Today’s lecture is that last lecture of Trauma lectures, and it’s about Non-

Accidental Injuries (NAI), or what we call child abuse.

A tragic cause of oral injuries in small children is manifested in the battered child
syndrome, Battered baby syndrome is: it’s a type of a child abuse , it’s another
terminology for child abuse, and battered means : the child has been hit

So , battered child syndrome : a clinical condition in infants who have suffered

serious physical abuse .

Child abuse are those acts or omissions of care , so it’s either an act or omission
(omission means : something should has not been giving to the child which should
have been giving like for example : feeding the child or cleaning him , or taking him
to medical practitioner if he is sick , if you don’t do that this called omission of
care) , that deprive a child of opportunity to fully develop his or her unique
potential as a person either physically , socially or emotionally , like shouting at the
child about every little thing he dose ,this is a form of verbal abuse , which will
affect the child socially and emotionally ,like when you keep calling him names or
keep making fun of him , or making him feel inferior , this will affect the
personality of the child in a long term .

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Physical abuse is :
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any injury where there is a definite knowledge or reasonable suspicion that the
injury was inflicted( the parent him self did the injury) , or knowingly not prevented
( like a mother seeing her child hitting by his father and she is okay with it ) , by
any person having the custody ,charge or care of the child , which is usually the
parents or the legal guardian .

These children are often victims of deliberate and sometimes, systemic injury by
their parents or other adults involved in their care .
Types of abuse
– Physical abuse
– Sexual abuse
– Emotional abuse
– Neglect
And the true incidence of each is unknown.

Frequency
Frequency of child abuse can be seen in the following statistics :
– In 1971, in New York city alone , 5,200 cases were reported .
– It has been estimated that in entire USA between 200 000 – 250 000
children are maltreated yearly and 6000 die because of abuse .
so these are studies which were done in USA , because things there get
reported there.
– Approximately 50% suffer facial or oral injures , the outcome is often fatal
due to intracranial hemorrhage , specially if there is head injuries has
occurred and involved with intracranial hemorrhage this is the leading
causes of death in these children .
– Head or facial trauma is often the principle reason for admission to hospital

Epidemiology of NAI
NAI ( non-accidental injuries) , recognized as an international issue and has been
reported in many countries , and it has been reported that child abuse occurs in
approximately 0.6 % , and that can be proximate it to 1 % . Page
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In Britain , at least 1/1000 children who are below 4 yrs of age suffers sever
physical abuse like : fractures ,brain hemorrhage ,sever internal injuries or
mutilation .

In USA, more than 95% of serous intracranial injuries during 1st year of life are a
result of abuse , so most of the head injuries that come to hospital are usually due
to abuse , because you know if the child has a regular accident of he fall he won’t
have intracranial hemorrhage , it can happened but not as much as common in the
abuse cases .

Children of all ages subjected to physical abuse , so abuse can happen to any child
at any age but mainly or the majority of this cases are occurs in young children
because they are defend less and more vulnerable and can’t seek help , not like
older child how can call the police or dial 991 in some societies , because they teach
them in the schools if they are been hit by their parents to call the police or ask
for help ,in developed countries the situation is different .

Children under 2 years of age are most at risk for sever NAI , and death from
abuse is rare after the age of 1 year .

Presentation of NAI cases

Orofacial region commonly traumatized during abuse episodes , and as we said 50%
of physically abused children suffer facial or oral injuries , the outcome is often
fatal due to intracranial hemorrhage

the pediatric dentist must be aware of the possibility of physical abuse in any
patient with dental trauma specially if we saw a particular signs , and common signs
include :

– Bruising, human hand marks where the child have been hit .
– Burns, with cigarettes.
– Bit marks you’ll see the indentation of the teeth .
– Eye injuries like blackness around the eye .
– And bone fractures .

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specially if this is repetitive every now and then the child come with the
same injuries then we have to suspect that .
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– bruising of soft tissues not overlying bony prominences , so for example on
area where there is no bone and the soft tissue get injured very frequently
then u should suspect child abuse specially if the injury takes a shape of an
object .

Oral injuries often a result of a blow to mouth to silence or a screaming

crying child ,so if the child crying or screaming because he is sick or hungry and
sometimes just because his bad personality ,then the parents or the care giver my
get angry and he slaps him , and if he slaps very strongly he might injured the
child .

laceration of mucosa on the inner aspect of the upper lip near the frenum , and
tearing of labial mucosa from gingiva are typical , and the children usually below 3
years of age , they are often presented for treatment after several a hours or
day’s delay , the don’t come to the clinic right away after the injury mostly because
the care giver don’t want to be catched .

Usually present with multiple bruises over the entire body as well as scaring of the
face, and some of them are fresh, some of them few day’s old , and some of them
has scars which shows you that he always being hit or being abused .

the bruises often of different colors because the one that have been healed are
brownish , the one that is has still healing is blue, and the fresh ones are usually red
in color , and this indicate different dates of origin .

RG exam will reveal multiple fractures , some of them has healed and some of them
are recent , and it can show evidence of previous injures to the primary dentition ,
or an old root fracture , or preapical problems ,or infections , pulp canal
obliteration,, or anything that show you that he is being traumatized very
frequently .

