Unlikely events written by a screenwriter for a bizarre movie? Think again, for these are actual events that occurred in average American neighborhoods, several of them here in Arizona.

Homicides. Molestations. Assaults. Sexual exploitation. Abductions. Shootings. Abuse. Neglect. Behind those police report titles are victims ranging in age from newborn to 17 years. Inside homes across the United States, the crime of child abuse is being committed every hour of every day. And while many believe it only occurs among members of lower socio-economic classes, the truth is that it cuts across all social, economic, ethnic, race, age and educational lines. Child abuse does not discriminate. The college professor may be just as guilty as being the perpetrator of child abuse as the blue-collar laborer.

Child abuse is not an isolated, rare event. It has reached epidemic proportions in the U.S., and is an international issue as well. According to the Arizona Department of Health Services, Office of Oral Health, three million children were reported abused or neglected in the United States in 1993, while 1,500 children died from abuse that year. And since many cases go unreported, experts believe that this number under represents the actual number of children being abused. Consequently, what was once considered to be a private issue has now become a public responsibility.

Where does that leave each member of the dental team? We're already screening for oral cancer, caries, periodontal disease, oral pathology, high blood pressure, diabetes, HIV, eating disorders and drug abuse to name a few. Can we add screening for suspected cases of child abuse and neglect to our professional responsibilities?

The answer is an unqualified yes. In most states, healthcare workers are required by law to report suspected cases of abuse. In Arizona, the law states, "Any physician...dentist...or any other person having responsibility for the care or treatment of children," is required to report suspected abuse. This includes all members of the dental team, be it dentist, dental hygienist or dental assistant. Every dental team member must play a significant role in protecting children from further abuse by assuming the role of child advocate. Learning to not only recognize the different manifestations of abuse, but to also document and report it to the appropriate authorities is a critical component of that advocacy. Additionally, early recognition and reporting are critical to prevent more serious, permanent injuries or fatalities from occurring.

Various studies have confirmed that approximately 65% of the cases of child abuse involve injuries to the head, neck, face and intraoral regions. These exposed and accessible areas have a higher incidence of injuries from abuse than any other parts of the body. Some reasons for this high incidence are that the head and/or facial areas are exposed and easily accessible, they are significant in communication and nutrition, and are representative of the child's "self." Injuries to the child's hands may also be a site easily observed. Children use their hands to protect or shield themselves or other parts of their body while they are being abused. Younger children may use their hands to misbehave and therefore may receive abuse-related injuries to the hands.

According to various state statutes, child abuse is defined as the non-accidental infliction of physical or psychological injury on a dependent child or the failure to provide reasonable care, protection and nurturing to such a child. In most cases, abuse is perpetrated on a child by an adult in a position of trust and with a moral and legal obligation to care for the child. Without intervention, child abuse is potentially fatal.

Dentists, hygienists and assistants are in an ideal position to recognize maltreated children. We may be seeing the child 1 - 2 times a year, and usually spend at least 45 minutes with that child conversing, observing and providing treatment. It has been observed that, to avoid suspicion, an abusive parent or caregiver may take a child to various physicians or hospitals over a period of time for treatment, but will visit the same dental office repeatedly.

Our first observation should be an overall assessment of the child as he or she walks into the treatment room. It is important to keep in mind that the following signs may not always be indicative of abuse in a child; however, they should not be ignored. When a realistic or adequate explanation is offered, though, these injuries can be viewed with less suspicion. Not all injuries or lesions that may look suspicious or unusual are the result of abuse - many are legitimate accidents or consequences of medical conditions. In addition, systemic ailments, such as osteogenesis imperfecta, skeletal abnormalities, leukemia or blood dyscrasias may all have oral manifestations reminiscent of but unlinked to abuse. Unfamiliar oral lesions or cases of severe facial trauma may require consultation and referral to an oral and maxillo-facial surgeon or oral pathologist. All injuries and lesions should be noted, however, since if the child presents again with similar suspicious marks, a pattern can be established.

It is also important to consider the age of the child and the extent of the injury. As they explore their environment and engage in athletic activities, most children get bruises on their foreheads, shins, and other areas overlying bone or bony prominences. They can get hurt when playing, riding bicycles, climbing trees and falling out of chairs. However, injuries overlying soft tissues that are not directly supported by bone, such as the cheeks (below the zygoma), lips, neck, inner thighs, and inner aspect of the upper arm should be viewed with suspicion, as they are more likely to result from abuse. Moreover, if the injury resembles an identifiable object such as a belt buckle, strap, electrical cord or hand, it should raise immediate suspicion.

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