course the improved technology, change existing negative societal atti- materials, and management that contem- tudes toward dentistry? Stranger things porary dentistry can offer can also help to have happened! CDA

362 CDA.JOURNAL.VOL.32.NO.5.MAY.2004 Impressions Photos: Steve McClelland Photography

“The 12,500 Fresh Concepts in square-foot facility “looks Dental Design like

today, ecently celebrating its one- the center that delivers dental care to not year anniversary, the USC approximately 150 patients a day. R School of Dentistry Oral According to USC Dean Harold Slavkin, yesterday.” Health Center serves as a DDS, the 12,500 square-foot facility “looks model facility designed to like today, not yesterday.” attract quality faculty, increase student Slavkin came to USC with a grand design enrollment and take the anxiety out of to recruit and retain top faculty by providing going to the dentist. a private-practice environment offering high- A waterfall, stylish wood paneling, indi- quality care focused on restorative and cos- rect lighting and concierge greet visitors to metic dentistry. An equal goal was to create a

MAY.2004.VOL.32.NO.5.CDA.JOURNAL 365 model center for the highest which reinterprets the cam- level of care and make it pus’ traditional design in a Slavkin’s accessible to the surround- modernist way favoring ing community as well as exploration of new materi- directive was the university community. als, ample space, fresh color to “design According to Slavkin, pallets and seamless integra- there has been a conceptu- tion of technology and beau- a state-of- al shift in the way dentistry is practiced ty. To create an optimal patient experience, the designers dedicated special attention to the-art faculty today. In the past, dentists were trained to diagnose quickly and spend significant time creating inviting visual elements, soft light- dental practice on treatment. Now, an ounce of prevention ing, acoustics and visual privacy. goes a long way. A large concern was to alleviate patient with the “We take a very careful, detailed fear that can be aggravated by shrill noises ambiance and approach to health promotion, risk assess- and pungent odors. Care was given to low- ment, disease prevention, diagnostics, treat- ering patient anxiety through design ele- service of a ment and therapeutics, and outcomes ments such as strategically placed foun- tains, vaulted ceilings, soft lighting and tex- Ritz-Carlton assessments,” Slavkin said. The 21st century is about health outcomes. To ensure the best tured walls. Hotel.” outcomes, facilities need state-of-the-art Directing the new center is former CDA equipment, optimal patient experience and President Jack Broussard, DDS. Former CDA proper technology to support administrative Speaker of the House Sig Abelson, DDS, is management. practice administrator. These individuals To support a vision of this scale, bring more than 60 years of combined prac- the school of dentistry needed a tice management experience and leadership more appropriate venue to house skills to the center. both a group faculty practice and “Our patients are in awe of the beauty an Advanced Education in General of the center,” Broussard said. “Our faculty, Dentistry teaching clinic under one residents and staff are committed to becom- roof. What’s more, the center would ing a valued asset to our community and to function in concert with the current our university.” teaching and leaning agenda of The center includes features such as dig- the school of dentistry, which includes ital imaging equipment, digital radiogra- health promotion, risk assessment and dis- phy, microscopes and intra-oral cameras. ease prevention. Current data on caries prevention and The challenge was to turn an ordinary strategic design focused on patient relax- space into an aesthetically beautiful and ation are all touches expected to help attract nurturing environment, yet make it func- quality faculty as well as increase student tional enough to house 24 operatories, diag- enrollment and enhance the equity of the nostic equipment and a planned Center for downtown Los Angeles area. Dental Technology. “In just one year, the center has Slavkin’s directive was to “design a state- increased its practicing faculty from 13 to 27 of-the-art faculty dental practice with the individuals.” Abelson said. “Some of the ambiance and service of a Ritz-Carlton Hotel.” finest clinicians in the world have joined our The Neiman Group, a Los Angeles-based faculty practitioners.” architectural firm, was selected to bring The center opened its doors in January Slavkin’s vision to life. The firm’s influence 2003 and has successfully integrated into led the university down a new stylistic path, the Los Angeles health-care community.

366 CDA.JOURNAL.VOL.32.NO.5.MAY.2004 Managing the Amelogenesis Imperfecta Patient

A rare developmental abnormality of enamel thickness and degree of mineraliza- the tooth enamel, amelogenesis imperfecta tion, and the ability of restorations to bond (AI) patient occurs in about 1:4,000 to sufficiently to the affected enamel; as well as 1:14,000 people in the Western populace. the strength of attachment of the enamel to Dental features associated with the condi- dentin and dentin quality. tion range from pulpal calcification, tau- The article further notes that children rodontism and root malformations, quan- and young teens can display the gen- titative and qualitative enamel deficien- eral features of AI, but may not be cies, failed tooth eruption and impaction similar in young adults where caries of permanent teeth, congenitally missing and noticeable sensitivity may result teeth, anterior and posterior open-bite from widespread exposed dentin in occlusions, as well as progressive root and permanent teeth. crown resorption. G In an article in The International h Journal of Prosthodontics, managing e AI patients can be complex. That is c why authors suggest that those in the prosthodontic profession can A have a major role in the rehabili- tation of rare disorders. B Among the recommendations is that treatment of AI patients should begin with early diagnosis and intervention to prevent later restorative d problems. The authors acknowledge some patients might not seek treatment until later when advanced tooth wear and the associated tooth Illustration: Matt Mullin sensitivity, functional and esthetic problems have already occurred, leading to numerous years of complex restorative treatments. Tax Credit Available for Disabled Access Authors noted that poor oral hygiene associated with gingivitis and gingival Dental practices, like all small commercial enterprises, are entitled to a non- hyperplasia may be factors adversely refundable disabled access federal income tax credit for expenses incurred in affecting restoration management. Poor making a business accessible to the disabled, according to consultant Milt Zall oral hygiene may stem from tooth hyper- in the January/February 2004 issue of Chicago Dental Society Review. sensitivity and the presence of an anterior The credit is half the amount of eligible access expenses for a year that open-bite associated with breathing exceeds $250 but under $10,250. An eligible small business is one that claims the through one’s mouth. disabled access credit and during the preceding tax year had either gross receipts When performing restorative work on AI (minus allowances and returns) of $1 million or less or no more than 30 full-time patients, aspects to contemplate include loss of occlusal vertical dimension and degree of employees. dentoalveolar compensation; size of the pulp Qualified expenses include the cost of removing architectural, transporta- chambers and amount of occlusal and inter- tion or communication obstacles preventing disabled individuals from access- proximal tooth wear; number, color, form, ing or using a business. sensitivity of the affected permanent teeth;

MAY.2004.VOL.32.NO.5.CDA.JOURNAL 367 Successfully Terminating the Dentist-Patient Relationship Ending a dentist-patient relationship car- ter one week before the scheduled treatment. ries the same cautions about refusing treat- In the letter, the dentist also must offer to ment to a new patient. In either case, the provide emergency care for a “reasonable The dentist, dentist must be careful to avoid potential period” such as 30 to 90 days following the legal claims, said Keith notice of termination, in ending Kerns, Ohio Dental and inform the patient Association director of they have the right to the relationship, Legislative and Legal view or obtain a copy of Services, in January’s must not abandon dental records includ- issue of ODA Today. ing impressions and X- the patient. The dentist, in end- rays. Additionally, the ing the relationship, must not abandon dentist should offer to forward the docu- the patient. If they do so, the dentist can be ments, upon the patient’s written request and held liable for abandonment by their failure authorization, to the new dentist. to give adequate notice to the patient and It is helpful, Kern said, to recommend refusal to provide treatment proximately the patient contact the local dental soci- causes injury. ety in obtaining a referral to another Kern recommended not terminating the dentist. The letter should be sent via cer- relationship during the patient’s course of tified mail. Following these simple guide- treatment and giving them plenty of notice. lines, Kerns said, can reduce the dentist’s For example, do not send a termination let- exposure to liability.

368 CDA.JOURNAL.VOL.32.NO.5.MAY.2004 Bridging the Billing Gap for Bridgework A technique has been developed in Michigan that may help dentists meet their patients’ request to bill part of a bridge in the last months of one year and for the remainder in January of the following year. In the Kalamazoo Valley District Dental Society’s Gutta Percha Clarion, Keith Konvalinka, DDS, suggested that in placing a three-unit bridge instead of preparing both teeth, a dentist might prep one and send it off. Rather than having the usual crown made, the lab can create a bridge abutment with the female portion of an MS attachment. The dentist may then request the lab fill the slot with acrylic so in the interim it doesn’t become a food trap. The dentist can cement it in, bill it as an abutment with precision attachment and be finished for the year. At the beginning of the next year, the other abutment can be prepped. This time, an impression should be taken with attention to capturing the entire cavity of the female attachment by syringing impression material into the slot fully. Or, if the lab prefers, using an abutment, pontic and the male end of the MS attachment. Insurance annual maximums often times do not cover the price of a full bridge. This leaves patients seeking to eliminate or reduce their portion of the cost. Dentists typically are forced to explain that bridgework has to be billed to insurance as one unit. By utiliz- ing this technique, Konvalinka said, a dentist can successfully bill two halves of a bridge in two insurance cycles.

Pacific Awarded Recruiting Grant The W.K. Kellogg Foundation and Not only will the Access to Dental American Dental Education Association Careers grant make available low-cost Access to Dental Careers grant of $100,000 loans to select students and enhance has been awarded to the University of the Pacific’s recruiting activities including Pacific School of Dentistry to assist with the identifying and recruiting recruitment of under-represented minority applicants at colleges and and low-income students. universities with popula- “This award is a great complement to the tions of pre-dental, under- applicant recruitment, community educa- represented and low- tion and curriculum enhancement aspects of income students, it will Pacific’s Pipeline program,” said Paul provide counseling to Glassman, DDS, associate dean for informa- applicants with the hope tion and educational technology and princi- of improving their qualifications either in ple investigator for the Pipeline program the pre-dental stage or at the start of the and Access to Dental Careers grant. application process. The award enhances Pacific’s current $1 Pacific is committed to addressing the million grant project, the California shortage of dentists from underserved and Initiative Dental Pipeline program, which low-income populations, a major issue fac- in addition to recruiting under-represented ing California as well as throughout the and low-income students also strives to pro- U.S. By recruiting more students from these vide dental students and residents in com- communities and helping them succeed munity clinics with more experiences in will benefit the diverse areas within the helping underserved populations. state as well as across the country.

MAY.2004.VOL.32.NO.5.CDA.JOURNAL 369 Ross Award Nominations Due by June 1 The deadline to nominate a dentist for explicitly describe their strides in periodontics, orthodontics, the influence of oral pathology, oral and maxillofacial the research on surgery as well as other clinical research clinical den- areas is June 1. tistry. A curricu- The Norton M. Ross Award for Excellence lum vitae with a in Clinical Research recognizes those who list of published have notably improved the diagnosis, treat- articles must be C.E. Credits Online ment and/or prevention of craniofacial-oral- included. Send The University of Colorado dental diseases. the nomina- Last year’s winner, periodontal tion to Marcia School of Dentistry, in partner- researcher Robert Genco, DDS, PhD, won for Greenberg, American ship with the Journal of the his work on the link between oral disease Dental Association, 211 E. Chicago American Dental Association, and cardiovascular diseases. Ave., Chicago, Ill., 60611. For more infor- has developed an online con- Selection is based upon the scope of mation, call the ADA at (800) 621-8099, research completed with its impact on clini- Ext. 2535. tinuing education module. cal dentistry, and the nominee’s publica- The Ross award is sponsored by the The module, which will tions in refereed journals. The winning American Dental Association through the offer up to two CE credits each researcher receives a plaque and $5,000 dur- ADA Foundation, with support from Pfizer month, provides complete ing an ADA Board of Trustees dinner in Consumer Healthcare. It is awarded in memory of Norton M. Ross, a dentist and online testing, submission, August in Chicago. Nominations must include a letter pharmacologist who contributed significant- grading and secure payment describing the nominee’s accomplishments ly to oral medicine and dental clinical for the program. Members of in the context of the award objectives and research. ADA will receive a discounted rate of $15 per submission. The Upcoming Meetings cost for non-members is $20 per submission. 2004 For more information, visit: April 27-May 2 American Academy of Cosmetic Dentistry’s 20th annual Scientific Session, Vancouver, British Columbia, www.aacd.com. ww June 24-26 ADA 18th annual New Dentist Conference, San Diego, (312) 440-2779, w.ada.org/goto/jada and click www.ada.org/goto/newdentconf the hyperlink “JADA CE Sept. 8-11 International Federation of Endodontic Association’s sixth Endodontic World Program.” Congress, Brisbane, Queensland, Australia, www.ifea2004.im.com.au. Sept. 10-12 CDA Fall Scientific Session, San Francisco, (866) CDA-MEMBER (232-6362). Sept. 30-Oct. 3 ADA Annual Session, Orlando, Fla., (312) 440-2500.

2005

April 6-9 Academy of Laser Dentistry 12th annual Conference and Exhibition, New Orleans, (954) 346-3776. To have an event included on this list of nonprofit association meetings, please send the information to Upcoming Meetings, CDA Journal, P.O. Box 13749, Sacramento, CA 95853 or fax the information to (916) 554-5962.

370 CDA.JOURNAL.VOL.32.NO.5.MAY.2004 INTRODUCTION

Making a Difference Kathleen A. Shanel-Hogan, DDS, MA; Jon Roth, MROD, CAE; and Marianne Balin, MPH

amily violence exists in every issue is focused on domestic and inti- city, every neighborhood, mate partner violence, and violence and every community. It is against people with special needs. often a silent cycle of physi- Articles address frequent questions the cal, emotional, verbal, and dental community has asked, such as: financial abuse that leaves its “Why doesn’t the abused person victims feeling trapped and in domestic violence just leave the helpless.F Because 65 percent of all relationship?” physical child abuse and 75 percent of “Why should dental professionals all physical domestic violence results get involved? What are some dentists’ in injuries to the head, neck, and/or experiences?” mouth, the dental professional is often “What are the signs of attempted the first person to render treatment to strangulation and why is that important abuse victims as well as being their first for the dental office to know?” line of defense. Even when victims of violence avoid seeking medical attention, they will keep routine and emergency treatment dental appointments. Dentists, registered dental hygienists, and registered dental assistants are designated by law as mandated reporters Author / Kathleen A. Shanel-Hogan, DDS, MA, is a consultant, educator, facilitator and family violence in California to report suspicions of prevention advocate. She works with the California abuse and neglect in patients. Dental Dental Association Foundation as a consultant and a mandated reporter trainer in all forms of family professionals and allied personnel violence (child abuse/neglect, domestic violence, must report domestic violence physical elder abuse/neglect). She is author of the Dental Professionals Against Violence Program, and testified assault cases in addition to suspected on behalf of dentistry at the California Assembly child abuse/neglect and elder Select Committee On Domestic Violence Hearing "Domestic Violence As A Public Health Issue." She abuse/neglect cases. participates on many California statewide commit- The April and May issues of the tees on family violence prevention. Dr. Shanel-Hogan has experience in private practice and hospital den- Journal of the California Dental Association tistry with medically compromised patients. are dedicated to Family Violence Jon R. Roth, MROD, CAE, is executive director of the California Dental Association Foundation. Prevention. The April issue focused on Marianne Balin, MPH, directs programming child abuse/neglect, and elder and and philanthropy focused on the prevention of domestic violence for the Blue Shield of California dependent adult abuse/neglect. The May Foundation.

MAY.2004.VOL.32.NO.5.CDA.JOURNAL 375 INTRODUCTION

Involvement of dental professionals in the community effort to foster change in family violence can make an important difference.

