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  • The dentist and his/her team are in a most pivotal position as you will see to identify a significant number of patients both in the office, school and in the community.
  • Studies have found repeatedly that bruises are the most common injuries in cases of partner abuse, and the most common location of injury is the head, neck, or face. In fact, it has been estimated that 75 percent of physical abuse cases result in injuries to the head, neck, and/or mouth—areas that are clearly visible to the dental team during examination. As much as 75% of physical abuse involves injuries to the head , face, or neck 50% of adults visit the dentist at least once/year…..oral healthcare providers are in routine contact with affected patients! Abusers often avoid the same physician, BUTreturn to the same dental office * Children are more likely to have regular preventive care in the dental office: Poor dentition/nursing bottle cariesMost often, injuries are seen within the oral cavity ** Torn labial and lingual frenum Lip lacerations Fractured teeth Dental neglect: nursing bottle caries The dental professional often has established trust with the patient. A typical appointment is 30-45 minutes with the dental hygienist 30-60 minutes with the dentist as opposed to 7-10 minutes with their physician.
  • Table 1 describes the summarizes the bivariate association between the SOP and the DP.
  • “ Dentists may play an important role in recognizing and referring patients who are domestic abuse victims.” Even more, dentists may be the first—or only—point of contact for domestic violence victims in a health care setting, and they may be the most capable of recognizing the signs of abuse.
  • Education about violence and abuse in the training of dentists has been insufficient even when the signs of abuse are present. Reasons for lack of identification may be divided into two types; 1. Inadequate education on the approach to identify victims, and 2. Barriers to questioning that include patients accompanied by their partners, family members, cultural norms, and personal embarrassment by the doctor.
  • Educators in the oral health have taken a variety of major steps to provide the knowledge base for dentists regarding the above stumbling blocks. The Prevent Abuse and Neglect through Dental Awareness (PANDA) coalition was started in Missouri in 1992 and Dr. Lynn Mouden, DDS, was one of its co-founders. The PANDA coalition was comprised of the Missouri Dental Association and Delta Dental Plan of Missouri, as well as, the Missouri Division of Family Services and the Missouri Bureau of Dental Health. As of January 2004, 46 states have replicated Missouri's program along with international coalitions in Romania, Guam, Peru, Canada, Finland, Israel, Belgium, Iceland, Nigeria, South Africa, the Federated States of Micronesia and Papua New Guinea .PANDA educational programs are given, which include information on the history of family violence in our society, clinical examples of confirmed child abuse and neglect and discussions of legal and liability issues involved in reporting child maltreatment. While originally intended for dental audiences, the PANDA education programs are also presented for physicians, nurses, teachers, day care workers and anyone that has an interest in preventing family violence.  
  • As of January 2004, 46 states have replicated Missouri's program along with international coalitions in Romania, Guam, Peru, Canada, Finland and Israel. Efforts are currently underway to start PANDA coalitions in, Belgium, Iceland, Nigeria, South Africa, the Federated States of Micronesia and Papua New Guinea.   PANDA educational programs are given, which include information on the history of family violence in our society, clinical examples of confirmed child abuse and neglect and discussions of legal and liability issues involved in reporting child maltreatment . While originally intended for dental audiences, the PANDA education programs are also presented for physicians, nurses, teachers, day care workers and anyone that has an interest in preventing family violence. For information on PANDA contact Delta Dental of Missouri at 314-656-3000 or 800-392-1167.
  • In 2008; Gibson-Howell etal published the results of 2 surveys; one sent in 1996 to associate deans of US and Canadian dental schools ; the other in 2007 to US schools only. . The surveys were forwarded to faculty member that taught a course on the topic of identifying pts who may be victims of V/A. The topics relevant to D/V as part of a curricula were scored from………….
  • Created in 1997, the Minnesota School of Dentistry and the Program Against Sexual Violence designed Family Violence: An Intervention Model for Dental Professionals for dental school and continuing education curricula. It educates dental professionals about the signs of abuse and neglect and teaches proactive and appropriate intervention. Two instructional videos are available: “Clinical Implications,” which shows injuries and descriptions of how these injuries would occur, and “Healing Voices,” which discusses effective intervention strategies for dental professionals. One of the most important factors in intervention is providing a safe environment for disclosure. According to the dental intervention model, nonverbal cues—such as family violence literature or posters in the waiting room—and questions about family violence on dental history forms create opportunities for patient disclosure. If a dentist suspects abuse, Dr. Skelton says, “He or she should document significant physical findings and ask specific questions regarding the etiology of the injury. The dentist should be very supportive and nonjudgmental. If the patient responds positively to screening questions and/or reports physical abuse, the caregiver should assess safety, make appropriate referrals, and report the case according to state regulations.” The State board of Dentistry approves 6 hours of CE for completion of the training program.