Role of the dentist

In view of relative frequencies of facial trauma in battered children , one should be
suspicious in cases o young children when there is marked discrepancy between
clinical findings and the history that is supplied by the parents , so if the history
doesn’t match what you are seeing then you should to be suspicious .

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If there is a reason to suspect child battering , than patient’s physician or
pediatrician should be consulted , or we could use or ask for help from forensic
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doctor , so it’s not wrong to go and seek for other opinions if you are suspicious .

So if the dentists and the physician agree that there is a child abuse , a state
agency should then be consulted and the findings must be reported , like what we
have here in Jordan ( ‫) دائرة حماية السرة‬

You can call them , or call the police and they’ll put you online with them , and you
can tell them what you have seen or heard and the place , you don’t have to tell
them your name , and they’ll come to the place that you gave them to check and if
they found any child abuse situation they’ll protect the child

Reporting of suspected cases of child abuse now mandatory for all professionals in
USA , and in most of the developed countries it’s mandatory by law , so if the
dentist didn’t report the suspected cases he’ll be libel .

The dentists should not feel guilt about referring children with suspected NAI to
pediatrician or GP, they’re not accusing either the parents , they are simply asking
and seeking for a 2nd opinion .

It’s neither in interest of the child nor the parents for the child abuse to be
covered up , to do so leaves the parents at greater risk of inflecting more injuries
if you ignored it , and being imprisoned and lone term loss of custody of the child ,
in the developed countries the care giver can loss the custody , and child will be
transformed to orphaned or for the adoption by another family .

Failure to follow up suspicions is a form of professional negligence

In summery, the dental practitioner’s role in the management of NAI is :

1- To recognize the possibility or to suspect that there is a child abuse , and

for sure to suspect based on sound grounds , not every case that come to
you like the child has been hit in the school you accused it with child abuse
no I have to have sound evidence .
2- To provide essential emergency dental treatment , if there is any treatment
you can provide .
3- and to inform the appropriate agency and authorities .

Diagnosis Page
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There is some criteria that you may relay on like :

– delay in seeking help

so the parents or the legal guardian don’t come straight away , they wait for
few days , they think that everything will be fine or the pain will go and the
bleeding will stop , and things don’t get better , so they comes after a few
day’s .
 – vague history
he doesn’t give you something clear about what happened , or he always give
you different type o stories , something mysterious something not clear ,
and the history will varies between the interviewees , so if I asked him he’ll
tell me a story , and if you asked him he’ll tell you another story, so he’ll give
you different stories .

– A history incompatible with the injury seen .

so if he said he felled of the bicycle or somebody pushed him means that
he’ll be injured on the front of his face , but you see an injury on his back ,
that means he was not telling you the truth and there is nobody pushed him ,
right !! It’s different.

– Abnormal behavior by the parents.

lack of concern about the child’s injuries , they are aggression , or they take
the child from the hospital early , if you told them you need to do some
investigation or tests , or you need to keep the child under observation ,
they get suspicious that the may get involved with problems so they take
the child and go .

– The child appearance.

he or she may appears sad , withdrawn ,frightened , inappropriately
friendly , attention seeking or may exhibit frozen watchfulness (staring
frightened gaze anticipating the next blow ) , such an expression which is
very characteristic of abuse , may be seen on the face of the child .

– other signs of abuse Page

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Such as neglect or deprivation may be apparent , disclosure by the child
himself or herself.

An example , a torn upper labial frenum , it’s not uncommon in young child who
accidentally falls while learning to walk , generally between 8-18 months , however
in very young non-ambulatory patient which is less than 1 year of age , or an older
more stable child like 2 years of age , should alert clinician to possibility of injuries
by abuse , Mean’s , if a child doesn’t walk yet then it doesn’t make any sense that
he felled , but if he is just learning how to walk it may happened with him

Done by
Sukainah Al-Fraid

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At the end since this is my last lecture in this semester

Then I won’t miss this opportunity to send my HelloZ to

Dalya (‫ )أحتاج ان اتحدث إاليك صوتًا‬always& forever :-p

 Um el ShuSh ‘’ good times & bad times girl ‘’ 

Far7 ( honey plZ stop listening to that song , it gives me a headache)

Ronza , Ftoom (miss you ) Lamiya, Hadeel ( I’ll keep buying shoes )

Madiha (new status , new comment ) , Daina &Mais, noor elnajar, ZezY
( disinfection addiction ) , Shahd & Ruba

Nur aymn , nur hydaio , najla & muna, sama o lina

And I won’t forget my colleagues starting with

Na3eem ( finally it’s a lecture for me less than 10 pages )

Muhammed Resh , Ali althani , Ali ka’6em , Abdullah 3aw’9i ( still hates
your lecture ) :-p , Hussain al shai5 ( yup , nup , chup ) x-d

Muhammed sh3ban ( my friend  ) , Mo7sen (next movie I’ll zip it ) , Nazirul

( thanQ for the pic , camera man ), abdullah 7al7oly , Eyas , Obulwaleed (
‫ ( !! نجلء فتحي‬Muhammed alshammari, mo3ath.

Good Luck for all in the coming examz

Good luck !!

Naa I think you need a hard luck, God be with ya

Peace Out

Your colleague

Sukinah Al fraid

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