“What can we see in our dental examinations?” Forms to report abuse “How do I approach cultural differ- Some copies of forms to report suspected abuse are included in this issue. These ences in my practice regarding family can be used as a “working draft” of the report form to assist the mandated reporter in violence?” collecting the information in an organized manner. It becomes much simpler to transfer “What is screening for information from the "working draft" to the formal report. domestic/intimate partner violence and The actual child abuse forms are in NCR format. Please contact the California a safety plan? Why is it important?” Department of Justice Bureau of Criminal Identification and Information, P.O. Box “How do I collaborate with law 90317, Sacramento, Calif., 94203-4170 to obtain actual forms. enforcement, family violence advocates, and the community?” Domestic Violence Form “How is the special needs patient http://www.ucdmc.ucdavis.edu/medtrng/domain/Suspect_Violent_Injury.pdf population impacted and how does that Documentation Chart for Attempted Strangulation affect my practice?” e-mail: [email protected] “Is there funding for dental care for victims of crime in California?” Dental Reimbursement In 2001, the California Dental http://www.boc.ca.gov/VCApp.htm Association Foundation (CDA Foundation) was established to promote the total health of Californians through oral abuse/neglect, intimate partner violence, Involvement of dental professionals health disease prevention, risk assess- and elder abuse/neglect. The goals are to in the community effort to foster ment and treatment initiatives. As the raise the dental community’s awareness change in family violence can make an charitable arm of the CDA, the Foundation of family violence using the most current important difference by increasing the desires to expand healthcare and other information regarding patient risk assess- awareness of how to detect abuse, espe- California mandated reporter groups’ ment, clinical signs and symptoms, and cially oral abuse, and to join the com- knowledge of abuse and neglect that dental professional’s legal obligation to munity effort. Community capacity to involves clinical implications for the oral identify and report elder, child and inti- prevent abuse and neglect depends on and maxillofacial structure. Through a mate partner abuse. The program the communication and collaboration strategic partnership with, and generous includes definitive action steps for dental of the entire community. Dentistry is funding from Blue Shield of California professionals to use in their practices and prepared and willing to be collaborative Foundation and Dental Benefit Providers, communities. partners with other healthcare providers, the Dental Professionals Against Violence DPAV also created an educational agencies, institutions, and policy makers (DPAV) was created. This program is the poster for the dental office that was in addressing domestic violence and next generation of PANDA and CDA included in the April Journal to place in family violence as a healthcare issue. Abuse Detection and Education Program the back office to assist the team in rec- The effect will be to positively impact present in California since 1994. ognizing and responding to abuse and children and their families. The victims DPAV consists of both Train-the- neglect in the dental practice. To obtain of abuse often speak to us in non-verbal Trainer and direct provider training pro- additional free copies and/or to learn language through signs and symptoms. grams to encourage and support dental more about what you and your organi- We have the opportunity to become professionals in a practical response to zation can do to respond to family vio- their voice. We can make a difference. family violence and to designed to assist lence, call the CDA Foundation’s Dental Now is the time. Family violence is not dental professionals and their teams in Professionals Against Violence coordi- just a social issue; it is a health issue that recognizing and responding to child nator at (916) 554-4921, ext. 8900. affects us all. CDA

376 CDA.JOURNAL.VOL.32.NO.5.MAY.2004 SPECIAL NEEDS

The Extraordinary Vulnerability of People with Disabilities: Guidelines for Oral Health

Paul Glassman, DDS, MA, MBA; Christine Miller, RDH, MHS, MA; Professionals Rick Ingraham, MS; and Emily Woolford, BA

ABSTRACT P URPOSE OF PAPER n the last 40 years, the national deinstitutionalization movement In the last 40 years, there has been a There is a national trend to normalize has resulted in a dramatic shift dramatic shift in living arrangements and deinstitutionalize people with dis- from placing people with developmental and other disabilities in for people with disabilities from large abilities and support them in home-like large state-operated institutions to state institutions to community-based community residential settings.1 This Imoving people with special needs into community living arrangements. In care. This shift has required communi- has resulted in increasing numbers of many states there have been significant ties to increase their clinical capacity individuals with special needs seeking declines in the institutional population in this time period.2,3 In Florida, two of including oral health care systems. oral health care in dental offices. six Developmental Services Institutions Oral health professionals must be cog- Dental professionals need to be aware (DSI); have been closed and the remain- ing four have been downsized by as nizant that the rate of abuse and of considerations involved in treating much as 65 percent.1 In California neglect experienced by people with this population. Among these is the between 1992 and 2002, the population of people being served by the developmental disabilities and other extraordinary vulnerability of this pop- Department of Developmental Services special needs is at least four times the ulation to abuse and neglect and the (DDS) who were living in a State Developmental Center decreased by rate experienced by the general popu- role of the dental professional in recog- Authors / Paul Glassman, DDS, lation. These trends have resulted in nizing and reporting potential abuse MA, MBA, is a professor of dental practice and community services, additional responsibility on community and neglect. associate dean for information and educational technology, director oral health professionals to provide of the Advanced Education in General Dentistry Program, and oral health services for many people co-director of the Center for Oral Health for People With Special Needs at the University of the Pacific School of Dentistry. who formerly lived in state institutions Christine Ernst Miller, RDH, MHS, MA, is an associate professor of Dental Practice and including recognizing and reporting Community Services, director of Community Programs, and co-director of the Center for Oral suspected abuse and neglect. Oral Health for People with Special Needs at the University of the Pacific School of Dentistry. health professionals must prepare Rick Ingraham, MS, is a manager of the Children and Family Services Branch of the California Department of Developmental Services. themselves to successfully carry out Emily Woolford, BA, is a community programs specialist with the California Department of these professional responsibilities. Developmental Services.

MAY.2004.VOL.32.NO.5.CDA.JOURNAL 379 SPECIAL NEEDS

45.8 percent while the population being found in at least a quarter of those with community resources for special needs served by DDS who lived in the com- cerebral palsy, as well as 30 percent of populations, such as an increased inci- munity increased by 78.2 percent.4 As of those with head injuries, and 17 percent dence of oral disease and difficulty October 2003, 70.3 percent of people of those with hearing impairment.10 A accessing oral health services, also con- with developmental disabilities served study commissioned by the Special tribute to an increased vulnerability to by DDS lived in their own home or with Olympics concluded that the oral health abuse and neglect of these individuals. a parent or family member; 14.6 percent of individuals with mental retardation is Oral health professionals can play an in a community care setting (group poorer than that of their peers without important role in providing oral health home); 8.5 percent in independent sup- mental retardation. Individuals with care for special populations and in rec- ported living arrangements; 4.7 percent ognizing signs of abuse and neglect. in an intermediate care facility or skilled nursing facility, and only 1.9 percent in People with Abuse and Neglect in People with a state developmental center.4 Special Needs There are many reasons for this developmental There is extensive literature that remarkable demographic shift, includ- demonstrates that people with developing parent advocacy for more commu- disabilities experience mental disabilities experience abuse at nity-based programs, recognition of the abuse at least least four times the rate experienced in civil rights of people with disabilities to the general population and possibly as live and participate in society, legisla- four times the rate much as ten times.21,22 There is also a very tive mandates to downsize institutions, high probability of repeat victimization and the establishment of government experienced in the prior to the abuse being reported or inves- programs to support community living tigated. Further, the perpetrator is usually arrangements.5 The result of deinstitu- general population and someone well known and trusted by the tionalization, however, is that people victim and his or her caregivers.21,23-29 with developmental disabilities and possibly as much as This literature indicates that: other special needs have become ■ There are 5 million crimes against increasingly dependent on community- ten times. people with developmental disabilities based resources for social services and each year in the U.S. compared with medical and oral health care. In many 8,000 hate crimes, 1 million incidents cases these resources are not avail- mental retardation have more untreated of elder abuse, and 1 million incidents able.6,7,8 In fact, people with special caries and a higher prevalence of gin- of spousal abuse. needs, particularly those with develop- givitis and other periodontal diseases ■ More than 70 percent of women mental disabilities, have more dental than those in the general population.19 with developmental disabilities are sex- disease, more missing teeth, and more Availability of dental providers ually assaulted in their lifetime. difficulty obtaining dental care than trained to serve special needs popula- ■ Thirty-nine percent to 68 percent other segments of the population.9-14 tions and extremely limited third-party of girls and 16 percent to 30 percent of The Surgeon General’s Report on support for the delivery of complex ser- boys with intellectual disabilities will be Oral Health points out that populations vices further complicate the issues sexually abused before age of 18. with mental retardation or other devel- entailed in addressing the oral health ■ The rate of robbery against per- opmental disabilities have significantly needs of this population.9 There is even sons with intellectual disabilities is 12.8 higher rates of poor oral hygiene and an congressional testimony where the times higher than against the general increased need for periodontal treat- opinion has been expressed the health population. ment than the general population.9 In care system in the United States prac- ■ Offenders are often caregivers pro- addition, people with disabilities have a tices active discrimination against peo- viding services related to the disability. higher rate of dental caries than the ple with disabilities for no other reason ■ Offenders often seek out persons general population, and almost two than the fact they have a disability that with disabilities because they are con- thirds of community-based residential makes the health care professional sidered to be vulnerable and unable to facilities report that inadequate access uncomfortable.20 seek help or report the crime. to dental care is a significant issue.15-18 Many of the factors that contribute ■ Forty-four percent of violent Untreated dental disease has been to increased dependence on scarce crime in the general population is

380 CDA.JOURNAL.VOL.32.NO.5.MAY.2004 reported nationally compared with 4.3 cific injuries or illness-related symp- with a patient with special needs. It is percent of violent crime reported toms. A person with cognitive limita- helpful for dental professionals to recog- against people with disabilities. tions may thus be confused or reluctant nize that persons with developmental or There are many factors that contribute to agree to dental care. other disabilities have a dramatically to the vulnerability of persons with devel- Second, the array of equipment higher incidence of abuse; the dental opmental disabilities. These include: immediately present for even a dental office can be a strange and confusing ■ Their physical and mental exam can be foreboding and confusing. place; the patient is asked to assume a impairments are apparent and thus per- Conversely, a medical exam room is physical position that is very vulnerable; ceived as “easy targets” who are unable more simply furnished with the exami- prior dental treatments themselves may to defend themselves. have involved pain or trauma, particu- ■ Their multiple service needs larly if oral health had been neglected require them to access many different for many years; the cognitive processing service delivery systems and thus Ensure that a of many persons with developmental expose them to many different types of disabilities in particular, varies from less providers. caregiver who knows sophisticated to significantly impaired; ■ Their limited problem-solving and caregiver follow through to main- capacity leaves them vulnerable to the patient and tain oral health may be less than opti- persuasion by others and less cog- their current health mal. Given these realities, it is important nizant of warning signs of dangerous to prepare for the dental visit. persons or places. information and who Pre-visit strategies that individuals in ■ Training on safety and sexuality the dental office can follow include is often lacking. the patient trusts will gathering information about previous ■ They often believe that if they dental care. It is important to under- report abuse, no one will believe them. be accompanying the stand not only what was done, but how ■ They are often segregated and the care was delivered and which tech- very dependent on their caregivers. patient. niques helped to make the treatment go ■ Residential care providers often smoothly and which did not. Some peo- hire unskilled care staff at minimum ple with developmental disabilities may wage and experience a high attrition rate. nation table, blood pressure apparatus, have received their oral healthcare and a few containers of swabs, tongue under general anesthesia in the past, People with Disabilities and the depressors, etc. particularly if they have a long history of Dental Office Environment Third, patients sitting in the dental institutionalization. In considering the Oral health professionals can be in a reception room are often cognizant of best approach to ensure success, the better position to provide dental treat- the distinctive shrill sounds of dental practitioner must take into account any ment for people with special needs and “drills” and polishing equipment. Fourth, previous trauma or pain history associat- to recognize signs of abuse or neglect if patients in dental offices are typically ed with oral health care. The pre-visit they consider some of the challenges the asked to assume a much more vulnera- information that is obtained should also dental office environment can present. ble position than patients in medical address whether pre-visit medication The dental office can be perceived quite offices who are asked to sit on the exam (e.g. sedative) has been routinely given differently compared to the physician’s table. Finally, the medical exam typi- in the past. Lastly, but perhaps most office, particularly for a patient with cally begins with some mildly invasive importantly, ensure that a caregiver who developmental disabilities. When seek- procedures (blood pressure, tempera- knows the patient and their current health ing medical care, the patient is often ture, stethoscope, etc.) compared to the information and who the patient trusts much more aware of his symptoms and course of the oral examination and will be accompanying the patient and be the need for treatment. Except for cases treatment. Procedures in the mouth available during the visit. of dental pain, even persons needing sig- can be perceived as very invasive even An excellent technique that also has nificant restorative work may not expe- if they are not painful. proven successful to prepare and help to rience limitations in their daily func- There are a number of strategies that “de-sensitize” anxious patients has been tioning. Conversely, persons accessing can be employed to increase the likeli- the pre-visit binder. This binder is a col- medical care typically present with spe- hood of having a successful dental visit lection of photos of the outside of the

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office building, reception desk, waiting If the techniques described above the health and well-being of the patient. room, exam/treatment rooms (includ- are combined with a friendly and caring You will enjoy the team mobilizing ing the exam light as the primary object demeanor and a willingness to be flexi- resources to follow through on your rec- in the field of vision during treatment), ble about routines normally followed in ommendations. In addition, you may staff likely to be encountered (both with the dental office, providing treatment have the opportunity to reaffirm the and without masks), particular cleaning for people with special needs can be critical role of the oral health practition- instruments likely to be used, and any very rewarding. The rewards include the er in peoples’ general health and well- “freebie” packs to be given and the end fact that the treatment experience may being. Speech therapists, occupational of the visit. An office would be well very well constitute a life-altering event therapists, nutritionists, the primary advised to keep several of these binders for the patient. Given the myriad of care physician, psychologists, and social available for “check-out” several days chronic medical and functional difficul- workers will all be waiting for your prior to the visit. The primary caregiver essential input before proceeding with should review the binder with the their course of treatment to improve the patient at least daily for three to four The rewards quality of life for the patient. days immediately prior to the visit. Finally, you will receive unequaled Pre-visit preparation can also include include the fact gratitude on the part of families, care- gathering information about the individ- givers, and social workers. The apprecia- ual’s particular medical, psychological, or that the treatment tion expressed by families of patients social situation. There is an excellent with special needs is often more pro- Web-based resource available for infor- experience may found than with any other treatment mation about developmental disabilities population. Just as life has been a terrif- called the Developmental Disabilities very well constitute ic struggle for persons with disabilities, Digest. It is a continually updated sum- their families and caregivers have been mary of the latest research on the 50 a life-altering alongside them in this effort to live as most common diagnoses and syndromes full a life as possible given their disabil- of developmental disabilities.30 event for the patient. ities. Family members have approached During the dental visit, there are many clinicians working with this pop- also some strategies to ensure success. ties these patients experience, oral ulation with tears in their eyes thanking Given the limited cognitive and percep- health is too often overlooked or less of them profusely for improving the qual- tual difficulties experienced by some a priority. Patients have been literally ity of their lives. Other measures of grat- persons with disabilities, a practitioner rescued from locked institutional care itude have included letters to the gover- should be prepared to make some minor and returned to their family homes nor and other elected officials, recogni- but important adjustments in interact- because someone recognized that tion awards from advocacy groups, and ing with the patient. First, have the behavior problems were resulting from peer recognition awards from profes- trusted caregiver/parent accompany the dental pain. Chronic medical condi- sional organizations. patient. This person can continue to tions have been resolved because reme- reassure the patient during the dental diation of oral cavity issues allowed the Recognizing Signs of Abuse or procedures. Second, err on the side of patient to eat and receive adequate Neglect in People with Special speaking too simply and too slowly. nutrition. Simply stated, you will have Needs Third, the closer you are to the patient, the opportunity to turn around some- The oral health provider who has the more slowly you should move. You one’s life. taken the time to incorporate people will recognize the importance of this Some patients will present with with special needs in their practice may strategy especially for those patients unparalleled clinical complexity. These observe signs of abuse or neglect. with histories of abuse or even bullying treatment opportunities can provide Clinicians must be alert to unexplained at their day programs or workshops. the oral health professional with fasci- or unusual bruising, any burns or frac- Fourth, display and explain the instru- nating clinical experiences reminding tures or significant weight loss and ments, as you are about to use them. If you why you became a clinician. You other possible physical symptoms of the pre-visit binder was done correctly will also enjoy the camaraderie of being abuse or neglect. Dental practitioners and utilized, there should be no stress- one of several clinicians on a multi-dis- are in a unique position to detect facial ful surprises for the patient. ciplinary treatment team focusing on injuries consistent with abuse including

382 CDA.JOURNAL.VOL.32.NO.5.MAY.2004 abilities have diminished because of age.” Dependent adults are also defined as “any person between the ages of 18 and 64 who is admitted as an inpatient to a 24-hour health facility.” In addition, “caregiver” is defined as “any person who has the care, custody, or control of, or who stands in a position of trust with, an elder or a dependent adult.”32 In California law, abuse of depen- Figure 1. Oral neglect may indicate Figure 2. Oral trauma, such as this general neglect or abuse. broken tooth, may be a sign of abuse. dent adults is defined as either physical abuse, neglect, financial abuse, aban- black eyes, bloody or swollen lips, and ious or nervous, or readily flinches or donment, isolation, abduction, or broken jaw or nose. Dentists may recoils when approached by others. Or, other treatment with resulting physical observe a persistent reluctance to the patient may display extreme muscle harm or pain or mental suffering or the remain seated in a standard position in tenseness while undergoing specific deprivation by a care custodian of the dental chair (possible reaction to dental procedures. The key distinction goods or services that are necessary to bruises or fractures) or even a vague ver- here is that with dental phobia, one avoid physical harm or mental suffer- bal reference from the patient (Figures would expect pervasive tenseness, often ing.33 Neglect is defined as “the negli- 1 and 2). from when first entering the office. We gent failure of any person having the Dental practitioners must also be would expect tenseness resulting from care or custody of an elder or a depen- alert to caregiver behavior for signs of fear of further abuse will be most mani- dent adult to exercise that degree of abuse of patients. Note how the patient fest when practitioners are in specific care that a reasonable person in a like presents generally. Is the patient dirty positions (e.g. directly over the patient). position would exercise or the negli- or unkempt? Are the clothes in good Further, when the patient demonstrates gent failure of an elder or dependent condition and well fitting? When prac- extreme timidity or appears overly com- adult to exercise that degree of self care titioners observe caregivers relying on pliant, one may wonder if this behavior that a reasonable person in a like posi- physical coercion or threats in a public is fear driven. tion would exercise.” Neglect is consid- venue such as a dental office, one must ered to include, but not be limited to wonder what transpires when no one is Reporting Abuse or Neglect of failure to assist in personal hygiene, or observing. One should query further if Dependent Adults in the provision of food, clothing, or the caregiver characterizes the patient There are federal and state laws that shelter; failure to provide medical care as “bad” or “evil” or uses other global specifically address the definition and for physical and mental health needs; negative terms or harshly criticizes the prohibition of abuse and neglect of failure to protect from health and safe- patient. Some caregivers who are abus- elders and dependent adults and ty hazards; failure to prevent malnutri- ing those entrusted to their care may requirements for reporting. A listing of tion or dehydration; and failure of an make offhand remarks about desires to these laws can be found on the Web site elder or dependent adult to satisfy the harm the patient or actually mention of the Department of Aging, Long Term needs described above for himself or harsh discipline practices such as belts, Care Ombudsman Program.31 Among herself as a result of poor cognitive sticks or other objects. these is Section 368 of the California functioning, mental limitation, sub- Patient behavioral indicators are less Penal Code which defines “dependent stance abuse, or chronic poor health.34 definite. Individuals commonly display adult” as “any person who is between Oral health professionals can play a a wide range of behavior with regard to the ages of 18 and 64, who has physical role in detecting and reporting signs of routine behavior. This is even more true or mental limitations which restrict his possible abuse or neglect in their depen- for reactions to high stress circum- or her ability to carry out normal activ- dent adult patients. In fact, as mandated stances such as abuse and neglect. ities or to protect his or her rights, reporters, oral health professionals are However, there are situations worth including, but not limited to, persons required to do so. Mandated reporters investigating further. Abuse may be sus- who have physical or developmental are those groups specifically identified pected when the patient appears anx- disabilities or whose physical or mental in California law as required to report