  • Preliminary studies were undertaken to examine am expedient way to identify victims of abuse. Early work was done in Atlanta at a Level 1 Trauma Center examining women and men who came to the Ed with head, face and neck injuries. It was found that more women with HNF were victims of violence/abuse. Ye only using HNF did not rule in disease as precisely. Another tool was added . A questionnaire that was used in ED’s across the country; PVS. This allowed a greater rule in and out of IPV. The question was can this tool be applied at other centers across the country or generalized throughout the population. Myself and other s decided to use this tool in another geographic area of the country to see if the results were valid
  • Based on our preliminary experiences at Grady, we developed the following protocol to identify women at increased risk for IPV-related injuries. Again, the sample is composed of women at risk for IPV injury defined as women presenting to the ED for evaluation and management of nonverifivable injuries. The first element to consider is injury location – HNF or other. If a patient has multiple injuries at least some of which are localized to the HNF region, she is included in the HNF group. Other injuries must be confined to regions other than the HNF region. The second element of the protocol are the subjects responses to the IPV screening questions. If the subject responds affirmatively to one or more questions, she is classified as questionnaire positive. Finally, we combine the finding of the two elements, injury location and screening questionnaire. Patients classified as at being at high-risk of IPV related injuries are those that have HNF injuries and are questionnaire positive. All other combinations are classified as low risk for IPV injury.
  • When the predictive model was applied to the validation sample, there was excellent agreement between the observed and actual number of women with IPV-related injuries as evidenced by the accuracy, i.e. 93%, and the goodness-of-fit assessed (p=0.64, Hosmer-Lemeshow statistic). A p-value of 0.64 suggests that there was not a statistically significant difference between the predicted and observed outcomes.
  • Both the general dentist and oral maxillofacial surgeons are in a unique position to recognize the impact that violence and abuse may play in their patient population. As stated by JP Kenney; “dental practitioners have four R’s of responsibility; recognize record, report and refer to protect our patients and their families from the cycle of violence. ” As such, the dentist or the oral and maxillofacial surgeon is often the first to see and evaluate victims of violence and abuse in the ER or the private practice environment. Now these practitioners need to do the steps to incorporate formal training in every dental school and residency program in the country .  

{4 F3 B3 C72 C219 4 Dbb 89 Bb Eec3 Ddf05 D61} {4 F3 B3 C72 C219 4 Dbb 89 Bb Eec3 Ddf05 D61} Presentation Transcript

  • Violence/ Abuse: Role of Dental Education in Identification/Intervention www.hi-dentfinishingschool.blogspot.com
  • Family Violence (V/A) and Dentistry
    • 1. As much as 75% of physical abuse involves injuries to the head , face, or neck
    • 2. Abusers often avoid the same physician, BUT
      • return to the same dental office
      • 3. The dental professional often has established trust
      • with the patient.
      • 4. Dentists may be the first or only point of contact for domestic violence victims in a health care setting, and they may be the most capable of recognizing the signs of abuse.
