child abuse and neglect

1. “Physical indicators and
identification of child abuse and
neglect”
Dr.Abhinav K Raj,
Consultant forensic odontologist
BDS, M.Sc.Forensic Odontology
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2. What is Forensic Odontology?
• “Forensic”- before the forum ( court of law)
• “Odontology”- the scientific study of structure and
disease of teeth.
• FDI definition
“the branch of dentistry which, in the interest of
justice, deals with the proper handling and
examination of the evidence and with the proper
evaluation and presentation of dental findings”.
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3. Forensic dentists are responsible for:
• Identification of found human remains
• Identification in mass fatalities
• Assessment of bite mark injuries
• Assessment of cases of abuse (such as child,
spousal or elder abuse)
• Civil cases involving malpractice
• Age estimation
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4. A child’s plea!!
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5. Child abuse and neglect
• Child abuse and neglect (child maltreatment) refers to
any non-accidental behavior by parents, caregivers,
other adults or older adolescents that is outside the
norms of conduct and entails a substantial risk of causing
physical or emotional harm to a child.
• Intentional or unintentional
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6. Who is more likely to get abused?
• Children who grow up in very poor families.
• Children with divorced parents.
• Overly stressed caregiver
• Children with physical or mental handicaps.
• Having an abusive husband who hurts his wife.
• Children under 12 years
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7. Types
• Emotional abuse
• Neglect and negligent treatment
• Physical abuse
• Sexual abuse
• Organized abuse
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8. Physical abuse
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9. Physical abuse
• Intentional infliction of bodily injury upon a child .
• Many parents say that when they hit their children it
is a form of discipline.
• There are differences between discipline and abuse,
“discipline teaches children right from wrong, not to
make them live in fear.
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10. Signs and how to recognize it..!!
• Frequent Injuries, unexplained bruises, welts, or
cuts.
• Pattern of injuries, usually from hand or belt.
• Shies away from touch, flinches at sudden
movements.
• Afraid to go home.
• Fearful
• Wears inappropriate clothing to hide injuries (
e.g: wearing long sleeves in a hot day ).
• Lack of medical or dental care.
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11. Physical abuse
• Careful intraoral and peri-oral examination is necessary in all
cases of suspected abuse.
• The oral cavity may be a central focus for physical abuse
because of its significance in communication and nutrition.
• The injuries most commonly are inflicted with blunt trauma
with an instrument, eating utensils, hands, or fingers or by
scalding liquids or caustic substances.
• The abuse may result in contusions; lacerations of the tongue,
buccal mucosa, palate (soft and hard), gingiva alveolar
mucosa or frenum; fractured, displaced, or avulsed teeth;
facial bone and jaw fractures; burns; or other injuries. 11

12. Classical features
• Multiple injuries
• Injuries in different stages of healing
• Injuries inappropriate for the child's stage of
development, or a discrepant history.
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13. • Age-appropriate non-abusive injuries to the mouth
are common and must be distinguished from abuse
based on:
 history,
 the circumstances of the injury
 pattern of trauma
 the behavior of the child, caregiver, or both.
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14. 14

15. Types of injuries commonly seen…
•Immersion burns :are often associated with toilet training
accidents. This girl was plunged into hot water .
•Sparing of the buttocks, which contacted the surface of the bath
tub and avoided being burnt.
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16. • Contact burn:burns on the chest and
abdomen from a curling iron. The burn
pattern on the injured skin indicates multiple
contact burns from an object the size and
shape of a curling iron.
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17. • Hand print bruise: bruise from a slap showing
the outline of hand is clearly seen on the back
of this adolescent.
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18. • Gluteal fold bruises: injury to the buttocks
demonstrates linear, parallel bruises near the
gluteal folds. Forceful spanking causes gluteal
fold bruises. They do not indicate a separate
trauma in addition to spanking.
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19. • Contact burn( heater gate): child was held
against a heater gate. The pattern became
more obvious with the child’s knee flexed.- the
position of the leg at the time of the injury.
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20. • Contact burn( cigarette): cigarette burns are
circular injuries with a diameter of about
8mm.
• Accidental burns will be less distinct and less
deep.
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21. • Looped pattern markings: are clearly seen
within the bruising on this child’s back.
• The marks indicates extension code, belt or
some similar object to punish him.
• The colour of the injury is red, indicates that
the injury is only few days old.
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22. • Pinch marks on pinna: children may be pulled
up along by their ears, causing this injury.
• A child’s ears should be inspected whenever
the abuse is suspected.
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23. • Strangulation bruise: child was beaten up at
the sitter’s and suffered circumferential linear
neck abrasions consistent with attempted
strangulation.
• There is also occipital echimosis from the
abuse.
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24. • Gagging bruise:this child had a sock stuffed into his
mouth and tied around his head. The bruises in the
corners of child’s mouth are indicative of gagging.
• In addition, there are circular bruises on his left and
right cheeks caused from the perpetrator's fingers
while holding the child still to insert the sock.
• Pattern markings within the bruises match the fabric
pattern of the socks.
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25. 25