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suspected abuse or neglect. Licensed Information about the state’s ombuds- dental professionals are among this man program can be found on the group and can be found guilty of a crime California Department of Aging Web for not reporting.35 This law is specific site.38 There is an Office of the State about the reporting requirements. It says Long-Term Care Ombudsman (OSLT- that “any mandated reporter who, in his CO) that develops policy and provides or her professional capacity, or within oversight to 35 counties’ Long-Term the scope of his or her employment, has Care Ombudsman Programs. The state observed or has knowledge of an inci- also maintains a 24-hour, seven-day-a- dent that reasonably appears to be phys- week crisis line at (800) 231-4024 to ical abuse, abandonment, abduction, receive complaints from residents. isolation, financial abuse, or neglect, or There is also a listing of county Long- is told by an elder or dependent adult Term Care Ombudsman Program con- that he or she has experienced behavior, tacts available on the Department of including an act or omission, constitut- Aging Web site.39 In an emergency, ing physical abuse, abandonment, report suspected abuse or neglect to abduction, isolation, financial abuse, or local law enforcement agencies using neglect, or reasonably suspects that the 911 system. abuse, shall report the known or sus- Another state agency concerned pected instance of abuse by telephone with abuse of dependent adults is the Figure 3. Poster from the California immediately or as soon as practicably Bureau of Medi-Cal Fraud and Elder Attorney General’s SafeState Campaign. possible, and by written report sent Abuse in the Office of the Attorney Used with permission by the California Attorney within two working days.” The General. This agency is concerned with General's Office. California Department of Social Services attempts to defraud California’s Medi- unable to meet their own needs, and who form for filing a written report can be Cal program, including health care are victims of abuse, neglect, or exploita- downloaded from the Web.36 providers and persons involved in the tion. The role of the county adult protec- Oral health professionals who suspect program’s administration. They are also tive services agencies is to investigate abuse or neglect in a dependent adult are concerned with abuse and neglect of reports of abuse of elderly and dependent required to report these suspicions to dif- patients in Medi-Cal-funded facilities, adults who are living in the community. ferent agencies depending on where the such as nursing homes, developmental They provide or coordinate support ser- abuse or neglect occurred. The California treatment facilities, and hospitals. They vices, such as counseling, money man- Attorney General’s Office launched a can be contacted at the state Attorney agement, conservatorship, and advocacy. “SafeState” Campaign in April 2003.37 General’s Bureau of Medi-Cal Fraud and They also provide information and edu- The campaign features a statewide hot- Elder Abuse toll-free hotline at cation to other agencies and the public line, (888) 436-3600, for reporting of sus- (800)722-0432.40 about reporting requirements and other pected cases of elder or dependent adult As indicated earlier in this article, the responsibilities under the elder and abuse. The hotline will directly connect vast majority of dependent adults with dependent adult abuse reporting laws.41 callers wishing to report suspected abuse developmental and other disabilities live There is a county contact list available on to the responsible agency including their in community care facilities, indepen- the APS Web site42 (Table 1). local Adult Protective Services Agency or dent or supportive living arrangements, the Long-Term Care Ombudsman crisis or in family homes. Suspected abuse or Report Follow Up line (Figure 3). neglect in these individuals should be Confidentiality for the reporter is As indicated earlier in this article, reported to the local Adult Protective protected by law. You will provide the few dependent adults with develop- Services (APS) agency or local law name of the person, the current location mental disabilities live in long-term enforcement. The California Department of the person, and the nature and extent institutional care facilities. However, if a of Social Services is responsible for of the suspected abuse or neglect. The dental professional suspects abuse or the various counties’ Adult Protective phone call must be followed up within neglect for someone in a long-term care Services Program. These agencies provide 36 hours by a written report to the pro- facility, they should report this to the assistance to elderly and dependent tective services agency. After the report, local long-term care ombudsman. adults who are functionally impaired, the county’s social services agency may

384 CDA.JOURNAL.VOL.32.NO.5.MAY.2004 Table 1 4. Department of Developmental Services Fact Book, Sixth Edition. Department of Developmental Services Information Services Division. Oct. 2003. Contact List 5. Chambless CE, Aldous S, Study of Dental Access by People with Developmental Disabilities Attorney General’s Elder and Dependent Abuse Hotline in Utah, Part I: ConsumerSurvey, Utah Governor’s Council for People with Disabilities and Division of ■ Referral to Ombudsman or Adult Protective Services: (888) 436-3600 Community and Family Health Services, Utah Department of Health, Feb. 1999. Reporting Suspected Abuse in Long-Term Care Facilities 6. Drainoni M, Haverlin K, Buchman SS. A Study of the Impact of Formal and Informal ■ State Ombudsman 24-hour, seven-days-a-week crisis line (800) 231-4024 Supports on Health Care Utilization for People with ■ List of Local County Ombudsman Programs: Developmental Disabilities, Medicaid Working Group, Boston University School of Public Health, http://www.aging.state.ca.us/html/programs/ombudsman_contacts.html October 2000. ■ California Attorney General’s Bureau of Medi-Cal Fraud and Elder Abuse hotline 7. Glassman P, Miller CE, Lechowick J, A (800) 722-0432 Dental School’s Role in Developing a Rural, Community-based, Dental Care Delivery System for ■ Local Law Enforcement Individuals with Developmental Disabilities. Spec Care Dent 16(5):188-93, 1996. Reporting Suspected Abuse outside of Long-Term Care Facilities 8. Waldman HB, Perlman SP, Why Dentists Shun Medicaid: Impact on Children, Especially ■ Adult Protective Services County Contact List with 24-hour, seven-days-a-week Children with Special Needs. J Dent Child 70(1):5-9, hotline number: http://www.dss.cahwnet.gov/pdf/apscolist.pdf Jan.-April 2003. ■ Local Law Enforcement 9. U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National or may not investigate. Indeed, budget Conclusion Institutes of Health, 2000. constraints results in varied response People with special needs including 10. The Disparity Cavity: Filling America’s Oral Health Gap. Oral Health Am May 2000. from county to county. Some counties those with developmental and other 11. Haavio ML. Oral health care of the mental- have been criticized for investigating disabilities are living and seeking dental ly retarded and other persons with disabilities in the Nordic countries: Present situation and plans only if there is a “gaping wound.” care in the community in greater num- for the future. Spec Care Dent 15:65-9, 1995. Typically, this “triage” approach is the bers than ever before. Dental profes- 12. Feldman CA, Giniger M, Sanders M, Saporito R, Zohn HK, Perlman SP Special Olympics, result of budget constraints. Generally, sionals can prepare themselves to pro- Special Smiles: Assessing the feasibility of epidemi- however, the county social service vide oral health services for these indi- ologic data collection. J Am Dent Assoc 128:1687-96, 1997. agency will investigate or at least docu- viduals and enhance their practices and 13. Waldman HB, Perlman SP, Swerdloff M, ment the report. This becomes valuable professional lives in the process. In the Use of pediatric dental services in the 1990s: Some continuing difficulties. J Dent Child 67:59-3, 2000a data if there are a number of these course of providing dental care, oral 14. Oral Health: Factors Contributing to Low reports over time regarding a particular health professionals may encounter Use of Dental Services by Low-Income Populations. United States General Accounting Office. Report to individual caregiver. signs of abuse or neglect which they are Congressional Requesters. Sept. 2000. If your concerns fall short of “reason- mandated to report. Knowing what, 15. Beck JD, Hunter RJ, Oral health status in the United States: problems of special patients. J able suspicion” of abuse or neglect, yet where and how to report suspected Dent Educ 149:407-25, 1985. you are concerned that the person is abuse and neglect is essential informa- 16. White BA, Caplan DJ, Weintraub JA, A quarter century of changes in oral health in the receiving less than optimal care you have tion for every dental practice. CDA United States. J Dent Educ 59(1):19-60, Jan. 1995. several options. The first would be to 17. Waldman HB, Perlman SP, Swerdloff M, What if dentists did not treat people with disabili- contact the patient’s service coordinator To request a printed copy of this article, please contact / Paul D. Glassman, DDS, MA, MBA, UOP ties? J Dent Child 65:96-101, 1998. at the local regional center if they are reg- School of Dentistry, 2155 Webster St., San 18. Dwyer, Northern Wisconsin Center for the Francisco, Calif., 94115-2333. Developmentally Disabled unpublished data, 1996. istered with the regional center system 19. Horwitz S, Kerker B, Owens P, Zigler E, The and discuss your observations with Health Status and Needs of Individuals with Mental Retardation. Special Olympics, 2000. him/her. Another option exists in the References / 1. University of Florida, College of Dentistry. Nova Southeastern School of Dental 20. Schriver T, Testimony before a Special case of a major wound or bruise but not Medicine. Access to Oral Health Care for Florida’s Hearing of a Subcommittee of The Committee On Appropriations of the U.S. Senate 107th Congress, a reasonable suspicion of abuse or Citizens with Developmental Disabilities. Florida Developmental Disabilities Council, Inc. 2002. first session. Anchorage, Alaska, March 5, 2001. neglect. You may complete a “Special 2. Braddock H, Hemp R, Fujiura G, Bachelder 21. Petersilia J, Written presentation to the California State Senate Public Safety Committee, Incident Report” for your local regional L, Mitchell D. Third National Study of Public Spending for Mental Retardation and Jan. 15, 1998. center. This documents your observation Developmental Disabilities. University of Illinois at 22. Sobsey D, Violence and abuse in the lives of people with disabilities: the end of silent accep- and assists the regional center in estab- Chicago: Institute for the Study of Developmental Disabilities. 12-15, 1989 tance? Baltimore: Paul H. Brookes Publishing lishing a “paper trail” should other team 3. Lakin A, De-Institutionalization of the Company, 1994. 23. Sobsey D, Doe T, Patterns of sexual abuse members make additional observations. Mentally Retarded: Big v. Little - A National and Florida Perspective. Med Sci Law 31:313-21,1991. and assault. J Sex Disab 9(3): 243-59, 1991.

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24. Rocher Institute, No More Victims: A man- 26. Mansell S, Sobsey D, Calder P, Sexual Women with Disabilities. National Electronic ual to guide counselors and social workers in abuse treatment for persons with developmental Network on Violence Against Women. addressing the sexual abuse with people with a disabilities. J Prof Psychol: Res Pract 23:404-9, 1992. http://www.vaw.umn.edu/documents/vawnet/dis mental handicap. North York, Ontario.1992. 27. Lang RA, Frenzel RR How sex offenders ab/disab.html. Accessed Oct. 13, 2003. 25. Wilson C, Brewer N, The incidence of lure children. Ann Sex Research 1(2): 303-17, 1988. 30. Center for Health Improvement. criminal victimization of individuals with an intel- 28. National Crime Victimization Survey, Developmental Disabilities: resources for health- lectual disability. Australian Psych 27(2): 114-7, Bureau of Justice Statistics Bulletin, April 1996. care providers. http://www.ddhealthinfo.org. 1992. 29. Nosek MA, Howland CA, Abuse and Accessed Dec. 1, 2003. 31. State of California, Department of Aging, Long-Term Care Ombudsman Program, Elder Abuse. Accessed http://www.aging.state.ca.us/ html/programs/elder_abuse.html on Nov. 15, 2003. 32. Health Administration Responsibility Project Web Site, California Penal Code, Section 368. Accessed http://www.harp.org/pc368.htm on Nov. 15, 2003. 33. California Welfare and Institutions Code. Section 15610.07. 34. California Welfare and Institutions Code. Section 15610.57. 35. California Welfare and Institutions Code section 15630. 36. State Of California, Health and Welfare, Department of Social Service, Report of Suspected Dependent Adult/Elder Abuse Form. Accessed http://www.dhs.co.la.ca.us/ems/manuals/policies/829-2.pdf on Nov. 15, 2003. 37. State of California. Office of the Attorney General. SafeState Campaign. Accessed http://www. safestate.org/ on Nov. 15, 2003. 38. State of California, Department of Aging, Long-Term Care Ombudsman Program Web Site. Accessed http://www.aging.state.ca.us/html/programs/ombudsman.html on Nov. 15, 2003. 39. California Department of Aging, Long- Term Care Ombudsman Program, Long-Term Care Ombudsman Program Contacts by County. Accessed http://www.aging.state.ca.us/html/programs/ombudsman_contacts.html on Nov. 15, 2003. 40. California Department of Justice. Office of the Attorney General. Bureau of Medi-Cal Fraud and Elder Abuse Web site. Accessed http://www.ag.ca.gov/bmfea/index.htm on Nov. 15, 2003. 41. California Department of Social Services, Adult Protective Services Web Site. Accessed http://www.dss.cahwnet.gov/cdssweb/Protective_ 175.htm on Nov. 15, 2003. 42. California Department of Social Services, Adult Protective Services Web Site, Adult Protective Services County Contact List. Accessed http://www.dss.cahwnet.gov/pdf/apscolist.pdf on Nov. 15, 2003.

386 CDA.JOURNAL.VOL.32.NO.5.MAY.2004 DOMESTIC VIOLENCE

Culturally Competent Responses for Identifying and Responding to Domestic Violence in Dental Care Settings Vibhuti Mehra on behalf of the Family Violence Prevention Fund

ABSTRACT P URPOSE OF PAPER he impact of abuse and neglect can manifest Dental care providers can play an impor- Domestic violence (DV) or intimate throughout the lifespan. tant role in identifying and preventing partner violence (IPV) is a health issue The immediate health consequences of domestic vio- intimate partner violence. Many victims of epidemic proportions in the United lence can be severe and Tsometimes fatal. In addition to injuries of domestic violence interact with dental States. It is estimated that between 20 sustained by victims during violent care providers, including dentists, dental and 30 percent of women and 7.5 per- episodes, physical and psychological hygienists, and dental assistants, thus cent of men in the United States have abuse is linked to a number of adverse medical health effects. However, new placing dental professionals in a unique been physically and/or sexually research shows that a history of expo- position to screen for early identification abused by an intimate partner at some sure to IPV is a significant risk factor for many chronic health problems and 1,2,3 and even primary prevention of abuse. point in their lives. During the past health risk behaviors. Women who An effective and successful response to 15 years, there has been a growing have been victimized by an intimate partner and children raised in violent intimate partner violence in a dental care recognition among health care profes- households are more likely to experi- setting involves creating a safe and cul- sionals that DV or IPV is a highly preva- ence a wide array of physical and mental health conditions including frequent turally competent environment for lent public health problem with devas- headaches, gastrointestinal problems, screening and disclosure, giving sup- tating effects on individuals, families, depression, anxiety, sleep problems, portive messages to victims, educating and communities. Author / Vibhuti Mehra is a senior program assistant patients about abuse and connection to at the Family Violence Prevention Fund’s National Health Resource Center on Domestic Violence. She moderates the FVPF’s Health e-News, and is current- health, offering strategies to promote ly working collaboratively to create a cultural competency tool for health care providers. She has previ- safety, and informing clients about rele- ously worked with Manavi, a New Jersey-based non- profit organization dedicated to empowering South vant community resources. Asian women who live in the U.S.

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and Post Traumatic Stress Disorder important steps in raising awareness Identifying and Responding to 4-7 (PTSD). about IPV in health care settings. In an Domestic Violence in the Dental For more than a decade, the Family effort to better guide health care Care Setting Violence Prevention Fund (FPVF) providers about how to carry out screen- through its publications, practices, edu- ing and intervention, the FVPF in col- Many victims of domestic violence cational programs and outreach efforts, laboration with an expert advisory com- interact with dental care providers, has promoted routine screening for mittee, published the National Consensus including dentists, dental hygienists, domestic violence and effective respons- Guidelines on Identifying and Responding and dental assistants, thus placing den- es to victims in health care settings. to Domestic Violence Victimization in tal professionals in a unique position to Attention to the issue of intimate part- Health Care Settings. The guidelines offer screen for early identification and even ner violence began in the emergency health care providers, in all settings, a primary prevention of abuse. According room and primary care settings. More to a 1998 national survey, 9.2 percent of recently, efforts have expanded to reach the women who sought health care for out to specialty settings including phys- Dental health care physical assault by an intimate partner ical therapy, orthopedics, and dentistry. saw a dentist.8 Studies have also shown This article will emphasize the providers routinely that most victims of intimate partner importance of routine screening for IPV violence are injured in the head and in the oral/dental health care setting as assess the head and neck areas; the clinical indicators are an effective intervention and preven- present in lacerations, bruises and frac- tion strategy while underscoring the neck areas of their tures. Dental health care providers rou- need to provide culturally competent tinely assess the head and neck areas of services to victims of abuse and neglect. patients and hence can their patients and hence can identify Recommended strategies and steps that whether their patient is being abused can help dental care professionals pro- identify whether their and intervene.9,10 vide an improved level of culturally Although the American Dental Asso- competent care to victims of domestic patient is being ciation enacted a policy in 1996 to violence, while identifying and pre- increase efforts to educate dental profes- venting abuse also are included. abused and intervene. sionals on identifying abuse and neglect of adults, much remains to be done to Health Care Response to concise protocol as well as justification improve screening and intervention for Domestic Violence for providing appropriate health and domestic violence in the dental care set- A host of professional health care safety assessment, intervention, docu- ting. Dentists and other dental care organizations have promulgated policy mentation, and referral to victims of providers cite various barriers for the statements, position papers, guidelines domestic violence. The guidelines also lack of response including lack of train- and monographs about this important cover the issue of culturally competent ing, cultural competency, and access to health issue describing the impact of responses. resources.11,12 However, these barriers can IPV on patients and suggesting strate- Routine screening for IPV, whether be overcome with appropriate training gies for screening and identification or not symptoms are immediately appar- and a concerted effort on the part of all of abuse. These organizations include ent, increases opportunities for both dental professionals to develop meth- the American Academy of Family identification and effective interven- ods, tools, guidelines, and resources that Physicians, American Academy of Pedi- tions, validates IPV as a central and legit- help create an environment supporting atrics, American College of Obstetri- imate health care issue, and enables victims of domestic violence, fosters their cians and Gynecologists, American providers to assist both victims and their safety and well-being, and facilitates Medical Association, American Nurses children. Asking about IPV and having their empowerment. Association, American Psychological resource and referral materials in health Association, Joint Commission on the settings also sends a prevention message Understanding the Dynamics of Accreditation of Health Care Organi- that IPV is unacceptable, has serious health Domestic Violence zations, and the Institute of Medicine, consequences, and provides the patient FVPF defines domestic violence or as well as others. with important community referral intimate partner violence as a pattern of The position statements represent information and resources. assaultive and coercive behaviors that