  • Epidemiology of Maxillofacial Injuries and IPV: n=12 Wilson, Dodson and Halpern,2008 Author Study Design Data Type Age(Range) N (%) Sex Injury Zacharides (1990) Retrospective Chart review 16 - 32 51 (9) Female H,N,F Fisher (1990) Cross-sectional Chart review 10-78 23(20) Female H,N,F Berrios and Gray, (1991) Retrospective Chart review 16-66 149 (68) Female H,N,F Ochs etal. (1995) Cross-sectional Cohort 18-51 15 (94) Female H,N,F Muelleman (1996) Cross-sectional Cohort 19-65 121 (51) Female H,N,F Hartzell (1996) Retrospective Chart review 15-63 7 (30) Female Ocular Huang etal. (1998) Retrospective Chart review 15-45 109 (36) Female H,N,F Perciacante etal (1999) Cross-sectional Cohort 24-56 34 (31) Female H,N,F Le etal. (2002) Retrospective Chart review 15-71 85 (30) Female H,N,F Halpern Dodson (2005-2006) Cross-sectional RCT Cohort 27-64 63 (31- 45) Female H,N,F
  •  
  • Family Violence and Dentistry
    • A 1998 national survey revealed that 16.7 percent of women who sought health care for rape injuries visited dentists *
    • 9.2 percent of women who sought care for physical assault by a partner saw a dentist **
    • Routine dental visits may alert dental professionals to evidence that patients are being abused and lead to early intervention
    • * Love etal. 2001
    • ** Tjaden and Thoennes, 1998
  • Studies :Identification/Intervention
    • “…… .dentists and dental hygienists least likely…to suspect abuse in children, elders or young adults…..if so are not responsible..” *
    • “ 87% never screened pts with head, and facial
    • injuries…..” **
    • “ 18% did not screen even when there were visible signs of head and neck injury” **
    • “ <1% of all child abuse reports are made by dental staff even though they are mandated so…” ***
    • * Tilden etal 1994; **Love etal 2001; ***Mouden and Smedstad, 2002
  • Consensus Statements : (ADA)/(AAOMS)
      • 1996: “ADA developed an educational policy…conflicting histories, behavioral changes, multiple injuries at variable stages of healing”
      • 1999: “In all 50 states , physicians and dentists are required to report suspected cases of child abuse…to Social Service or law enforcement agencies…. and to collaborate in order to increase the prevention, detection and treatment of these conditions” *
      • 2006: “ADA ran a commentary ….. importance of educating the dental community and obligation to recognize signs and symptoms of family violence/abuse”
    • 2008: “ Oral and maxillofacial surgeons are dedicated to the health and well-being of all our patients, including those affected by violence and abuse, post traumatic stress disorders or traumatic brain injury” *
      • *American Academy of Pediatrics and American Academy of Pediatric Dentistry, 1999
      • * American Association of Oral/Maxillofacial Surgeons (AAOMS)
  • DV/IPV and Oral Health
  • Barriers for Identification
    • Education:
      • The training of healthcare providers has been insufficient even when the signs of abuse are present.
      • Inadequate education on the approach to identify victims.
      • Barriers to questioning that include patients accompanied by their partners, family members, cultural norms, and personal embarrassment by the doctor.
      • Fear of litigation if mistaken
      • Risk Predictors for victims: Physical vs. Psychological: What are they??????????
  • Oral /Maxillofacial Surgeons and Dentistry; P.A.N.D.A. TM * *
    • P : Prevent
    • A : Abuse
    • N : Neglect
    • D : Dental
    • A : Awareness
    • * Artwork and acronym used by permission of the P.A.N.D.A. TM Coalition developed by Delta Dental of Missouri, copyright 1992
    • * L Mouden, with permission
  • Alaska Guam Romania Peru Ontario HI Israel Finland US Army Dental Command Mexico IHS The P.A.N.D.A. Explosion
  • Curricula in Pre-doctoral Programs
    • Medical Schools:
      • “ medical educators have emphasized the need to identify/intervene ….. victims of DV,IPV” *
    • Dental Schools:
      • “ dental educators.. Instruction on the familiarity with signs and symptoms…. monitoring regulations…” **
      • Do Dental Professionals face the same challenges and barriers to addressing violence and abuse in their training programs? ***
      • &quot;There is recognition in both dentistry and medicine that oral health directly impacts systemic health,……each profession's academic community should address the role that oral health education ultimately plays in patient care quality.&quot;
      • Alpert etal.1998; ** ADEA/ADA,2007 ; ***AVA Blueprint; Halpern,2008
      • * AAMC Medical Education Director Alexis L. Ruffin.
  • Dental Curricula in the US *
    • Inclusion of DV curricula in dental school/ dental hygiene :
      • Dental School: 96%,CA; unknown for IPV/EA
      • Dental Hygiene school : 70%,CA;54.9%,EA;46%,IPV
    • Surveys:
      • 1996 : 53 US and 11 Canadian Dental Schools (N=55)
      • 2007: 55 US Dental Schools (N=25)
    • Topics relevant to DV:
      • Responsibility of healthcare professional
      • Physical and behavioral indicators
      • Referral protocol
      • Reporting protocol
      • Prevalence
      • Documentation
      • Characteristics
      • Interviewing skills
      • * Gibson-Howell etal 2008
  • Results of Survey:1996-2007*
    • Dental Curriculum:
      • Responsibility of healthcare provider
      • Physical/behavioral variables
      • Prevalence
    • Critical questions:
      • Translation of above into daily practice patterns
      • Comfort zone of exam
      • Impact of IPV/DV on society
        • Direct costs
        • Indirect costs
      • Do cultural norms influence ethics of care
      • * Gibson-Howell etal 2008
  • Pre-doctoral Dental Education Model: 1. University of MN
    • 1997: School of Dentistry/ Program Against Sexual Violence :
    • Family Violence: An Intervention Model for Dental Professionals *www.ojp.usdoj.gov/ovc/publications/bulletins/dentalproviders/welcome.html
      • Ethical and legal responsibilities of dental professionals.