26. SEXUAL ABUSE
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27. What is a sexual abuse??
• “sexual abuse is any action related to sex that
harms a child”
• Most sexual abuse is caused by someone related
to the child, ether it be a parent or a
sibling(incest).
• Most unreported abuse
• Sexual abuse is , a parent, family friend, stranger,
sibling touching a child inappropriately for their
own pleasure, having the child touch the abuser,
showing the child pornography, and taping a child
performing a sex act.
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28. SEXUAL ABUSE
• Physical signs
Difficulty walking or sitting
Stained or bloody under wear
Genital or rectal pain, itching, swelling,
redness or discharge.
Bruises or other injuries in the genital or rectal
areas.
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29. Behavioral or emotional signs
 Difficulty eating or sleeping
 Soiling or wetting themselves even after being potty
trained.
 Acting younger than their age.
 Excessive crying and sadness
 Refusing to play with other children and adults.
 Talking about acting out sexual acts, older than
normal for the child’s age.
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30. Signs in the oral cavity
• The presence of oral and perioral gonorrhea or
syphilis in prepubertal children is pathognomonic of
sexual abuse.
• Pharyngeal gonorrhea is frequently asymptomatic.
Therefore, when a diagnosis of gonorrhea is
suspected, lesions should be sought in the oral
cavity, and appropriate cultures should be obtained
even if no lesions are detected
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31. • Laboratory confirmation using two different types of
tests is needed to properly identify N gonorrhoeae.
• Detection of semen in the oral cavity is possible for
several days after exposure. Therefore, during
examination of a child who is suspected of experiencing
forced oral sex, cotton swabs should be used to swab the
buccal mucosa and tongue, with the swabs preserved
appropriately for laboratory analysis of the presence of
semen.
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32. • Unexplained erythema or petechiae of the palate,
particularly at the junction of the hard and soft palate,
may be evidence of forced oral sex.Although cases of
syphilis are rare in the sexually abused child, oral lesions
also should be sought and dark-field examinations
performed.
• Oral or perioral condylomata acuminata, although
probably most frequently caused by sexual contact, may
be the result of contact with verruca vulgaris or self-
inoculation. The presence of a sexually transmissible
agent from a child beyond the neonatal period is
suggestive of sexual abuse
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33. Bitemarks
• “A physical alteration in a medium caused by
the contact of teeth.”
• “A representative pattern left in an object or
tissue by the dental structures of an animal or
human “
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34. BITE MARKS
• Bite marks are lesions that may indicate abuse.
• Bite marks should be suspected when ecchymoses, abrasions, or
lacerations are found in an elliptical or ovoid pattern. Bite marks may have
a central area of ecchymoses (contusion) caused by two possible
phenomena:
1) positive pressure from the closing of the teeth with disruption of small
vessels or
2) negative pressure caused by suction and tongue thrusting.
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35. The normal distance between the maxillary canine teeth in
adult humans is 2.5 to 4.0 cm, and the canine marks in a
bite will be the most prominent or deep parts of the bite.
Bites produced by dogs and other carnivorous animals
tend to tear flesh, whereas human bites compress flesh and
can cause abrasions, contusions, and lacerations but rarely
avulsions of tissue.
If the intercanine distance is <2.5 cm, the bite may have
been caused by a child. If the intercanine distance is 2.5 to
3.0 cm, the bite was probably produced by a child or a
small adult; if the distance is >3.0 cm, the bite was probably
by an adult.
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36. • Self inflicted bite marks : Mostly found on the
forearms of the children caused by themselves.
Sometimes arms may be pushed into the child’s
mouth to stop crying or due to intense pain; children
may bite themselves because of fear.
• Mentally retarded and psychologically disturbed
people may also inflict bite on themselves. Self
inflicted bite marks are also seen in Lesch Nyhan
Syndrome, an X-linked recessively transmitted disease
with insensitivity to pain .
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37. Location Of Bite Marks
• The neck, breasts and shoulders are often
bitten in a sexually motivated attack, while in
child abuse cases, bites of the arms and the
buttocks are common.
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38. Judicial Punishment
• Juvenile or a boy is a person who has not
completed 18.
• Board may advice or admonish.
• Or order to participate in group counseling or
perform community service.
• Sent to a special home for a period until he
becomes a major.
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39. Rape
• Sexual intercourse by a man with a girl under
15 years even if she is his own wife, or with
any other girl under 16 even with her consent
is rape. (S.375, I.P.C.)
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40. Kidnapping
• To kidnap a child with the intention of taking
dishonestly any movable property, if the age
of the child is under 10 years (sec.369,I.P.C.)
• To kidnap a minor from lawful guardianship if
age of the boy is under 16 and that of a girl is
under 18 years (sec.361.I.P.C.)
• Maim a minor for the purpose of begging.
(363-A)
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41. Employment
• No to Below 14 – in factory or mine or in other
risky employment.
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42. Attainment Of Majority