388 CDA.JOURNAL.VOL.32.NO.5.MAY.2004 may include inflicted physical injury, measure to ensure safety for themselves dard terminology currently used in psychological abuse, sexual assault, pro- as well as their children, family or health care. It refers to the process by gressive social isolation, stalking, depri- friends which the provider combines general vation, intimidation and threats. These ■ Emotional, financial dependence knowledge about various groups with behaviors are perpetrated by someone or even physically dependence (e.g. dis- specific information provided by the who is, was, or wishes to be involved in abled person) on the abuser victim about his/her culture, incorpo- an intimate or dating relationship with ■ Language rates an awareness of one’s biases, and an adult or adolescent, and are aimed at ■ Immigration status approaches the definition of culture establishing control by one partner over ■ Social or institutional oppression, with a critical eye and open mind. the other. e.g. racism, classism, ageism, sexism, Becoming “culturally competent” with Research indicates that a vast major- homophobia, xenophobia victims of domestic violence is a chal- ity of victims of abuse in intimate rela- lenge. To achieve cultural competency, tionships are women whose partners are practitioners need to be aware of, and men. Heterosexual women are five to avoid, making assumptions about eight times more likely than heterosex- To a chieve cultural patients. Health care providers should ual men to be victimized by an intimate neither minimize nor overplay differ- partner.13 An October 2001 report of the competency, ences between diverse groups of peo- U.S. Bureau of Justice Statistics on inti- practitioners need to ple. For example, if a patient belongs mate partner violence found that 85 to the upper class, a dental care percent of IPV victims are women. Most be aware of, and avoid, provider should not assume that of the studies conducted to date have she/he cannot be a victim of domestic measured the prevalence and impact of making assumptions violence. Similarly, if an Asian woman abuse on women and children. However, discloses herself as a victim of domestic it is important to note that some vic- about patients. violence, the dental care provider can- tims of IPV are men in heterosexual not simply fault her cultural upbring- relationships and that IPV is also preva- ing for the violence. lent in lesbian, gay, bisexual, and trans- Domestic violence affects people A common mistake is to accept the gender relationships. regardless of race, ethnicity, class, sexu- traditional concept of culture. As a Domestic violence serves the pur- al and gender identity, religious affilia- result, the bias has been to look only for pose of establishing power and control tion, age, income and education levels, differences while ignoring commonali- through various tactics. This establish- immigration status and ability. Because ties. It should be remembered that ment of an abusive power and control is of the sensitive nature of abuse, provid- while domestic violence may impact fundamentally what distinguishes DV ing culturally relevant care is critical communities differently, both women or IPV perpetrators from victims. when working with victims of abuse. and men have challenged and resisted Victims of domestic violence may face many norms and standards within their several barriers that can impact their Providing Culturally Competent societies, redefining the very notion of decision to disclose abuse to a health Care “culture.” This resistance cuts across care provider. Some of the barriers faced Culture in this context refers to var- demographic boundaries. by domestic violence victims include: ious shared experiences or other com- Exploring options with patients has ■ Feeling disempowered and low monalities that groups of individuals to be done with victim safety at the self-esteem have developed based on race, ethnici- forefront. Victims are constantly bal- ■ Isolation from friends and family ty, sexuality, class, disability, status, reli- ancing safety and risk. If an option is ■ Feeling of being trapped in the gion, age, immigration, and other axes unsafe at a particular point of time, it abusive situation of identification in relation to changing may not be later. The viability of an ■ Shame, embarrassment, guilt social and political contexts.14 The con- option depends largely on sources of about the violence or acceptance of it as temporary concept of culture, its norms support both within the victim’s com- the victim’s fault and responsibility and traditions, recognizes that “culture” munity(ies) and that which is made ■ Religious or familial pressure is multifaceted, often changing and available by providers. A health care ■ Fear of retaliation from the contains contradictory elements. intervention is likely to work only if the abuser and using silence as a survival Cultural competence is the stan- provider gently negotiates without

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infringing upon the victim’s right to For a successful health care interac- patients can facilitate discussion and dignity or privacy, letting the victim tion within diverse client populations, help dental care providers offer appro- know of her/his options that are avail- the provider needs to effectively com- priate and effective interventions. It is able at the time. Keep in mind that municate with the patient, be aware of important to adapt your screening options have to make sense from the his/her personal assumptions, ask questions and approach to each indi- victim’s frame of reference. questions in a culturally sensitive way, vidual patient. For culturally compe- In order to offer care that is accessible and provide relevant interventions. tent screening: and tailored to each patient, health care Eliciting specific information about ■ Avoid making assumptions based providers must consider the multiple the patient’s beliefs and experience on the person’s appearance. Do not issues victims may deal with simultane- assume the victim’s economic, educa- ously (including language barriers, limit- tional and immigration status, her/his ed resources, homophobia, accultura- sexuality, or the community(ies) she/he tion, accessibility issues and racism) and Screening and belongs to based on name, clothes, or recognize that each patient who is an accent. IPV victim will experience both the intervention for ■ Ask about support systems avail- abuse and the health system in cultural- able in each of the victim’s communi- ly specific ways. Disparities in access to domestic violence does ties for victims who identify with multi- and quality of health care may also not mean attempting ple communities. impact providers’ abilities to help abused ■ Listen to patients; pay attention patients. For example, women of racial to “fix” the abuse or to words that are used in different cul- and ethnic minority groups are more tural settings and integrate those into likely than white women to experience for the patient to screening questions. For example, for difficulty communicating with their coastal Inuit groups, “acting funny” physicians and often feel they are treated leave the abuser. describes IPV, in some Latino commu- disrespectfully in the health care set- nities “disrespects you” indicates IPV. ting.15 English-speaking Latinos, Asians ■ Use the term “partner” or “any and African American patients report not with abuse, sharing general informa- other family member” or “anyone close fully understanding their physicians and tion about IPV relevant to that experi- to you” when you interview regarding feeling like their physicians were not lis- ence and providing culturally accessi- domestic violence. tening to them.16 People with cognitive ble resources in the community, ■ Focusing on actions and behav- or communication disabilities may be improves the quality of care for vic- iors as opposed to culturally specific ter- dependent on an abusive partner and tims of violence. At the same time, it minology can also help. Some groups thus at especially high risk. is very important for health care may be more willing to discuss abuse if Health care providers also enter providers to bear in mind that screen- you use general questions. patient encounters with their own cul- ing and intervention for domestic vio- ■ Be aware of verbal and non-ver- tural experiences and perspectives lence does not mean attempting to bal cultural cues such as eye contact or unique from those of the victim. Often, “fix” the abuse or for the patient to not, patterns of silence, spacing and providers assume they know the vic- leave the abuser. active listening during the interview. tim’s beliefs or experiences based on ■ Be aware that for lesbian and gay previous interactions with the victim’s Effective Screening Strategies victims, disclosing abuse may be their community(ies). This knowledge may be It is recommended that dental care first experience coming out. useful at times. However, in a clinical providers screen all adolescent and ■ When screening victims from encounter it may also create difficulties adult patients for domestic violence communities of color and immigrant leading to incorrect assumptions about regardless of cultural background. communities, be aware victims may the victims. This is why it is important Screening should include men when have legitimate concerns and fears for the provider be fully aware of bias they present with clinical indicators in about law enforcement and/or immigra- and the source of knowledge about any order to reach out to male victims who tion authorities. community. It is easy to use the incor- are in same-sex, bisexual and hetero- ■ Address victim’s concerns about rect assumptions to impose the sexual relationships. confidentiality; inform the patient of provider’s values on others. Sensitive screening questions for all any mandatory reporting requirements

390 CDA.JOURNAL.VOL.32.NO.5.MAY.2004 Table 1 experience a loss of control over their lives. As a result, many victims may feel Sample Screening Questions: they are placing themselves in greater jeopardy by disclosing abuse. To help ■ Begin by being indirect: “If a family member or friend was hurt or threatened by a restore a sense of control in the victims’ partner, do you know of resources that could help them?” lives, it is suggested to: ■ Use your patient’s language: “Does your boyfriend disrespect you?” ■ Discuss with the patient what ■ Be culturally specific: “Abuse is widespread and can happen even in lesbian rela- steps she/he has taken in the past to tionships. Did your partner ever try to hurt you?” make her/him safer. Discuss the devel- opment of a safety plan with her/him, ■ Focus on behaviors: “Has your partner ever hit, shoved, or threatened you?” taking into account the culturally spe- ■ Provide the victim with an opportunity to talk with someone else from their com- cific needs of the patient. munity if they are uncomfortable with you: “If you are not comfortable with me, let ■ Explain all dental/health care us figure out whom you can talk to about this situation.” procedures in a simple, easy-to-understand manner for victims whose primary language is not English, and for vic- or other limits to patient/provider con- tims with low-literacy levels. fidentiality. As in all other ■ Inform the victim about her/his ■ Ask whether the victim would rights, and resources and referrals that prefer to use an interpreter if English is domestic violence serve specific community(ies) the vic- not the victim’s first language. Do not tim identifies with. use a partner, children or any accompa- interventions, it is ■ Gather information and knowl- nying person to interpret. edge about community resources, includ- ■ Be aware of your own assump- important to provide ing domestic violence advocates and cul- tions about family. Victims belong to unconditional support turally specific agencies who might work and are part of families, extended fami- with you and the victim. lies and communities. As a result, the for the choices that ■ Save questions regarding sexual victim’s definition of family might be identity and immigration status for later different from that of the provider the victim makes, even in the interview. Asking too soon can (Table 1). create fear amongst victims who do not if you disagree. want to be reported, or who have con- Health and Safety Assessment cerns that they will receive less care Assessment can enable dental care because of their status. providers create a supportive environ- Intervention with Victims of ■ Convey an appreciation to the ment in which the patient can discuss DV/IPV patient for disclosing and encourage the abuse. Assessment also allows A culturally competent intervention her/him to schedule follow-up visits. providers to gather information about respects a victim’s right to determine Finally, as in all other domestic vio- the potential danger/lethality of the the course of her/his actions. This lence interventions, it is important to abuse as well as health problems associ- means acknowledging a victim may provide unconditional support for the ated with the abuse, and consider the have multiple pressures, including com- choices that the victim makes, even if immediate and long-term health and munity expectations that prevent the you disagree. Only the victim knows safety needs for the patient in order to acceptance of safety options. Though the perpetrator and the safety risks develop and implement a response. the provider’s goal is to ensure victim involved. An adult victim has the right Dental care providers should ask the safety, it is important to remember a to self-determination. victim about the community’s response victim will accept an option only when to marriage, divorce, domestic violence, it makes sense from her/his frame of ref- Preparing Your Practice health and healing, and find out how erence. Validating the victim’s experi- It is essential the clinical setting for the victim responds to cultural expecta- ences, and providing unconditional any dental care practice be designed to tions, allowing the victim to define support is important. support the staff to respond effectively her/his culture and community. Victims of domestic violence often and efficiently to victims of abuse. In

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ual, and transgender Save the Date ■ Feedback mechanisms for providers The Family Violence Prevention Fund will hold its biennial National Conference on Health Care and Domestic Violence: Health Consequences Over the Lifespan on Oct. Improved Staffing and Community 22-23 at the Park Plaza Hotel in Boston, Mass. For more information or to submit abstracts, contact Mari Spira, conference coordinator, (415) 252-8900, Ext. 20 or Outreach [email protected]. You can also visit the Web site http://endabuse.org/health/ Hiring and designating diverse staff conference/. that represent the patient population served at your clinic can greatly impact A pre-conference workshop for dentists, dental hygienists and dental assistants from the public perception of your practice 1 to 4 p.m. Oct 21, preceding the 2004 National Conference. Lynn Mouden, DDS, MPH, as being sensitive to the needs of will be a faculty presenter. Mouden is president of the Association of State & Territorial Dental Directors, and director of the Office of Oral Health, Arkansas diverse communities. It is also impor- Department of Health. Participants at this workshop can earn continuing education tant to train staff, from dental assis- credits. For more information, contact Vibhuti Mehra at (415) 252-8900, ext. 29 or tants to dentists, on how to ask and [email protected] talk to a patient about domestic violence, and identify resources available in the community. preparing the practice, it is advisable to ■ Have handouts that are multicul- Dental care providers should also obtain support from the leadership and tural, multilingual and reflect patient develop links to and initiate collabora- administration at your setting as well diversity for victims and perpetrators, tion with community based agencies in as staff input. Given that a majority of and that describe the impact of IPV on their vicinity that specialize in domestic dental care providers function as solo children. These include brochures, palm violence. To ensure supportive staff practitioners, it is recognized dental cards, discharge instructions, safety response for victims of abuse presenting professionals often find it challenging planning instructions, resource and at your clinic: to conduct routine screening for and referral lists. Place these in exam rooms ■ Identify and establish relation- responding to IPV. However, there are and private places such as the rest ships with community programs pro- a number of easy steps dental profes- rooms. Take into account the literacy viding culturally specific advocacy for sionals can take to overcome the chal- level of your patient population when victims of domestic violence. lenges and make their clinical setting collecting and/or developing these ■ Refer patients to advocacy and conducive to identifying and respond- materials. support services within the community. ing to victims of IPV in a culturally ■ Have member or patient newslet- Offer a choice of available referrals competent way. ters that contain information on IPV. including local DV resources or the Dental care providers also need to National DV Hotline (800) 799-SAFE, Physical Environment have access to resources in order to TTY (800) 787-3224. The dental care setting should pro- screen and respond effectively. Provider ■ Refer patients to organizations vide a culturally appropriate environ- resources should include: that address their unique needs such as ment for all the populations served at ■ Chart prompts in medical records organizations with multiple language the clinic. The physical environment of ■ Documentation and assessment capacities, or those specializing in work- the clinic or department should: forms ing with specific populations (i.e. teen, ■ Allow for confidential interview- ■ Posters and practitioner pocket elderly, disabled, deaf or hard of hearing, ideally establishing a policy that cards ing, particular ethnic or cultural com- requires a portion of the interview be ■ Materials, that are regularly updat- munities or lesbian, gay, bisexual or conducted in private. ed, are easily accessible to providers transgender clients). ■ Have posters/visual images on ■ Consultation with on-site or off- ■ Trained domestic violence advo- IPV that are multicultural, multilingual site DV advocates, legal and forensic cates or social workers, as well as skilled and reflect patient diversity; that pre- experts, counselors with expertise in interpreters who are trained to under- sent available resources, and that trauma treatment, and community stand domestic violence (and who are include information about victims, per- experts from diverse communities such not family members, caregivers, or chil- petrators and or other family and com- as the disabled, elder, teen, ethnic spe- dren of non-English speaking patients), munity members affected by abuse. cific, immigrant and lesbian, gay, bisex- can be made available on-site at dental

392 CDA.JOURNAL.VOL.32.NO.5.MAY.2004 offices housed within primary care clin- Training for staff should include: gies, reporting policies and confiden- ics or settings. Dental offices housed ■ Survivors’ perspectives tiality rules within larger clinical settings can also ■ Cultural competency ■ Roles and responsibilities of staff hire and/or designate specific health ■ Dynamics of victimization and All staff should receive an orienta- care staff to oversee the IPV program, perpetration tion on the protocol. It should also be and invest in training and retaining the ■ Physical and mental health con- updated regularly and inform of new designated staff. sequences of IPV on victims and chil- knowledge, laws, and policies regarding dren exposed IPV. It should be accessible to all staff. Training Staff ■ How to screen, assess, intervene, To maintain progress of current Training on domestic violence and support, and document appropriately practices, dental care providers should cultural competency should be part of ■ Interactive role playing and ensure continuous quality improve- staff orientation — ongoing, repeated, modeling of screening and response ment programs are in place at dental institutionalized, and mandatory for all techniques care clinics or facilities. A continuous employees. Dental care providers who quality improvement program may will be screening and documenting in Set Quality Improvement Goals and entail: the medical record should receive train- Implementation Methods ■ Regular discussions during staff ing on the dynamics of IPV and clinical Systems should be in place in the meetings regarding functioning of IPV response, as well as other staff and allied dental care clinical setting that help program health professionals. The FVPF has providers ensure relevant educational ■ Patient satisfaction surveys developed a training video/CD titled materials for patients are always avail- ■ Links to other quality improve- Screen to End Abuse for health care able; that providers and staff have the ment efforts providers that would be a useful training training and tools they need, and that ■ Scheduled audits of select med- tool for dental and oral health providers specific quality improvement goals for ical records to review compliance with (To order a copy of the video/CD, visit: IPV screening and intervention are protocol http://store.yahoo.com/fvpfstore/). developed. These goals can be set for ■ Links to any medical informa- Receptionists and security, which can screening and response protocols or for tion system developments play an essential role in identifying vic- the number of patients dental care ■ Continuous quality improve- tims, should receive general awareness providers expect to identify and assist in ment goals are shared with providers training on IPV. Interpreters in particu- their practice. lar should be trained in advance about Dental care providers should ensure Conclusion the dynamics of IPV and the importance that the screening and response proto- Dental care providers, along with of confidentiality and non-judgmental cols for their clinical setting include: other health care professionals, can play interpretation and appropriate word ■ Definitions, guiding principles, an important role in identifying and pre- choices for translation of routine screen- routine screening, assessment, inter- venting intimate partner violence. ing questions. vention, and documentation strate- Routine, culturally competent screening, with a focus on early identification of all victims of IPV whether or not symptoms How to reach us are immediately apparent, is a primary starting point for an improved response The Family Violence Prevention Fund is a national non-profit organization committed in dental practice. Brief interventions to mobilizing concerned individuals, allied professionals, women’s rights, civil rights, with clients disclosing IPV have led to other social justice organizations and children’s groups through public education/prevention campaigns, public policy reform, model training, advocacy programs and increased use of victim services, more organizing. safety behaviors, and less physical abuse.17,18 At the same time, dental care The FVPF’s National Health Resource Center on Domestic Violence (HRC) provides providers must bear in mind there are both free and low-cost resources, training materials, and technical assistance to all many reasons why a patient may or may health care providers serving victims of domestic violence. not disclose abuse. Therefore, success of For technical assistance, call (888) Rx-ABUSE; TTY: (800) 595-4889; or visit the Web the provider’s response should not be site: www.endabuse.org/health based on disclosure alone. The dental care provider’s job is not to “fix” inti-

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mate partner violence or for the patient Health Care Settings 2003. 14. Family Violence Prevention Fund. From to leave the abuser. Dental care providers sensitivity to competency: Clinical and depart- should instead focus on helping the vic- mental guidelines to achieving cultural competency. Improving the Health Care Response to Domestic tims by identifying the abuse, validating Violence: A Resource Manual for Health Care Providers the victims’ experiences, being support- 1996. 15. The Commonwealth Fund. Health Care ive, and helping them to identify Quality Survey. The Commonwealth Fund, 2001. options. Success in a dental care setting 16. The Commonwealth Fund and Princeton Survey Research Associates. Racial and Ethnic involves creating a safe and culturally Variations in Patient-Physician Communication competent environment for screening and Adherence to Doctor’s Advice. The Commonwealth Fund, 2001. and disclosure, giving supportive mes- 17. McFarlane J, Parker B et al, Safety behav- sages to victims, educating patients iors of abused women after an intervention during pregnancy. J Obstet Gynecol Neonatal Nurs 27(1):64- about abuse and connection to health, 9, 1998. offering strategies to promote safety, and 18. McFarlane J, Soeken et al, An Evaluation of interventions to decrease intimate partner violence informing clients about relevant com- to pregnant women. Public Health Nurs 17(6):443- munity resources. CDA 51, 2000.