      • Definitions and dynamics of family violence.
      • The impact of abuse on victims.
      • Intervention skills and techniques.
      • Methods for creating a safe office environment.
        • Videos:
          • Clinical implications : 6 minutes
          • Healing Voices : 11 minutes
          • Comprehensive curriculum:
            • Images of injuries of abuse
            • Effective intervention strategies
  • Pre-doctoral Dental Education Model: 2. UCSF School of Dentistry
    • Ask: Asking patients about abuse
    • Validate: Providing validating messages that acknowledge that battering is wrong while confirming patient’s worth
    • Document: signs, symptoms ,disclosures in the patient’s dental record in writing and with
    • photographs
    • Refer: to DV specialists and resources in the community
    • 2001: (Gerbert etal):
      • Survey: “ dentists in UCSF study have major barriers to screening for domestic violence …a partner during the office visit;…. lack of training and the dentist's own embarrassment “
      • AVDR: to help patients without imposing unreasonable expectations that dentists solve the problem of family violence.
    • 2004: JADA:
      • RCT with a multimedia Tutorial on preparing dental students to recognize/respond to DV
    • 2006: JADA:
      • “ the intervention effectively improved dentists’ intentions to practice ADVR intervention……..perceived knowledge both of DV and of how to help victims…after taking the tutorial, dentists reported that they would be more likely to inquire about a patient’s safety after recognizing injuries to the head or neck”.
  • Pre-doctoral Dental Education: Model: 3. Tufts Univ. (TUSDM): * VVIP *: A Public Health Approach to Domestic Violence In An Academic Dental Setting
        • Mission:
        • 1. To develop an interdisciplinary group of healthcare providers that will identify and treat victims of violence and abuse.
        • 2. To educate / train future dentists at both the pre-doctoral and post-doctoral levels on the diagnoses of oral disease as a predictive risk factor.
        • 3. To care treat and follow up with populations at risk for
        • violence, abuse, neglect :Child, Adult, Elders.
        • 4. To educate future dental care providers in an academic dental care setting, through classroom trainings, clinical dental practice, outcomes assessment, and community outreach.
        • * Victims of Violence Intervention Program ; * Gul etal. 2004
  • Structure of the program*
    • SCHEMA:
    Clinical Care Community Dental Care In-Class Training Outcomes Research
    • For DV populations
      • To assess the patient’s
      • dental condition to
      • improve the dental care
      • options for these population
    • For Dental Providers
    • To measure the outcomes of
    • the DV program’s in class
    • and clinical training components :
    • 1.Diagnostic protocols
    • 2. Tutorials
    • 3. Measures of
    • interventional success.
      • * Gul etal. 2004,2005
  • Model in the Dental Center
    • Shelters Internal Referrals Clinics
    • TUSDM VVIP
    • De-Identify (Adults, Children)
    • Blue Card
    • Introduction to Student Dental Providers
    • Medical Consults Dental Consults
    • Comprehensive Dental Treatment
    • Follow-Up/Intervention (Outcomes measurement)
  • TUSDM Faculty Supervision/ Education TUSDM VVIP “Model ” TUSDM VVIP Quality Patient Care Outcomes Assessment/Research Didactic Year ’01 Year ’02 Year ’03 Clinical Year ’03 Year ’04 TUSDM Student Education Mass Health Access Program (MAP) Dental Student Award: 2 Recipients from TUSDM TUSDM VVIP C.E. Courses: Training the Community Dentist
  • Pre-doctoral Dental Education: Model: 4. Harvard School DM/MGH: A Diagnostic protocol to diagnose IPV:
    • Injury location as a marker for IPV: Head, Neck and/or Facial *
    • Responses to a questionnaire (Partner Violence Screen : PVS ) * * as markers for IPV
      • Have you been kicked, punched, hit in a relationship?
      • Do you feel unsafe in a relationship?
      • Past feelings of being unsafe?