• Completion of 18 years.
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43. Evidence
• Competence of giving evidence depends on
understanding but not on age.
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44. Age Estimation Using Cameriere’s
Seven Teeth Method
• Radiographic age estimation using teeth rely on
developmental stages of teeth especially in children .
• Age determination of cadavers is carried out in victims of
mass disasters such as fires, crashes, accidents, homicides,
feticides and infanticides etc
• In living person, the age estimation is done to assess whether
the child has attained the age of criminal responsibility such
as rape, kidnapping, employment, marriage, premature
births, adoption, illegal immigration, orthodontic
malocclusion and when the birth certificate is not available
and records are suspect for reasons such as criminal cases.
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45. • Once the measurements were recorded in
digital panoramic radiograph, it is calculated
by dividing magnification factor 1.2, which
was applied in Cameriere’s Indian formula.
Dental maturity was evaluated with the
normalized measurements of the 7 left
permanent mandibular teeth. (xi= Ai/Li, i =
1……7), the sum of the normalized open
apices (s = x1+x2+x3+x4+x5+x6+x7)
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46. • Dental age estimation was done by using Cameriere’s
Regression formula: Age = 9.402- 0.879c+0.663No-0.711s-
0.106sN0,
• C = variable boys (1) and girls (0)
• No: teeth with apical ends of the roots completely closed. s:
sum of A/L ratio for every tooth at open apex.
• Ai: radiographic distance between inner sides of the open
apex.
• Li: radiographic tooth length. (Li, i= 1… 7).
• An example of tooth measurement. Ai, i = 1. . . 5 (teeth with
one root), is distance between inner sides of open apex; Ai, i =
6 and 7 (teeth with two roots: A7 is the sum of the distances
(A7=A7a+A7b) between inner sides of the two open apices,
and L7 is the length of second molar)
and Li, i = 1. . . 7, is length of seven teeth and N0 = tooth with
a closed root: A6.
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47. An Example of a Panoramic radiograph (male)
:Chronological age was 8.7y and by
Cameriere Method
• N0: total no of teeth with apical ends of the roots completely closed; (central
incisor,lateral incisor and first molar) 31,32, 36 = 3,
• the length of the teeth to size of open apex of canine, first premolar, second
premolar and second molar were measured;
• x3= A3 /L3( 0.41/1.70 with dividing by Magnification factor: 1.2 =0.24),
• x4= A4/L4(0.43/1.30) =0.33,
• x5 = A5/L5( 0.76/1.02) = 0.74,
• x7 =A7/L7(0.82/0.95) = 0.86,
• s=X3+X4+X5+X7 = 0.24 + 0.33 + 0.74 + 0.86 = 2.17
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48. • Dental age = 9.402 – 0.879c + 0.663N0 –
0.711s – 0.106sN0
= 9.402 – 0.879×1 + 0.663×3 –
0.711×2.17 – 0.106×2.17×3
= 6.53 + 2.23 = 8.76 y]
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49. If You Suspect Abuse
• Do not conduct your own investigation.
- It is the law enforcement officials to
investigate the report.
• Report your suspicions to the right people,
organization or authorities.
• Know the child’s name or address so when its
time to report, the correct organization will
know where to investigate.
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50. Conclusion
• Physicians and dentists are usually the first
professionals to observe and recognize signs of non-
accidental or intentional injury. Sexual abuse of
children must be reported to the Child Protection
Council, preferably directly to the Child Abuse Team.
The decision to prosecute depends on the nature of
the offence, the offender’s attitude, the availability
of treatment, and the evidence available
• When a child has oral injuries or dental neglect is
suspected, the child will benefit from the physician's
consultation with a pediatric dentist or a forensic
odontologist.
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51. • Physician members of multidisciplinary child abuse and
neglect teams should identify such dentists in their
communities to serve as consultants for these teams. In
addition, physicians with experience or expertise in child
abuse and neglect should make themselves available to
dentists and to dental organizations as consultants and
educators. Such efforts will strengthen our ability to
prevent and detect child abuse and neglect and
enhance our ability to care for and protect children.
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52. • Section 317 states that is it a crime against children,
if their mother or father expose or leave a child in a
place with the intention of abandonment. This does
not prevent the law from pursuing further if the
abandonment results in the death of the child. The
parents would then be charged with culpable
homicide or murder.
• Section 372 discusses the selling of a child (below the
age of eighteen) for the purpose of prostitution or to
illicit intercourse with any person, or knowing that it
is likely that the child is being sold for such a
purpose. Section 372 states it is a crime to buy a
child for the purpose of prostitution or to illicit sex
from any person. 52

53. • Children have unique rights under international law
and societies are based on legislation that uses age,
therefore denying age is denying identity, which is a
human rights violation (UNICEF, 1989) and correct
age estimation is not just for the child’s rights, but
also for those around him/her (other children)
• Child sexual abuse laws in India have been enacted
as part of the nation's child protection policies.
The Parliament of India passed the 'Protection of
Children Against Sexual Offences Bill, 2011'
regarding child sexual abuse on May 22, 2012 into
Act.
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54. National Commission for Protection of
Child Rights
http://ncpcr.gov.in/
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