To request a printed copy of this article, please Recommended reading / To download or order a contact / Vibhuti Mehra, Family Violence copy of the publication National Consensus Prevention Fund, 383 Rhode Island St., Suite 304, Guidelines on Identifying and Responding to Domestic San Francisco, Calif., 94103-5133, (415) 252-8900, Violence Victimization in Health Care Settings, visit Ext. 29. Web site www.endabuse.org/health.

References / 1. National Institute of Justice and Centers for Disease Control and Prevention. Prevalence, incidence and consequences of violence against women: Findings from the National Violence Against Women survey. National Institute of Justice and Centers for Disease Control and Prevention, 1998. 2. McCauley J, Kern DE et al, The ‘battering syndrome’: Prevalence and clinical characteristics of domestic violence in primary care internal medicine practices. Ann Intern Med 123(10):737-46, 1995. 3. Dearwater SR, Coben JH et al, Prevalence of intimate partner abuse in women treated at community based emergency departments. JAMA 280(5):433-8, 1998. 4. Coker AL, Smith PH et al, Physical health consequences of physical and psychological intimate partner violence. Arch Fam Med 9:451-7, 2000. 5. Campbell JC, Lewandowski LA, Mental and physical health effects of intimate partner violence on women and children. Psychiatr Clin North Am 20(2):353-74, 1997. 6. Lehman P, Post Traumatic Stress Disorder (PTSD) and child witnesses to mother-assault: A summary and review. Child Youth Servs Rev 22(3/4):275-306, 2000. 7. Graham-Bermann SA, Levendosky AA Traumatic stress symptoms in children of battered women. J Interpers Violence 13(1): 111-28, 1998. 8. Lowe C, Gerbert B et al, Dentists’ attitudes and behaviors regarding domestic violence: The need for response. J Am Dent Assoc 132: 85-93, 2001. 9. Love Op. Cit. 10. Short S, Tiedemann JC et al, Family violence: An intervention model for dental professionals. Northwest Dent 31-5, 1997. 11. Love Op. Cit. 12. Short Op. Cit. 13. Family Violence Prevention Fund. National Consensus Guidelines on Identifying and Responding to Domestic Violence Victimization in

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Domestic Violence: Casey Gwinn, JD; George E. McClane, MD; Kathleen A. Shanel-Hogan, DDS, MA; and No Place for a Smile Gael B. Strack, JD

ABSTRACT t was the loose tooth that caused Because dentists routinely assess a patient’s head, neck and mouth, they have a Samantha to seek out her dentist. unique and excellent opportunity to recognize whether or not a patient is being abused. If the tooth fell out, she would have to explain what happened to This article seeks to enlist the collaboration of the dental community in the effort her co-workers. She wasn’t ready to tell, at least not yet. As she to prevent domestic/intimate partner violence and provide more information about Idrove to the dentist’s office, she prac- the signs and symptoms of domestic violence injuries, including strangulation, ticed her story: She fell while trying to change the bathroom light bulb. which is often overlooked by medical and dental professionals. Strangulation has Makeup would conceal the rest. The only been identified in recent years as one of the most lethal forms of domestic pain in her throat and the difficulty swallowing, no one would notice that. violence. Unconsciousness may occur within seconds and death within minutes. It If only she hadn’t resisted so much is known that victims may have no visible injuries whatsoever yet because of when her husband tried to choke her. But the minute Samantha checked in, underlying brain damage by a lack of oxygen from being strangled, victims may the receptionist knew something wasn’t have many serious internal injuries or die days or several weeks later. right. It may have been the aimlessness with which she walked, the sadness in Strangulation is often indicative of a high level of domestic violence in a relation- her eyes, or maybe the resignation in ship. Attempted strangulation may cause physiological changes evident in the her voice. Her dentist sensed something too. Her voice sounded hoarse and a lit- course of a dental examination. For these reasons, dentists should be vigilant in looking for its symptoms. P URPOSE OF PAPER Despite our collective efforts, domestic violence continues to be a problem. A Authors / Casey Gwinn, JD, is the missing ingredient is a strong partnership with the dental community. The legal city attorney for San Diego. George E. McClane, MD, is an community needs the expertise of the dental community to detect and document emergency physician at Sharp Grossmont Hospital and medical domestic violence injuries. Victims need support and referrals from their dentists. director for San Diego Justice Center’s Forensic Medical Unit. Early detection and intervention can save lives. Kathleen A. Shanel-Hogan, DDS, MA, is a consultant, educator, facilitator and family violence prevention advocate. She works This article seeks to enlist the help of the dental community and provide more with the California Dental Association Foundation as a consultant and a mandated reporter training in all forms of family violence. She is author of the information about the signs and symptoms of domestic violence injuries, includ- Dental Professionals Against Violence Program. Gael B. Strack, JD, is assistant city attorney for ing strangulation, which is often overlooked by medical and dental professionals. San Diego.

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tle raspy. Beneath her makeup, he addressed the issue of domestic violence. finds that although some controversy noticed a rash and a thumb-sized bruise Health care professionals have also exists regarding the need for screening on her neck. This was not the first time become increasingly involved in the and which methods of screening are he had noticed injuries that seemed fight against domestic violence. In 1985, best, it is prudent to offer some form of inconsistent with her explanations and former U.S. Surgeon General C. Everett screening to all patients presenting to certainly not the first time that Koop brought national attention to the health care system. This can be Samantha refused to smile. But this domestic violence as a public health done by direct clinician inquiry, patient time, things seemed more serious. To problem.5 The surgeon general stated: health questionnaires or system query the dentist the injuries suggested vio- “Identifying violence as a public in the form of posters and information lence, possibly even attempted strangu- health issue is a relatively new idea. available for distribution. Effective lation. What should he do? Should he screening sets the stage for intervention say something to Samantha? To some- Because dentists and successful intervention sets the one else? Did his suspicions put him stage to break the cycle of violence.7 under any sort of legal obligation? routinely assess a In a recent survey conducted by the Domestic violence leaves no room UCSF School of Dentistry, it was found for a smile — not in one’s home, at patient’s head, neck that many dentists currently don’t screen work, or even in a dentist’s office. for, or even report, signs of domestic vio- Domestic violence is now recognized as and mouth, they have lence, but more than half the dentists sur- one of the nation’s most pressing veyed said they would like more training women’s health problems.1 The Centers a unique and excellent in this area. Aside from a lack of proper for Disease Control and Prevention education in detection of the clinical reports that the health-related costs of opportunity to signs and symptoms of human abuse,8 intimate partner violence against the UCSF researchers found other reasons women exceed $5.8 billion annually in recognize whether for the lack of screening: the presence of the U.S. The cost to the criminal justice family members during the visit; con- system (police, prosecutors, the courts — or not a patient is cerns about offending the patient and the civil, juvenile and criminal) has yet to be dentist’s own embarrassment when talk- calculated. It is estimated that nearly 4 being abused. ing to the patient. million women each year suffer domes- Under California law, health care tic violence.2 When battered women are Traditionally, when confronted by the providers must report suspected or severely injured, they seek help. They circumstances of violence, the health known domestic violence due to physi- seek help from police officers and their professions have deferred to the criminal cal assault to local police by telephone health care professionals, including their justice system … [Today] the professions immediately and in writing within 48 dentist. Between 22 percent and 35 per- of medicine, nursing and the health- hours.9 Dentists, registered dental cent of women’s visits to hospital emer- related social services must come forward hygienists, and registered dental assis- gency departments are prompted by and recognize violence as their issue.”6 tants are mandated reporters and are injuries or illness related to ongoing required to report. Failure to report abuse or stress from such abuse.3 The lit- Dentists can play a key role in domestic violence exposes the health erature reports 36 percent to 95 percent the fight against domestic care provider to a misdemeanor which is of battered women are suffering injuries violence punishable by a maximum $1,000 fine to the face, neck or head.4 It is important Because dentists routinely assess a and/or six months in county jail. Not to also recognize that men or women patient’s head, neck and mouth, they only is the failure to report a violation of can be battered by intimate partners of have a unique and excellent opportuni- law, it also makes it more difficult for either sex. Dentists naturally observe a ty to recognize whether or not a patient the dentist to defend against potential patient’s head, neck and mouth. As is being abused. One of “the most civil lawsuits. More importantly, failing such, dentists have a unique opportuni- important contributions physicians can to report suspected or known instances ty to recognize whether or not a patient make to ending abuse and protecting of domestic violence represents a missed is being abused. the health of its victims is to identify opportunity to assist the patient in Over the last 20 years, due to height- and acknowledge the abuse,” according escaping an abusive relationship. ened awareness, both the health care to the Council on Ethical and Judicial There is some controversy regarding and criminal justice system have Affairs, AMA, 1992. Dr. Ellen Taliaferro the efficacy of screening and reporting

400 CDA.JOURNAL.VOL.32.NO.5.MAY.2004 laws but this is not the subject of this understanding and support — even updated list of local domestic violence article. Rather, this article is intended to within the limited confines of an office service agencies19 and other community inform health care providers that they visit — can provide a much-needed mea- resources to give to battered patients. are subject to the law and that they must sure of hope for the battered woman. Materials from Dental Professionals follow the law’s relatively straightfor- Because a battered woman is subject to Against Violence (DPAV) can assist the ward reporting requirements. In fact, 45 an intense level of emotional degrada- dental professionals in preparing a proto- states have laws that mandate reports of tion on an almost daily basis, a few col for the dental offices. For more infor- injuries caused by weapons, crimes or words of encouragement may help her to mation contact DPAV at the California domestic violence.10 At least one study begin to re-evaluate her relationship and Dental Association Foundation (916) has shown that mandatory reporting possibly move her beyond the violence. 443-3382, ext. 8900. laws do not deter patients from seeking Dr. Barbara Gerbert, who is a UCSF medical care.11 Researchers using both professor and chair of the Division of simple interview techniques and ques- By asking a few Behavioral Sciences in the School of tionnaires in medical surroundings have well-placed questions, Dentistry, suggests a model in which den- found that identification of domestic tists ask patients about abuse. Give vali- violence is not difficult.12 Also, in many dentists can confirm dating messages which acknowledge that cases women do talk quite frankly about battering is wrong and which confirm the causal factors when asked directly and the presence of patient’s worth; document signs, symp- often battered women are waiting for toms and disclosures in writing and with someone to do just that.13 The dental domestic violence photographs; and refer victims to domes- professional often has established trust tic violence specialists in the community. with the patient and appointments are and set the stage for While detection of domestic vio- often 45 minutes to 90 minutes long. lence injuries is generally not difficult, The research indicates that by asking a positive intervention it does require the healthcare profes- few well-placed questions, dentists can sional to be perceptive. There is a ten- confirm the presence of domestic vio- in the lives of dency of abused patients to minimize lence and set the stage for positive inter- domestic violence and/or hide their vention in the lives of battered women. battered women. injuries. For this reason, it is important It is true for all victims and it is true to review the obvious signs of injuries as for victims in dentists’ offices: “[I]identi- In any event, it is unlikely she will forget well as the subtler signs and symptoms fication of domestic violence is the first the intervention.16 of strangulation. stage of intervention. Asking about abuse In the absence of intervention, bat- helps to break the isolation a battered tering tends to recur with increasing fre- Domestic Violence Injuries woman may experience and lets her quency and severity.17 To safeguard vic- The head, face and neck are the know resources are available if and when tim safety, Warshaw and Ganley recom- most frequent places injury is received she feels she can use them.”14 In a study mend that health care providers should during domestic violence. There is also of how physicians helped victims of inform patients of their legal obligation evidence to suggest that male attackers domestic violence, UCSF researchers to report if domestic violence is indicat- may tend to avoid striking the face so found that physicians who provided val- ed.18 It is recommended that before mak- that injuries will not be apparent to idation — acknowledged that the abuse ing a report, a concerned dentist should onlookers; instead, a blow to the back of had occurred and confirmed the explain that the consequences of the the head may be more common.20 Drs. patient’s worth — had a positive impact report may include a law enforcement Salber and Taliaferro have identified the on patients. The study found validating response. Asking the patient to partici- following injuries as characteristic of messages such as “battering is wrong” pate in the telephone call to make the domestic violence.21 and “you deserve better treatment” not report can facilitate a dialogue between ■ Bilateral injuries, especially to the only provided relief and comfort to the patient and law enforcement. The extremities women, but also helped them realize the response can then work collaboratively ■ Injuries at multiple sites seriousness of their situation and helped with the patient regarding timing and ■ Fingernail scratches, cigarette them move forward toward safety.15 A type of response with attention to the burns and rope burns dentist who recognizes the signs of safety of the patient and any children. ■ Abrasions, minor lacerations or domestic violence and is willing to offer Dentists should also have available an welts

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■ Pattern injuries such as bite marks; that may be detected by a dentist23 are: later.25 Strangulation is often indicative marks from jewelry, belts or keys; or ■ Intraoral bruises from slaps, hits of a high level of domestic violence in a designs or patterns stamped or imprinted and soft tissue pressed on hard struc- relationship. Attempted strangulation on or immediately below the epithelium tures like teeth and bones. may cause physiological changes evi- by weapons ■ Soft and hard palate bruises and dent in the course of a dental examina- ■ Injuries that are inconsistent with abrasions from implements of pene- tion. For these reasons, dentists should the victim’s explanation tration could indicate force from a be vigilant in looking for its symptoms. ■ Multiple injuries in various stages sexual act. In a study conducted by the San of healing ■ Fractured teeth, nose, mandible Diego City Attorney’s Office of 300 ■ Injuries during pregnancy and/or maxilla. Signs of healing frac- domestic violence cases, visible injuries The typical bite mark, according to tures may be detected in panoramic such as tiny red spots on the face, bloody Dr. Sperber, is a “round or oval, ring- radiographs. red eyes, red marks, scratches and bruis- shaped injury consisting of two facing ■ Abscessed teeth could be from ing on the neck, were only visible 16 per- arches, each made up a series of aligned tooth fractures or repeated hitting to cent of the time.26 Often, when visible contusions, abrasions and/or lacera- one area of the face. injuries were present, the injuries were tions. The center injury measures 3 cm ■ Torn frenum (a fold of membrane subtle and hard to find. The study dis- to 4 cm. The individual markings com- closed other symptoms. To understand prising the arches represent the biting the medical significance of the findings surfaces of front teeth distributed Attempted from the study, the city attorney’s office around the upper and lower jaws.” enlisted the help of George McClane, an There are also variations in the pat- strangulation may emergency physician, and Dean Hawley, tern:22 a specialist in forensic pathology, for ■ Central ecchymosis — contusion cause physiological their medical perspective. within the center of the bite mark caused by capillary bleeding. It occurs as changes evident in the The Medical Perspective a result of compression of tissue by the course of a dental Strangulation is defined as a form of teeth with or without suction. asphyxia characterized by closure of the ■ Drag marks — radiating, linear examination. blood vessels and/or air passages of the contusions or abrasions at the periphery neck as a result of external pressure on of the mark indication of scraping of the neck.27,28 The three forms of stran- teeth along the skin as the bite occurred. which checks or restrains the motion of gulation are hanging, ligature, and ■ Avulsed bite mark — when the a part, such as the fold on the underside manual. Almost all attempted or actual bitten tissue is torn off, leaving a central of the tongue or upper lip) from assault homicides by strangulation involve lacerated defect. or forced trauma to the mouth. either ligature or manual strangulation. ■ One arched bite mark — rare, but ■ Hair loss from pulling, black Ten percent of violent deaths in the U.S. may occur. eyes, ear bruises, other trauma and lac- each year are due to strangulation, six ■ Half-bite mark — when only the erations to the head. females to every male. right or left side of a bite mark shows up. Ligature strangulation is strangula- ■ Double-bite mark — bite mark The Signs and Symptoms of tion with a cord-like object (also referred within a bite mark. Occurs when skin is Attempted Strangulation to as garroting), and may include any- bitten, then starts to slip out between Strangulation has only been identi- thing from a telephone cord to articles of teeth and is bitten again. fied in recent years as one of the most clothing.29,30 Manual strangulation or ■ Overlapping bite marks — multi- lethal forms of domestic violence. throttling is usually done with the hands, ple, separate bite marks made repeated- Unconsciousness may occur within sec- but notable variants include using the ly in the same general location. onds and death within minutes.24 It is forearms (as when police officers use the ■ Toothless bite mark — shows a known that victims may have no visi- carotid restraint) to standing or kneeling contused ring of compatible size and cur- ble injuries whatsoever, yet because of on the victim’s throat.31,32 Manual vature but without well-defined, individ- underlying brain damage by a lack of self-strangulation is not possible, because ual tooth marks. Occurs in healing bite oxygen from being strangled, victims when the individual loses consciousness, marks and bite marks on soft or fatty skin. may have many serious internal pressure can no longer be applied. Typical domestic violence injuries injuries or die days or several weeks A review of neck anatomy is critical