        • An affirmative response to any of the above questions was considered positive as a marker for IPV
    • * Ochs etal. 1995; Perciaccante etal. 1999;2002; Halpern etal.2005;2006
    • * Feldhaus etal. 1997
  • Schema: Diagnostic Protocol for IPV Females with non-verifiable injuries presenting to ED for evaluation and treatment Injury location HNF Other Questionnaire Questionnaire Positive Positive Negative Negative High Risk Low Risk Low Risk Low Risk
  • Performance of Protocol by Institution *
    • Self Report of IPV: HI (Grady) Self-Report of IPV: H2 (MGH)
    • Probability IPV Other Total Probability IPV Other Total
    • High 61 5 66 High 14 22 36
    • Low 7 127 134 Low 5 159 164
    • Total 68 132 200 Total 19 181 200
    • Sensitivity 0.90 Sensitivity 0.74
    • Specificity 0.96 Specificity 0.88
    • PPV 0.92 PPV 0.39
    • NPV 0.95 NPV 0.92
    • Odds Ratio 18 (8.6<OR<36.5;p=0.01 ) Odds Ratio 13 (4.9<OR<31;p=0.01)
    • * Halpern etal. 2006: J. Trauma, 60(5):1101-1105.
  • Diagnostic Protocol: Predictive Model *
    • Multivariate Regression model to evaluate predictor variables of model set versus outcome as an IPV-related injury etiology
    •  
    •  
    • Predictor Variable Odds Ratio 95%CI p value
    •  
    • Age * 0.9 89, .99 0.01
    •  
    • Race ** 3.7 1.2, 12.0 0.01
    •  
    • Risk *** 10.4 3.2, 34 0.01
    •  
    •  
    •   *Age: As age increases, the likelihood of reporting IPV-related injuries decreases.
    •  
    • **Race: White is the reference category and compared to nonwhite. Nonwhite females are 3.7 times more likely to report IPV-related injuries compared to white females.
    •  
    • ***Risk: Low risk is the reference category and subjects coded as high-risk were 10.4 times more likely to report IPV-related injuries than subjects coded as low risk.
    • * Halpern and Dodson, JADA, 2006, 137 (5): 604-609.
  • Future Directions/Conclusions: Strategies/Approaches
    • 1. Change the learning environment:
      • - Minimize a formal lecture format to one that invites speakers from the community
    • 2. Convert lecture format to student –centered
      • Role play and “real-life” scenario
        • Mock interviews
        • Community service/ shelter clinic environment
        • Outreach vans
    • 3. Develop a standard template/protocol/Web/DVD
      • Risk predictors
        • Injury location
        • Other; i.e.; health risk predictors
    • 4. Asking is an intervention
      • Studies demonstrate that abused women
      • want their providers to query them about IPV/
      • and “side effects”.
  • Future Directions/Conclusions: Successful Intervention
    • 5. Making a connection between their health history, previously incomprehensible symptoms and h/o V/A may have a significant therapeutic effect.
      • Long term negative health consequences
        • i.e. Chronic illnesses : New Risk Predictors????
        • a paucity of data exists to measure the consequences of these physiologic responses.
    • 6. Education on domestic violence needs to be
    • “ standardized and incorporated into dental school and continuing education curricula, thus normalizing intervention with victims and making it a standard part of a dentist’s/oral healthcare providers professional responsibility”. *
  • Acknowledgments/Funding
    • American Association of Oral and Maxillofacial Surgeons
    • AMA National Advisory Council on Violence and Abuse
    • Thomas B. Dodson, DMD,MPH
      • Director, Center of Clinical Investigation, MGH, HSDM
    • Lynn D. Mouden, DDS, MPH
      • Director, Office of Oral Health, Arkansas Department of Health and Human Services; Professor, UAMS College of Public Health
      • Founder of P.A.N.D.A. TM
    • David McCullum, MD, MPH,
      • Former Chair, AMA, National Advisory Council on Violence and Abuse (NACVA)
      • President of Academy on Violence and Abuse (AVA)
    • Megan Gerber, MD, MPH,
      • Assistant Clinical Professor, Harvard Medical School
      • Women’s Health Center, Veteran’s Administration , Boston, MA
    • Funding
    • Oral and Maxillofacial Surgery Foundation
    • Harvard Medical School, Center of Excellence in Women’s Health
    • Dep’t Oral/Maxillofacial Surgery, Massachusetts General Hospital/Harvard School of Dental Medicine
    • Harvard Vanguard Medical Associates , ATRIUS HEALTH, MA.
    • Thank you