Behind the mask

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Behind the mask of domestic violenceIf a patient presents with suspected injuries from domestic violence, how should a dentist respond? Frank Leggett investigates.

Domestic violence is a spreading scourge right across Australia. So much so, that in September last year, Prime Minister Malcolm Turnbull announced a $100 million package of measures to provide a safety net for women and children at high risk of experiencing violence. 

A recent study by the Australian Bureau of Statistics revealed that there were 95 domestic violence-related homicides in 2014. In addition to this, 53,976 cases of domestic violence-related assaults were recorded in just five states during the same period (Victoria and Queensland were excluded due to differences in reporting definitions). That’s 148 assaults a day.

These numbers are even more tragic when NSW Health makes the point that only about half of all domestic violence assaults are reported.

With so many victims of domestic violence, it is inevitable that dentists will be repairing the damage caused by these assaults. In fact, many women who have been subjected to domestic violence will seek treatment from a dentist rather than other practitioners.

Dr Manjula O’Connor, a Melbourne psychiatrist with extensive experience in domestic violence issues, explains: “Victims—the vast majority are women—often suffer from shame and embarrassment at the prospect of telling their full story. While doctors tend to ask probing questions, dentists tend to just repair the immediate problem. GPs are trained to watch for the possibility of family violence, particularly unusual bruises and injury. To many women, the easiest thing is to visit a dentist who fixes the tooth and says, ‘See you next time’.” Dr O’Connor delivered the keynote address at the ‘Where the Mind Meets the Mouth’ conference last year, where she called for increased training to
help dentists identify and respond to family violence.

“Domestic violence issues are not covered in any dental course,” explains Dr O’Connor. “This is a ridiculous situation when 75 per cent of injuries to women happen to the neck and head.”

Ultimately, she would like to see dentists have their awareness of domestic violence issues raised so they can effectively act as first responders.

Dr Lisa Crighton, who obtained medical and dental degrees before specialising as a maxillofacial surgeon at South Melbourne Maxillofacial Surgery, spoke with Dr O’Connor at a ‘Dentists Against Domestic Violence’ fundraiser last year.

She also sees a role for dentists as first responders to domestic violence. “Bruises and lacerations will heal whereas a fractured front tooth isn’t going to repair itself,” she says. “This becomes the issue that draws a patient to seek care. Dentists are on the front line of treating fractured teeth and that’s where the patient will often present.”

“Domestic violence issues are not covered in any dental course. But 75 per cent of injuries to women happen to the neck and head.” –
Dr Manjula O’Connor

An obvious indicator that domestic violence might have taken place is the age of the injury. “Delayed presentation is something that should ring a bell with any dentist. If a patient reports they received the injury some weeks ago, it could be that they were waiting for the facial swelling, bruising and contusions from a violent episode to disappear. Often the injury is explained away with ‘I just tripped and chipped my tooth’.”

Other indicators

There are many other indicators that can point to domestic violence including frequently missed appointments, injuries that are inconsistent with the explanation of the cause, multiple injuries at different stages of healing, and attempts to hide or minimise the extent of an injury. The behaviour of the patient can be another telling indicator, with victims often appearing frightened, withdrawn, anxious or depressed. Very controlling men will sometimes attend the appointment with their partner and often appear dominant and aggressive.

“The dentist is not expected to counsel abused women but to simply open the lines of communication,” says Dr O’Connor. “About 70 to 80 per cent of patients want to be asked about their abuse by a professional they can trust.”

Dr Crighton agrees. “It’s always up to the individual patient to disclose how much information they divulge. However, if the patient is looking very anxious or timid, I tend to ask open-ended question like, ‘Is there anything else you want to tell me about your injury?’ ‘Can I assist in any other way?’ ‘Have you sought other specialists or have you sought your doctor’s advice about this particular injury?’ Your job is to make them feel safe so they can open up and talk.”

Extremely shy or scared patients can be encouraged with gentle questions along the lines of ‘Is everything okay at home?’ or ‘Can I ask you how you received this injury?’

When the patient confirms that she is a victim, the dentist should respond with compassion and validate the patient’s experience with statements like, ‘You don’t deserve this.’ ‘What can I do to help you?’ or ‘I am concerned for your safety.’ The important thing is to be empathetic and not blame the victim. The simple act of asking about violence is a powerful intervention.

At that point, the patient can be given fliers on domestic violence and numbers for domestic violence services. Dr O’Connor believes all dental practices should have this information on hand.

When help is refused

The most difficult situation for a dentist is when they believe the patient is in immediate or life-threatening danger but refuses all help.

“If she has serious injuries or it is not the first time, then the dentist should do something to protect her life,” says Dr O’Connor. “Even over her objections, I would suggest calling the police or a domestic violence service on her behalf. There is an organisation in Victoria called Safe Steps (www.safesteps.org.au, 1800 015 188) that provides this kind of support and help.”

“The most important thing is to empower the patient,” says Dr Crighton. “Empathy is one way of helping the patient feel that they have some sort of control over the situation. Providing general information about domestic violence groups is often a way to start the process of taking control.”

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