402 CDA.JOURNAL.VOL.32.NO.5.MAY.2004 Hyoid Bone Carotid Artery Thyroid Cartilage (with fracture shown) Jugular Vein Tracheal Rings

Figure 1. Anatomy illustration of the neck. Figure 2. These markings may have been Figure 3. Classic abrasions caused by the victim’s fingernails in an attempt caused by victim’s own nails while to remove a chokehold. They also may be attempting to remove assailant’s caused by the assailant adjusting their hands hands or ligature. The vertically ori- and applying force during a vigorous struggle. ented pattern demonstrates bicep The webbing between the thumb and index fin- muscle strength at its best advantage ger can produce the linear lesions shown. in this defensive maneuver. in order to understand adequately the ately, consciousness will be regained Behavioral changes may manifest clinical features of a strangled victim. within 10 seconds. To completely close early as restlessness and combative- The hyoid bone, a small horseshoe- off the trachea, three times as much ness due to temporary brain anoxia shaped bone in the neck, helps to sup- pressure, 33 pounds, is required. Brain and/or severe stress reaction, and sub- port the tongue. The larynx, made up of death will occur in four to five minutes, sequent resolve.35 While dentists may cartilage, not bone, consists of two if strangulation persists. not have the opportunity to observe parts: the thyroid cartilage (so-called these early symptoms, changes can because it is next to the thyroid gland) Signs and Symptoms also be long-term, resulting in frank and the tracheal rings. Symptomatic voice changes will psychosis and amnesia. Carotid arteries are the major vessels occur in up to 50 percent of victims, and Visible injuries to the neck include that transport oxygenated blood from may be as mild as simple hoarseness or as scratches, abrasions, and scrapes. These the heart and lungs to the brain. These severe as complete loss of voice.34 may be from the victim’s own finger- are the arteries at the side of the neck Swallowing changes are due to injury of nails as a defensive maneuver, but com- that persons administering cardio-pul- the larynx cartilage and/or hyoid bone. monly are a combination of lesions monary resuscitation check for pulses. Swallowing may be difficult but not caused by both the victim and the Jugular veins are the major vessels that painful, or painful. Breathing changes — assailant’s fingernails. transport deoxygenated blood from the normally the result of the hyperventilat- Lesion location varies depending on brain back to the heart (Figure 1). ing that goes hand in hand with a terrify- whether the victim or assailant used The general clinical sequence of a vic- ing event—may more significantly be the one or two hands, and whether the tim who is being strangled is one of result of an underlying neck injury. The assailant strangled the victim from the severe pain, followed by unconscious- victim may find it difficult to breathe front or back. Three types of fingernail ness, then brain death. The victim will (dyspnea) or may be unable to breathe markings may occur, singly or in com- lose consciousness by any one or all of (apnea). It is critical to note that breath- bination: impression, scratch, or claw the following: blocking of the carotid ing changes following an attempted marks (Figure 2). arteries (depriving the brain of oxygen), strangulation may be subtle or mild. Impression marks occur when the fin- blocking of the jugular veins (preventing However, the, underlying injuries may gernails cut into the skin; they are shaped deoxygenated blood from exiting the kill the victim up to 36 or more hours like commas or semi-circles. Scratch brain), and closing off the airway, caus- later due to the decompensation of the marks are superficial and long, and may ing the victim to be unable to breathe. underlying injured structures. Because be narrow or as wide as the fingernail Only 11 pounds of pressure placed dentists are unlikely to see the victims of itself. Claw marks occur when the skin is on both carotid arteries for 10 seconds is attempted strangulation until hours or undermined; they tend to be more vicious necessary to cause unconsciousness.33 days after the event, they should be espe- and dramatic appearing36,37,38 (Figure 3). However, if pressure is released immedi- cially watchful for labored breathing. Because most victims are women, the

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Figure 4. Often, when a single bruise is the Figure 5. Diffuse petechiae with a confluent Figure 6. Subconjunctival hemorrhages are sole finding on a victim’s neck, it may be caused pattern found on upper eyelid of a young child essentially confluent petechiae caused by the rup- by the assailant’s thumb as this opposing digit has strangled by an adult male. Due to a thin dermal ture of the capillaries in the ocular sclerae bursting the greatest vector force in a human grip. It may layer, the eyelids are among the most susceptible from venous back up due to external pressure placed or may not manifest up to 24 hours after the tissue to manifest visible petechiae on both the upon the jugular veins. Though dramatic, they are assault took place. external and internal surfaces. painless, harmless and resolve in a matter of days. scratches caused by their longer nails fre- they may be found around the eyes in the from a strangulation attempt that may quently are more severe than the scratch- peri-orbital region, anywhere on the face, appear minor, dentists should encour- es caused by the assailant. Claw marks and on the neck in and above the area of age a medical evaluation of all victims may be grouped, parallel markings verti- constriction (Figure 5). who report being strangled or “choked.” cally down the front of the neck, but Petechiae tend to be most pro- At the Forensic Medical Unit located often are scattered in a random fashion. nounced in ligature strangulation.42 at the San Diego Family Justice Center, Redness on the neck may be fleeting, Blood-red eyes are due to capillary rup- the accompanying form (see page 408) but may demonstrate a detectable pat- ture in the white portion of the eyes is used for the documentation of stran- tern.39 These marks may or may not dark- (Figure 6). This phenomenon suggests a gulation injuries. Dentists are encour- en to become a bruise. Bruises may not particularly vigorous struggle between aged to use this form, or an equivalent, if appear for hours or even days. Fingertip the victim and assailant. they suspect or know a patient has been bruises are circular and oval, and often Ligature marks such as rope burns subjected to attempted strangulation. faint. A single bruise on the neck is most may be very subtle, mimicking the nat- frequently caused by the assailant’s ural folds of the neck. They may also be Small Window of Opportunity thumb40 (Figure 4). much more dramatic, reflecting the type The window of opportunity to inter- However, bruises frequently may run of ligature used, e.g., the wave-like form vene in domestic violence cases is short. together, clustering at the sides of the of a telephone cord, or the braided pat- Depending on the victim, her willingness neck, as well as along the jaw lines, and tern of a rope or clothesline. If the vic- to tell the truth may last only minutes may extend onto the chin, and even the tim has been strangled from behind, the and usually no more than a few days. She collar bones. impression from the ligature generally may also be experiencing guilt, one of Chin abrasions are also common in will be horizontally oriented at the same four characteristics of the Battered victims of manual strangulation, as the level of the neck. Woman Syndrome47 — guilt, denial, victim lowers the chin in an instinctive Swelling of the neck may be caused enlightenment or responsibility. For this effort to protect the neck, and in so by any one or combination of the fol- reason, a dentist who suspects domestic doing, scrapes the chin against the lowing: internal bleeding,43-45 injury of violence needs to work fast and intervene assailant’s hands. It is important that a any of the underlying neck structures, as quickly as possible. Recognize that by dentist document visible injuries to the or fracture of the larynx allowing air to the time a women seeks dental care for neck and face; photographs are an espe- escape into the tissues of the neck. her injuries, she may have had further cially effective form of evidence. Last, victims may have no visible contact with the batterer and may The tiny red spots, petechiae, charac- injuries whatsoever, with only transient already be entering the “honeymoon teristic of many cases of strangulation are symptoms — yet because of underlying phase.” Accordingly, a dentist should not due to ruptured capillaries — the smallest brain damage by lack of oxygen during be surprised if the patient refuses to admit blood vessels in the body — and some- strangulation, victims have died up to to any violence and attempts to describe times may be found only under the eyelids several weeks later.46 Because of these her injuries as the result of an accident. (conjunctivae).41 However, sometimes unforeseen consequences of injuries Even when the victim denies that

404 CDA.JOURNAL.VOL.32.NO.5.MAY.2004 domestic violence is taking place, this is a tive evidence-based prosecution50 simply The authors recognize the typical den- good opportunity to ask the victim if she means documenting the demeanor, tist’s office may not be equipped with spe- feels safe and if she believes it is OK to be description and physical condition of cial domestic violence forms, body maps abused. Usually victims will respond: the victim — including injuries or lack of and/or a camera to document additional “No, it’s not OK.” If this is the response, injuries; identity of the reporting party; information about domestic violence. The another follow up question could be: the party’s dental treatment; obtaining a good news is today there are many “What would you like to see done?” or medical release from the victim to later resources for medical professionals to “How can the behavior be stopped?” This corroborate her injuries; and any other improve their documentation.51 There is discussion helps the victim understand information — such as the identity of no need to reinvent the wheel. The why police and prosecutors need to go the abuser — that the victim is willing to Family Violence Prevention Fund has forward in order to stop abusive behavior provide that will assist in the prosecution developed health kits which may be easi- even if she does not to participate in the of the batterer. ly obtained via Web site www.fvpf.com to criminal proceedings. It also helps vic- For purposes of mandated reporting address the issue of domestic violence in tims understand that police and prosecu- under California Penal Code section the dental office. Included in this issue is tors are trying to help.48 11161, mandated reporters are required a copy of Sacramento County’s Intimate By understanding why victims deny to provide the following: Violence Mandated Report Form devel- that domestic violence is taking place, oped through the collaboration of all the dentists will be able see through the vic- healthcare systems in Sacramento, the tim’s “protection mechanism,” and Personal beliefs, dental community, law enforcement, jus- develop supportive and compassionate tice system, and fire/EMS departments. interviewing skills which will elicit biases or Domestic violence professionals such as truthful information as opposed to police officers, prosecutors and/or advo- “shutting” her down. prejudices should cates, are frequently available to provide training and other materials that contain Documentation never appear in a information about local resources. Often, Documentation is key to a successful medical record. a single phone call to a local domestic vio- intervention. When accurately and objec- lence shelter can provide a wealth of tively documented, documentation of phone numbers from which additional domestic violence incidents can be useful ■ The name of the injured person, resources and professionals can be locat- for criminal prosecution as well as civil if known. ed. And, DPAV provides continued train- cases. Language is critical. Personal ■ The injured person’s where- ing and support of dental professionals to beliefs, biases or prejudices should never abouts. recognize, respond and report domestic appear in a medical record. As an exam- ■ The character and extent of the violence situations as well as child abuse/ ple, the following phrase casts doubt on person’s injuries. neglect and dependent and elder abuse/ the victim’s credibility: “the patient ■ The identity of the person who neglect. For more information contact claims that her boyfriend hit her” as inflicted the wound, other injury, or DPAV at the California Dental Association opposed to “the patient stated “I was hit assaultive or abusive conduct upon the Foundation (916) 443-3382, Ext. 8900. by my boyfriend.” injured person. As a general rule, documentation of Even if victims are initially reluctant domestic violence injuries will generally to report, she may later want to pursue Penal Code Section 11161 further result in the quicker disposition of cases legal remedies. She may also change her recommends the following additional in court without requiring a health care mind. Documentation of past incidents information be included in medical provider’s in-court testimony. More will help either a criminal or civil case,49 records: importantly, clear documentation can especially if that documentation is absent ■ Include any comments by the greatly increase victim safety and offend- of bias. injured person regarding past domestic er accountability. By providing complete, Even when victims recant or become violence and the name of the abuser. objective and bias-free documentation in unavailable for trial, prosecutors can still ■ Map of the injured person’s body dental records, dentists can substantiate a proceed with prosecution without the showing and identifying injuries and victim’s account of the incident52 and victim’s testimony through what is now bruises at the time of the health care visit. make available more accurate data. The commonly referred to as evidence-based ■ Copy of the law enforcement data in turn lays the groundwork for prosecution. From the dentist’s perspec- reporting form. effective prevention strategies, improved

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policies and legislation. Patient charting and their children. The time has come for brain injury in female victims of domestic violence. Am J Obstet Gynecol 188: S71-6, 2003. is the essential first step toward injury the dental and legal professions to share 21. Salber P, Taliaferro E, The Physician’s Guide prevention.53 Structured charting may their expertise and work more closely to Domestic Violence 5: 57-9. Volcano Press, 1995. 22. Sperber N, Bite mark evidence in crimes provide yet more complete data collec- with other domestic violence prevention against persons, FBI Law Enforcement Bulletin. tion.54,55 The dental chart reflects collect- professionals. No single group can do it 23. Shanel-Hogan KA, Jarrett JA, Dentistry as a CDA collaborative partner in domestic violence recogni- ed information and data regarding inci- alone. Together we can! tion, Home Front, California District Attorneys’ dents of trauma, routine examinations, Association, Winter 2000; See also educational pro- and treatments that often include chart- To request a printed copy of this article, please gram Dental Professionals Against Violence contact / Gael Strack, assistant city attorney, San through the California Dental Association ing of the soft and hard tissues of the Diego City Attorney’s Office, Family Justice Center, Foundation (916) 443-3882 ext 8900; Manual of 707 Broadway, Suite 7900, San Diego, Calif., 92101. Forensic Odontology published by the ASFO and head and neck. Periapical radiographs of Forensic Dentistry published by CRC Press in Boca individual teeth and panoramic radi- Raton, Fla. ographs of the head may be available for References / 1. Sheridan D, Treating survivors of 24. Smith D, Mills T, Taliaferro E, Violence: intimate partner abuse: Forensic identification and Recognition, management and prevention, fre- pre- or post-trauma comparison. If the documents. Forensic Emerg Med 203-28, 2001. quency and relationship of reported symptomology patient has had restorative or orthodon- 2. Novella A, From the surgeon general, U.S. in victims of intimate partner violence: The effect Public Health Service. JAMA 276(23):31-2, 1992. of multiple strangulation attacks. J Emerg Med 21:3: tic treatment, available plaster or stone 3. Randlaa T, Domestic violence intervention 323-29, 2001. study models may demonstrate pre-trau- calls for more than treating injuries. JAMA 264: 25. Hawley D, McClane G, Strack G, Violence: 939-40, 1990. Recognition, management and prevention. A ma conditions. Intraoral photographs 4. Ochs HA, Neuenschwander MC, Dodson review of 300 attempted strangulation cases part III: may document structures prior to trau- TB., Are head, neck and facial injuries markers of Injuries in fatal cases. J Emerg Med 21(3): 317-22, domestic violence? J Am Dent Assoc 127(6): 757-61; 2001. ma. If trauma is demonstrated inside the Family Dent, wwww.cincytoothdoc.com, June 1996. 27. Strack G, McClane G, Hawley D, Violence: mouth, intraoral color photography pro- 5. Koop CE, Foreword. Violence in America: A Recognition, management and prevention. A public health approach. Ed. ML Rosenberg. New review of 300 attempted strangulation cases part I: vides documentation. Extraoral pho- York: Oxford University Press, 1991. Criminal legal issues, J Emerg Med 21(3): 303-9, tographs may be available also. 6. Flitcraft, A., Physicians and domestic violence: 2001. Line, WS Jr, Stanley RB Jr, Choi JH, Challenges for prevention, Health Aff 154-5, 1993. Strangulation: a full spectrum of blunt neck trau- 7. Taliaffero E, Screening and identification of ma. Ann Otol Rhinol Laryngol 94(6:1): 542-6, Nov. Conclusion intimate partner violence, Clin Fam Pract 5(1): 89, 1985 2003. 28. Iserson, KV, Strangulation: a review of liga- Efforts have improved identification, 8. Dr. Rajiv Khosla’s Web site, www.geoci- ture, manual, and postural neck compression documentation, professional education, ties.com/drkhosla1/news/news61.hmtl: See also injuries. Ann Emerg Med 13:3, 179-85, March 1984. Fam Dent, the Loewe and Wright Way, www.cincy- 29. Rupp JC, Suicidal garroting and manual forensic examination, community pre- toothdoc.com. self-strangulation. J Forensic Sci 15(1): 39-5, Jan. vention efforts and funding of services for 9. California Penal Code section 11160. 1979. 10. Houry D, Sachs C, Feldhaus K, Lindon J, 30. Hansch CF, Throat-skeleton fractured by victims of domestic violence.56 California Violence-inflicted injuries: Reporting law in the strangulation. Z Rechtsmed 79(2): 143-7, March, now boasts sophisticated responses to fifty states. Ann Emerg Med 39:1, 2002. 1977. 11. Houry D, Feldhaus K, Thorson AC, et al. 31. Hocking FD, Hanging and manual strangu- domestic violence from domestic vio- Mandatory laws do not deter patients from seeking lation. Med Sci Law 6(1): 49-1, Jan. 1966. lence response teams; vertical units in medical care. Ann Emerg Med 34: 336-41, 1999. 32. Srivastava AK, Das Gupta SM, Tripathi CB, 12. Robertson J, Domestic violence and health A study of fatal strangulation cases in Varanasi police departments or prosecutor’s office, care: An ongoing dilemma, Albany Law Review (India). Am J Forensic Med Pathol 8(3): 220-4, Sept. specialized courts, the California Medical 68:1199, 1995. 1987. 13. Ibid. 33. Luke JL, Reay DT, Eisele JW, Correlation of Training Center and Family Justice 14. Warshaw C, Ganley A, Improving the Health circumstances with pathological findings in Centers in San Jose and San Diego which Care Response to Domestic Violence: A Resource asphysixial deaths by hanging: A prospective study Manual for Health Care Providers published by the of 61 cases from Seattle, Wash., J Forensic Sci 30(4): houses the Forensic Medical Unit spon- Family Violence Prevention Fund 2(7): 64. 1140-7, Oct. 1985. sored by Sharp Grossmont Hospital. The 15. www.ucsf.edu/today/. 34. Stanley RB, Hanson DG, Manual 16. Robertson J, Domestic violence and health Stragulation Injuries of the Larynx. Arch Otolaryngol CDA Foundation with funding from care: An ongoing dilemma, Albany Law Review 109: 344-7. May 1983. Blue Shield Foundation and Dental 68:1207. 35. Patel F, Strangulation injuries in children. 17. Stark E, Mandatory arrest of batterers: A The Journal of Trauma: Injury, Infections and Critical Benefit Providers has expanded the pre- reply to its critics. Am Behav Scient 36(5):651-80, Care 40(1): 68-72, Jan. 1996. vious PANDA efforts to become DPAV 1993. 36. Perper JA, Sobel MN, Identification of fin- 18. Warshaw, C, Ganley A, Improving the Health gernail markings in manual strangulation. Am J to educate dental professionals, other Care Response to Domestic Violence: A Resource Forensic Med Pathol 2(1): 45-8, March 1981. mandated reporters, and foster commu- Manual for Health Care Providers published by the 37. Starrs JE, Procedure in identifying finger- Family Violence Prevention Fund, 2(9): 75. nail imprint in human skin survives appellate nity collaboration. 19. Dentists can obtain information about review. Am J Forensic Med Pathol 6(2): 171-3, June If battered victims with injuries seek their law enforcement response to domestic vio- 1985. lence by calling their local police department or 38. Harm T, Rais J, Types of injuries and inter- help from the legal and medical system, local shelter, as well as the Commission on Police related conditions of victims and assailants in then it is clear that the dental and legal Officer’s Standards (POST); California District attempted and homicidal strangulation. Forensic Sci Attorney’s Association; Statewide California Int 18:101-23, 1981. communities must work more closely Coalition for Battered Women; National Domestic 39. Ikeda N, Harada A, Suzuki T, Homicidal together. By developing strong partner- Violence Hotline. manual strangulation and multiple stun-gun 20. Corrigan J, Wolf M, Mysiw U, Jackson R, injuries. Am J Forensic Med Pathol 13(4):23-32, 1992. ships, we can restore the smiles of victims Bogner J, Early identification of mild traumatic 40. Harm T, Rajs J, Face and neck injuries due

406 CDA.JOURNAL.VOL.32.NO.5.MAY.2004 to resuscitation versus throttling. Forensic Sci Int E, Caraway N, Baskin DS. Strangulation as a 12:109-15, 1983. Method of Homicide. Arch Pathol 83:64-70, Jan. 41. Jaffe FA, Petechial hemorrhages: A review 1967. Luke JL. of pathogenesis. Am J Forensic Med Pathol 15(3):203- 47. The relevance of battered women’s syn- 7, Sept. 1994. drome evidence and the common experiences of 42. Luke JL, Strangulation as a method of battered women was initially defined by the criteria homicide. Arch Pathol 83(1):64-70, Jan. 1967. set out in People v. Bledsoe 36 Cal. 3d 236, 249-51, 43. Maxeiner H, Mucosal hemorrhage of the 1984. larynx in strangulation and other causes of death. 48. Questions developed by Detective Mike Beitr Gerichtl Med 47:429-35, 1989. Agnew from the Fresno Police Department with 20 44. Stanley RB, Manual strangulation injuries years of experience working with victims of domes- of the larynx. Arch Otolaryngol 109(5):344-47, May tic violence. 1983. 49. Hyman A, Mandatory reporting of domes- 45. Gardel J, Injuries of the larynx. Probl tic violence, prepared for the Family Violence Actuels Otorhinolaryngol 133-44, 1965. Prevention Fund. 46. Maxeiner H, Delayed death following 50. San Diego City Attorney Domestic Violence strangulation. Arch Kriminol 180(5-6): 161-71, Nov. Prosecution Protocol prepared by Casey Gwinn, 1989, 1987. Zasshi NH, A case of phypoxic brain damage and Prosecuting Domestic Violence Cases without consequent to ligature strangulation. 43(2):186-90, Victim Participation by Gwinn. April 1989. Kubo S, Ogata M, Iwasaki M, Kitamura 51. Recognition and Evaluation of Injuries in O, Shimokawa I, Suyama H, Hironaka M, On the Victims of Domestic Violence (72-slide presenta- absence of cutaneous lesions of the neck in cases of tion, instructor test and 26-page manual) devel- strangulation. Minerva Medicoleg 87(6):299-02, Nov. oped by Dr. William Smock and Dr. Sandleback. 1967. Nathan, F, Italian. Case report. Delayed death Slide Program is $159. CD ROM, $79.50; combo after pressure on the neck: possible causal mecha- package $185.50. For more information, send an nisms for mode of death in manual strangulation email to [email protected]. A two-hour strangu- discussed. Forensic Sci Int 78(3):193-97, April 1996. lation training video tape with accompanying Anscombe AM, Late neuropathological conse- materials in a CD is available through IMO quences of strangulation. Resuscitations 15(3):171- Productions, Inc., at www.impoproductions.com or 85, Sept. 1987. Simpson RK Jr, Goodman JC, Rouah e-mail: [email protected].

MAY.2004.VOL.32.NO.5.CDA.JOURNAL 407 Documentation Chart for Attempted Strangulation Cases

Symptoms and/or Internal Injury:

Breathing Voice ChangesSwallowing Behavioral OTHER Changes Changes Changes

Difficulty Breathing Raspy voice Trouble swallowing Agitation Dizzy Hyperventilation Hoarse voice Painful to swallow Amnesia Headaches Unable to breathe Coughing Neck Pain PTSD Fainted Other: Unable to speak Nausea Hallucinations Urination Vomiting Combativeness Defecation

Use face & neck diagrams to mark visible injuries:

Face Eyes & Eyelids Nose Ear Mouth

Red or flushed Petechiae to R and/or L Bloody nose Petechiae Bruising Pinpoint red spots eyeball (circle one) Broken nose (external and/or ear Swollen tongue canal) (petechiae) Petechiae to R and/or L (ancillary finding) Swollen lips eyelid (circle one) Bleeding from ear canal Scratch marks Petechiae Cuts/abrasions Bloody red eyeball(s) (ancillary finding)

Under Chin Chest Shoulders Neck Head

Redness Redness Redness Redness Petechiae (on scalp) Scratch marks Scratch marks scratch marks Scratch marks Ancillary findings: Bruise(s) Bruise(s) Bruise(s) Finger nail impressions Hair pulled Abrasions Abrasions Abrasions Bruise(s) Bump Swelling Skull fracture Ligature mark Concussion

Used with permission by the San Diego City Attorney’s Office.

408 CDA.JOURNAL.VOL.32.NO.5.MAY.2004 Questions to ASK: Method and/or Manner:

How and where was the victim strangled?

One hand (R or L) Two hands Forearm (R or L) Knee/Foot

Ligature (Describe):______

How long? ______seconds ______minutes Also smothered?

From 1 to 10, how hard was the suspect’s grip? (Low): 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 (high)

From 1 to 10, how painful was it? (Low): 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 (high)

Multiple attempts:______Multiple methods:______

Is the suspect RIGHT or LEFT handed? (Circle one)

What did the suspect say while he was strangling the victim, before and/or after?

Was she shaken simultaneously while being strangled? Straddled? Held against wall?

Was her head being pounded against wall, floor or ground?

What did the victim think was going to happen?

How or why did the suspect stop strangling her?

What was the suspect’s demeanor?

Describe what suspect’s face looked like during strangulation?

Describe prior incidents of strangulation? Prior domestic violence? Prior threats?

MEDICAL RELEASE

To All Health Care Providers: Having been advised of my right to refuse, I hereby consent to the release of my medical/dental records related to this incident to law enforcement, the District Attorney’s Office and/or the City Attorney’s Office.

Signature:______Date:______

MAY.2004.VOL.32.NO.5.CDA.JOURNAL 409 CASE STUDIES

Forensic Odontology: A Global Activity George A. Gould, DDS

ABSTRACT P URPOSE OF PAPER orensic odontology is not one of Forensic odontology is an important and It is the purpose of the article to famil- the recognized specialties of dentistry but rather the applica- expanding field of dentistry. The appli- iarize medical and dental personnel on tion of a field of special interest cation of these forensic techniques in the recognition of and appropriate in dentistry to matters of law. In recent years, research, technolo- identification, criminal justice and den- response to dentally related matters Fgy and tribunal activities have resulted in tal liability are being practiced world- most commonly encountered in profes- a refinement of the criteria for those dentists interested in functioning as a foren- wide. In some mass disaster events, sional offices and referred by public sic consultant and hence, expert witness notably large commercial aircraft crash- safety officials. The intent is to assist for forensic odontology. Forensic dentistry has major divi- es, the traumatic forces are such that dental professionals to know how and sions of interest, which are: dental iden- fragmentation and conflagration result under what condition it is necessary to tification1 and mass disaster management,2 bite mark analysis,3 dental liabil- in only the most durable of human tis- initiate a response, and when it is nec- ity and malpractice4,5 fraud,6 age deter- sues-dentition survive and become a essary to seek the services of a col- mination,7 and human abuse and neglect. All of these divisions of activity potential source of identification. league more advanced and versed in have structured formats and procedures forensic odontology. to appropriately manage the acquisi- tion, custody and analysis of evidence. In addition, there is established terminology to define the evaluation when

Author / George A. Gould, DDS, is a full-time dental consultant for Delta Dental Plan of California’s DentiCal Division, surveillance and utilization review; provides consultation services to the California Department of Justice’s Missing and Unidentified Persons Bureau, as well as to the Sacramento and Placer counties’ coroner and sheriff’s departments. He was in private practice for more than 30 years. He is a diplomate of the American Board of Forensic Odontology, and a fellow of the American Academy of Forensic Sciences. 410 CDA.JOURNAL.VOL.32.NO.5.MAY.2004 composing a forensic dental report.8 It may be lost due to changes related to pattern injury. The swab is then air dried is an objective of this article to present rapid tissue responses, fading and pos- and returned to a sterile glass tube, and a various techniques that are customarily sibly distortion of the image. second swab is used dry and rubbed over used to conduct a forensic odontology It is common the only available pho- the same area to absorb much of the investigation. tographs in a criminal or civil matter moisture that remained from the first There are organizations that offer involving dental evidence are those swabbing. This swab is also air dried and structured programs of special training taken by an individual other than the returned to the tube, which is sealed. and education, such as the Armed Forces forensic dentist. Based on this history, it The objective of the second swab- Institute of Pathology and the University is in the best interest of both the forensic bing is to capture dried saliva cells con- of Texas in San Antonio. Some of these taining DNA loosened by the first swab- programs lead to supplemental creden- bing. A second tube of swabs is used in tials accepted by many courts, both with- The photographs the same way on a separate non-injury in the U.S. and internationally, as verifi- area of the individual to act as a control. cation that the witness has undertaken become a key element 9 advanced training in forensic odontology. Forensic Photography Within a geographic area, usually a and an integral Scientific photography is essential city or county, an individual function- to document and preserve images when ing as a forensic odontologist has a part of forensic conducting identifications, bite mark responsibility to communicate perti- investigations and other dentally relat- nent information to enhance a profes- investigations and are ed forensic activities. In pattern injury sional relationship with local law cases, the photographic images of the enforcement, health and welfare agen- usually the basis for pattern are used during the comparison cies and social service organizations. with other objects or an overlay image Some of the signs of human abuse, determinations of of the incisal biting surfaces of a sus- often seen by emergency room and pected individual. responding law enforcement person- responsibility. The photographs become a key ele- nel, can be manifested in injuries that ment and an integral part of forensic may be difficult to initially identify as dentist and all those involved with the investigations and are usually the basis bite marks. It is a duty of the forensic documentation of evidence that appro- for determinations of responsibility. dentist to conduct seminars designed to priate techniques are utilized. Due to their central importance in assist in the recognition of potential In addition to forensic photogra- these cases, it is required they be shared patterned injuries that might be of den- phy, the correct method to recover with other parties to a legal undertak- tal origin.5 The community odontolo- DNA evidence10 from bite mark sites ing. Photography is equally important gist should stand ready to educate such must be included in the presentation when performing identification to pre- personnel on recognizing and collect- of forensic investigative techniques. serve images of the dentition. ing evidence pertaining to patterned A positive match of DNA from a bite Currently there are numerous man- injuries. mark site and that of a suspect is a ufacturers of quality digital and conven- The seminars should include infor- significant finding that adds to sci- tional 35-mm cameras available for mation on appropriate photography9 entific certainty. forensic investigations. A primary crite- of the injury area as shown in a follow- One method recognized as appropri- ria in the selection of a camera has the ing portion of this article. The issue of ate is known as double swabbing. One ability to provide high quality 1:1 close- elapsed time may be a critical factor in swab is dipped into sterile water and up macro images. the capture of important features that applied with a circular motion over the It is suggested the photography be

MAY.2004.VOL.32.NO.5.CDA.JOURNAL 411 CASE STUDIES

Figure 1. Field of view, using a scale, shows Figures 2 and 3. Dividing the pattern into two portions and photographing each separately. area of interest. Figure 3 also shows the camera oriented 90 degrees to the surface. in black and white, as well as color. dimension to the injury area. The light Other considerations are field of view, source and angulation will determine the appropriate shutter speeds, f-stop set- existence or position of shadows and tings for depth of field, and control of highlights. light intensity, source and angulation. It is recommended the photograph- Field of view should show the area er take several pictures using the same of interest centered and millimeters camera orientation but varying the light scale, preferably an ABFO No. 2,11 close source position, as illustrated. If the to but not obscuring any portion of the light-generating equipment has intensi- injury (Figure 1). ty controls, that feature may also be used to enhance the image quality. Curved Surfaces Light control angulations render a Figure 4. The use of four sample light source angulations. In many situations, due to the cur- specific variety of highlights and shad- vature of an injury area, it is necessary ows to a bite mark, especially if it has a to divide the pattern into two portions depth dimension. tics such as misorientation or fractures and photograph each as a separate of incisal edges. image thus avoiding a common source Video Superimposition Video superimposition provides the of distortion (Figures 2 and 3). By the use of two video cameras in dynamic features of sweeps and other conjunction with a digital mixing comparison views inherent in the pro- Camera Angulation device, the overlay of one image over grams of the digital mixing device. Figure 3 also demonstrates the cam- another, is an effective technique to The author has applied the video era must be oriented 90 degrees to the compare two objects (Figures 5 and 6). superimposition technique to bite surface. Attention to this matter will For example, a life-size image of the mark analysis and identification cases. usually provide an accurate view with- incisal edges of a dentition can be When the customary antemortem den- out angulation related distortion. superimposed over a life-size photo- tal records and X-rays are not available, graph of a bite mark. A definitive com- it is possible to achieve a positive iden- Light Control and Angulation parison may be possible if the bite mark tification by comparing antemortem Figure 4 demonstrates the use of four displays specific registration of individ- photographs with remains. sample light source angulations. This ual teeth such as the mesial to distal and This technique requires a consider- issue is especially significant with situa- facial to lingual dimensions, and arch able amount of equipment and is not tions where there is a depth or third alignment and any unusual characteris- necessarily recommended as a system to

412 CDA.JOURNAL.VOL.32.NO.5.MAY.2004 the investigation. At a later time, just before the trial, the detective was meeting with a local forensic dentist to discuss a review of photographs. He immediately recognized the neck pattern injury was a probable bite mark and not a handprint. The dentist contacted the author to collaborate on the analysis of what was determined to be a bite mark with numerous significant and unique fea- Figure 5. Two video cameras superimposition. Figure 6. Digital video mixing board. tures for comparison. Plaster models of the suspects teeth were obtained and be included in a forensic odontologist clearly showed the upper front teeth compared to the pattern injury using inventory. It is reasonable to seek assis- (Figure 8). the customary overlay technique. tance from those forensic dentists famil- The remains were sent to the The comparison yielded an opinion iar with special methods when a consul- Sacramento facility for further analysis that, within reasonable dental certainty, tation would enhance an investigation. by the MUPS staff, and the author, who the dentition of the suspect did make In fact, it is not uncommon for forensic functions as a DOJ forensic odontology the pattern injury bite mark. It has been odontologists to seek peer review when consultant. By the use of video super- the author’s experience many suspected conducting cases. imposition, a positive identification was bite marks do not have sufficient specif- The author presents two cases: one established (Figure 9). ic detail to establish a cause and effect an identification and the other a bite The author has also used photo- relationship to a specific dentition. mark where superimposition was used graphic superimposition in other cases This case is an example of the usual to perform an analysis and arrive at where antemortem dental X-rays and analytical techniques of bite mark inves- determinations. records were not available. Some of tigation. This is customarily to superim- these identifications were central issues pose the overlays of the anterior incisal Identification in criminal matters and some required edges of the suspected dentition on pho- This identification case involves par- testimony in homicide cases. tographs of the injury pattern. The tially skeletonized human remains degree of clarity the photograph displays found in northern Mexico (Figure 7). It Bite Mark Comparison the dimensions, or oddities of alignment was determined the individual was The following case involved a brutal or acquired unique features, will deter- probably from California. Mexican offi- assault by a male acquaintance who was mine its evidential value. cials contacted the Missing and stalking a woman. The incident took The following pictures show facial Unidentified Persons unit (MUPS) of the place at night while she was sleeping in view (mirror image) of suspect dentition California Department of Justice (DOJ). her residence. After he gained entrance, (Figure 10); bite mark photograph (Figure A search of the MUPS list of persons he attacked her in her bed. She awoke 11); overlay of incisal view superimposed reported missing within the previous six with his hands around her neck, and on bite mark (Figure 12); and incisal view months established only one individual the violent struggle ended with her ren- (mirror image) (Figure 13). had matching physical characteristics of dering him unconscious by striking him The central incisors have an atypi- height, gender, age and hair color. with a heavy object. cal rotated alignment, and chipped The reporting person, a close rela- When she gave her statement to the and worn biting edges that have a tive, was contacted to obtain ante- police detectives, she thought the marks unique concordance with the drag mortem data helpful in an identifica- on her neck were from his strangulation marks in the bite mark image. In addition. Exhaustive efforts were able to hold. The police photographer docu- tion, the left lateral incisor is above provide only a recent photograph that mented the injuries as a routine part of the plane of occlusion and would not

MAY.2004.VOL.32.NO.5.CDA.JOURNAL 413 CASE STUDIES

Figure 9. Superimposition of Figures 7 and 8.

Figure 7. Remains from partially skeletonized human. Figure 8. Antemortem photograph from rel- atives. Summary It has been the author’s experience that bite mark cases that consist of images with definitive features repre- senting the responsible dentition, when appropriately documented with pho- Figure 10. Mirror image showing irregular tography and other evidence manage- incisal edges and left lateral above the plane of ment techniques, often result in a occlusion. forensic report that garners a stipulated acceptance in a court of law. The lesson learned from a variety of Figure 11. Bite mark displaying striated drag circumstances is that an observation of marks and a lack of marking in the position of a left lateral incisor. a pattern mark or injury should be properly documented by photography and presented to experts for analysis. In emergency and law enforcement responses, forensic dentists should be requested to participate in matters that have an initial suspicion or observation of being potentially a dental-related matter. Organized forensic dentistry has Figure 13. Mirror image incisal view of incorporated the concept of dissemi- maxillary anterior teeth, upon which the overlay Figure 12. The overlay of the maxillary shown in Figure 12 was constructed. nating community awareness of this anteriors and bicuspids superimposed on the bite 12 mark photograph. scientific portion of dental practice. In doing so, it will assist the general be expected to register on a bitten sur- rounding details until the analysis was dentist to ascertain the need for an face, a feature consistent in the bite completed and an opinion submitted. appropriate referral or when the mark photograph. DNA swabbings were not taken on necessity exists, to function correctly In the bite mark case presented, the this case because the initial investigation as the initial responding health care prosecution had the advantage of a living did not suspect the injury was due to a professional. victim who was able to positively identi- bite. The author has experienced other sit- With increasing frequency, forensic fy the attacker. The suspect was also uations where a pattern injury, thought to odontology is being applied in a variety found by the police to be unconscious on be of some other origin, was in fact a bite of cases of civil and criminal adjudica- the floor next to the victim’s bed. This mark. The opposite is also true, where an tion, including identification, homi- validated the findings of the odontolo- investigator suspected a bite mark that cide, abuse, fraud, malpractice, profes- gist, who was not informed of the sur- analysis determined otherwise. sional misconduct and liability. CDA

414 CDA.JOURNAL.VOL.32.NO.5.MAY.2004 To request a printed copy of this article, please Inc.(ABFO) Guidelines and Standards Manual of contact / George A. Gould, DDS, 6101 Puerto Forensic Odontology, third edition, 11;299, 1997. Drive, Rancho Murieta, Calif., 95683. 9. Bernstein M, Krauss T, Forensic Photography Manual of Forensic Odontology, third edition, 9;258, 1997. References / 1. Wright FD, Dental Identification, 10. Smith B, Holland M, Sweet D, Dizinno J, Manual of Forensic Odontology, third edition, 2; 9, DNA and Forensic Odontology, Manual Of Forensic 1997 Odontology, third edition, 10;283, 1997. 2. Warnick A, Mass Disaster Management, 11. American Board Of Forensic Odontology, Manual of Forensic Odontology, third edition, 8; 236, Inc.(ABFO), No. 2 scale available from Lightning 1997. Powder Co, Inc., 1230 Hoyt St. SE, Salem, Ore., 3. Sweet DJ, Bite mark Evidence, Manual of Catalog No. 6-3875. Manual of Forensic Odontology, Forensic Odontology, third edition, 5; 148, 1997. third edition, 9;267, 1997. 4. Schafler NL, Fraud and Concealment, Dental 12. Bowers M, Introduction To Forensic Malpractice-Legal and Medical Handbook, third edi- Odontology, Manual Of Forensic Odontology, third tion, Vol.1,2,3, 1996 edition, 1;1, 1997. 5. Vale GL, Dental Jurisprudence, Manual of Forensic Odontology, third edition,4;106, 1997. Suggested Reading / American Society of Forensic 6. Schafler NL, Fraud and Concealment, Dental Odontology, Manual of Forensic Odontology, third Malpractice-Legal and Medical Handbook, third edi- edition revised, 1997, tion, Vol. 2, § 3.62;83, 1996. Dental Malpractice-Legal and Medical Handbook, 7. Bowers M, Mincer HH, Lorton L Age third edition, Vol.1,2,3, 1996 Determination, Manual of Forensic Odontology, third edition, 3, 1997. 8. American Board Of Forensic Odontology,

MAY.2004.VOL.32.NO.5.CDA.JOURNAL 415 C OMMENTARY

Dental Reimbursement: Helping Victims Smile Again Catherine A. Close, JD

ABSTRACT P URPOSE OF PAPER he California Victim Compensation and Govern- By educating themselves and their staff A close personal encounter with vio- ment Claims Board (board) members about services for crime vic- lence can cause pain too deep for has been helping victims of crime get through tough tims, dentists play a crucial role in help- words. Feelings of anger, guilt, sad- times since 1965. Authorized ness, despair, and helplessness are Tby Government Code Sections 13950 et ing crime victims receive the care they seq, the Board’s Victim Compensation need. When a crime victim needs dental typical. Shock, numbness, and denial Program (VCP) is the largest and oldest in work, they may be unaware of the other are also common reactions. the nation and has paid out more than $1 billion in assistance to crime victims. assistance available through the A victim’s financial security may be Between June 30, 2002 and July 1, Victims Compensation Program. Dental threatened after a violent trauma. 2003, the VCP received 61,430 applications from California crime victims or care made possible through compensa- Victims often miss days at work in the their family members. During the year, tion helps victims begin to heal. aftermath of a crime, and difficulty con- the board paid out more than $117 million in compensation to crime victims centrating can cause job performance and family members to reimburse them to suffer. Trauma can overwhelm a vic- for a variety of expenses incurred as a result of a crime. The VCP paid nearly tim’s sense of control, connection, and $1.8 million dollars in dental expenses meaning. A crime victim may have a during that time. hard time asking for help, but this is a How do Crime Victims Get Help? time when getting help can make all Victims are assisted throughout the state by a large network of helping pro- the difference. fessionals. A victim’s first contact may be with a domestic violence shelter,

Author / Catherine A. Close, JD, is interim executive officer for the State of California’s Victim Compensation and Government Claims Board. She previously served as chief counsel to the board and has provided legal advice to the board members, executive director, and program managers on all legal issues affecting the board’s victim compensation, government claims, and administrative programs, as well as the Revenue Recovery and Compliance Division.

416 CDA.JOURNAL.VOL.32.NO.5.MAY.2004 crime victim’s spouse, child, parent, sib- crime is not eligible for the program. Restoring a Smile – One Victim’s ling, grandparent, grandchild or house- ■ Anyone involved in events lead- Story hold member. Victims of crimes resulting to the crime does not qualify for the ing in physical injury or threat of physi- program. She was assaulted as she was leaving a cal injury, as well as victims of most sex- ■ Anyone who is incarcerated, or convenience store one spring evening. ual assault and child abuse crimes, can on probation or parole for committing a The attacker hit her in the mouth with a apply to the program. felony, cannot be paid by the program beer bottle. Compensation payments may cover for expenses while incarcerated or on “I had two teeth completely knocked out. I medical and dental bills; the cost of a felony probation or parole. felt very violated. The incident hurt my funeral or memorial service; wage loss ■ Applications must be filed with- self-esteem regarding my appearance for a surviving victim or loss of support in one year of the date the crime because of my smile. I was really for legal dependents of someone who occurred, although an application filed depressed about it and didn’t want to after that date may be accepted if there return to work until my teeth were fixed. I is good cause. worked with the public, so I would have to Emergency awards may also be smile and talk all of the time. The dentist Many victims find out requested. fixed everything, and I was able to return to work quickly and go to court with confi- about the program By law, the VCP is the “payer of dence. I am always passing on information last resort.” If any other sources of about the Victim Compensation Program. through brochures reimbursement are available for the I’m very grateful to them. I got support applicant’s crime-related losses, for from them emotionally and financially. For and applications instance, if the victim has health a while, I was really depressed and (VCP) insurance or is covered by workers’ helped me a lot.” they find in the office compensation, those sources must be used before the VCP can begin to of their dentist, cover the victim’s losses. Applicants rape crisis center or a victim assistance are responsible for informing the VCP center. Each of California’s 58 counties doctor, or mental of all reimbursement sources for their is home to a victim assistance center. In losses, including: some counties, the center is in the dis- health counselor. ■ Medical/health, dental, or vision trict attorney’s office, in some it is in a insurance county probation department, and a ■ Public program benefits (Medi- few victim assistance centers are private has been killed or disabled; mental Cal, unemployment insurance, or dis- non-profit agencies. These centers are a health counseling for a victim and fam- ability benefits, etc.) resource to help crime victims access ily or household member; crime scene ■ Auto insurance compensation. Advocates can help vic- cleanup of a homicide; some home ■ Workers’ compensation benefits tims fill out applications and gather security improvements or relocation ■ Court-ordered restitution bills, receipts, and police reports to help expenses; job retraining for a disabled ■ Civil lawsuit recoveries speed the process. Victims can also mail victim; and home or vehicle modifica- in their applications or apply on-line at tions for a disabled victim. The program www.victimcompensation.ca.gov. cannot pay for the replacement of prop- Help in a Hurry Many victims find out about the pro- erty that is lost or destroyed because of gram through brochures and applica- a crime except for medically necessary He was sitting in his car, waiting for his tions they find in the office of their items such as dentures, eyeglasses, and girlfriend. The attacker came up to him and pistol-whipped him with a gun. His dentist, doctor, or mental health assistive devices. jaw was broken and he needed dental counselor. There are a few requirements that work. He went to an emergency room The VCP provides help for California must be met in order to qualify: that same day and needed maxillofacial ■ residents regardless of where the crime A victim must cooperate with surgery. The VCP paid for the dental occurred, and for nonresidents who the investigation of the crime and con- work that he would not have been able become victims of violent crime within viction of the perpetrator. to afford. California. The program can also assist a ■ Anyone participating in the

MAY.2004.VOL.32.NO.5.CDA.JOURNAL 417 C OMMENTARY

How Does a Provider Obtain the treatments are necessary as a result Helping A Child Move On Payment from the VCP? of the crime. Provider bills are then sent to the board’s billing service. Like most She was a little girl, riding in the car with In 22 victim assistance centers, the “third-party” payers, such as insurance her family when a drunken driver hit board contracts to operate claims pro- companies, the board generally pays them. Her mother was killed and the rest cessing centers or joint powers units bills at a lower rate than the billed of her family injured. She suffered a bro- (JPs). Teams of compensation specialists amount. At the present time, dental ken jaw and her face was disfigured. She at the board office in Sacramento also bills are reimbursed at the California needed oral and maxillofacial surgery. The program helped pay for the dental process claims. DentiCal Program rate. A provider who work to repair her injuries. Dental care The VCP can pay a bill in one of two accepts payment from the board for ser- helped heal her physical wounds, and ways: by reimbursing the victim or by vices to a crime victim, cannot accept the program also assisted her in finding paying the provider directly. Because any payment from another source that a counselor to help her cope with her would exceed the maximum rate set by emotional pain. the board for that service. In other Anytime a patient words, when a provider accepts a victim compensation payment, that represents shows up in a dentist’s payment in full, and the victim cannot How Can Dentists Work With the be held accountable for any additional VCP to Help Crime Victims? office with a problem amount for that service. Usually when a victim needs den- The victim is notified which expens- tal work as a result of a crime, that that can be attributed es the board is able to pay and how crime has just occurred. The victim much will be paid. If the victim dis- may be uncertain about compensation to a crime, it is agrees with any of the decisions that program benefits or how they work. have been made, he or she can appeal The dentist can make a referral to the worth a call to a local the decision, returning the notice with local victim assistance center if the victim assistance an explanation and supporting docu- victim has not yet applied for comments, if needed. pensation, or call the advocate at the center or to the VCP. Bills can usually be processed within center who is working with the victim two weeks up to a month after the time if there are questions. Victims and they are received. However, processing providers can also call the VCP direct- most dental and medical expenses due can take longer, depending on the num- ly at (800) 777-9229 to find out more to injuries suffered in a crime are unex- ber of bills the program has received from about compensation benefits. Filing pected expenses, victims usually can- throughout the state. Sometimes other an application is simple. not pay the bills directly. Providers factors, such as communication with Sometimes a victim may not realize themselves submit most bills received insurers or other third-party payers, can he or she needs dental work until by the program. delay a payment. A provider can help some time has passed. In cases of When a dentist submits a bill for obtain prompt payment by answering domestic violence, a victim may be payment, a verification letter is mailed any request for information from the pro- prevented from getting timely medical to the dentist to complete and return. gram as soon as possible. Once payment treatment by his or her abuser. This verification letter asks whether the is authorized, the provider should receive Anytime a patient shows up in a den- service is crime-related and to what a check from the State Controller’s Office tist’s office with a problem that can be extent. The dentist will also notify the seven to 14 business days later. attributed to a crime, it is worth a call board in this letter of any payments The VCP is made possible by the col- to a local victim assistance center or to received so far by either the victim or lection of fines levied on persons con- the VCP to help a victim apply for another insurance source. victed of crimes in California. The VCP compensation. Even in a case where The board does not pre-authorize receives no support from the state’s gen- an arrest has not been made, or an dental treatment. Treatment bills are eral fund. The U.S. Department of offender is not prosecuted for some submitted and then approved for pay- Justice Office for Victims of Crime also reason, a crime victim may still be eli- ment. Treatment plans are still helpful, provides funding through the Victims gible for compensation benefits. however, for showing the board how of Crime Act, which is supported

418 CDA.JOURNAL.VOL.32.NO.5.MAY.2004 through fines paid by federal criminals. to heal; they also have a role in helping victims for mental health care expenses The Restitution Fund, which their patients recuperate from the psy- to treat emotional trauma. Please refer finances the VCP, is sustained through chological trauma caused by crime. By these patients to VCP. They can either the combined efforts of judges, district simply educating themselves and their contact their local victim assistance attorneys, county revenue collection staff members about services for crime center or call the VCP directly at (800) staff, corrections professionals, and resti- victims, dentists play a crucial role in 777-9229. Dental care made possible tution specialists. Restitution fines, resti- helping crime victims receive the care through compensation helps victims tution orders, penalty assessments, and they need. Dentists can receive more begin to heal. CDA diversions fees paid by state and federal information about the Victim offenders make the VCP possible. Compensation Program by calling the To request a printed copy of this article, please contact / Catherine A. Close, JD, Victim program or accessing the board’s Web Compensation Board, 630 K St., Sacramento, Summary site: www.victimcompensation.ca.gov. Calif., 95814 When dentists help victims return Posters and compensation applications to work by restoring a smile, healing a are available free of charge. man’s jaw as he recovers from an attack, When a crime victim needs dental or correcting the disfigurement of a lit- work, they may be unaware of the tle girl injured in a tragic car crash, they other assistance available through the are not just helping their patient’s body VCP. The program also compensates

MAY.2004.VOL.32.NO.5.CDA.JOURNAL 419 Dr. Bob Robert E. Horseman, DDS

Frill-Free Dentistry … And Don’t Forget Your Own Bur

e’re still under 20 bucks for a cleaning here thing that causes all the bleeding and you at Family Dental 6, but we’ve taken the arti- won’t experience that awful taste from rubber ficial flavoring out of the pumice. We don’t gloves, because we don’t use them. charge for frills like colored bibs and brand- We try to hold costs down at Family name facial tissues. Bring a towel of your Dental 6, so don’t expect all those fancy fea- choice and an empty cup. If you want a par- tures like disposable needles and insurance ticular rinse, the vending machine has sev- forms. In fact, we won’t bother you with eral choices for under a dollar. needles at all; you can bite on a piece of rub- W Here at Family Dental 6 you can expect a ber eraser if you have one when the going fairly clean room on almost every visit, except gets troublesome. Most of our patients bring for the bathroom that we have eliminated their own burs and diamonds, although our because, after all, you’re only going to be here slightly used ones are available at extra cost for 30 minutes unless you want to wait for the at the check-in counter. dentist to show up. We promise never to Unlike those other high-priced dental scrape your teeth with that annoying scraper Continued on Page 433

434 CDA.JOURNAL.VOL.32.NO.5.MAY.2004 Dr. Bob Continued from Page 434

“If it ain’t broke, don’t fix it” and we won’t unless it’s profitable and doesn’t involve much effort. offices, we don’t have a bunch of people dures you never heard of to replace standing around doing nothing, so things that don’t even hurt all that much. when you arrive just walk right in and Here at Family Dental 6, our motto find a chair. We leave the front door is: “If it ain’t broke, don’t fix it” and we propped open with a brick so the air can won’t unless it’s profitable and doesn’t circulate a little and dry up the mold. involve much effort. And we won’t send Everybody has been X-rayed at one you out chasing all over town to stand time or another, so if you have any old in line at some expensive specialist’s X-rays lying about at home, particularly office. Our own people might be able to if any of them feature actual teeth, patch it up themselves. Remember, den- bring them along and we will help you tistry doesn’t have to be costly. At guess what your problem might be. Family Dental 6, a simple extraction can The thing is, if a mouth that’s free of usually solve the problem and we disease and containing a lot of unrealisti- absolutely guarantee it won’t return to cally white teeth is all that’s important to that tooth again. you, go ahead and visit one of those We’ll leave the operating light burn- super deluxe dental offices where the ing for you, and you try to stay out of pressure is extreme to submit to proce- trouble by not brushing so often. CDA

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