A national random survey of 321 dentists by the UCSF School of Dentistry has found that the majority of those in the study never screened for domestic violence, and many of the dentists reported they didn't screen even when patients presented with visible signs of trauma on their head or neck.
The study on the topic "Dentists' Attitudes and Behaviors Regarding Domestic Violence---The Need for an Effective Response" will appear in the January issue of the Journal of the American Dental Association. In the study, dentists throughout the country were asked about their attitudes and clinical practice behaviors related to domestic violence, said lead author Barbara Gerbert, PhD, UCSF professor and chair of the division of behavioral sciences in the School of Dentistry.
"The health consequences of domestic violence are severe," Gerbert said. "It is the most common cause of serious injury to women and accounts for more than 50 percent of all female homicides." Another study published by the American Medical Association on "Diagnostic and Treatment Guidelines on Mental Health Effects of Family Violence" estimated that women in the United States face a 20 to 30 percent lifetime risk of battery. Contrary to commonly held beliefs, abuse happens to women of all ages, races, religions, income and education level, and sexual orientation.
Research also has shown that the majority (68 to 94 percent) of domestic violence victims suffer head and neck injuries including lacerations, bruising and fractures, Gerbert said. "Given that oral health care professionals routinely assess a patient's head and neck, dentists have a unique opportunity to recognize that a woman is being abused and to intervene," she said.
Research on physicians' response to domestic violence has found that identifying women who are being abused can be difficult due to many factors, Gerbert said. Domestic violence victims are reluctant to disclose abuse to their providers mainly due to fear of their partner's retaliation, shame, humiliation, denial about the seriousness of the abuse, and concern over confidentiality. According to physicians' responses, the patient's evasiveness and failure to disclose information is a major barrier to the identification of domestic violence. Gerbert said that while many studies focused primarily on physicians' responses to domestic victims, there are few focused on dentists' responses.
The dentists in the UCSF study reported that the major barriers to their screening for domestic violence were the presence of a partner or children during the office visit; the dentist's lack of training in dealing with the issue, concern about offending patients, and the dentist's own embarrassment about bringing up the topic of abuse.
Because of these and other barriers to screening in the oral health care setting, the UCSF researchers do not recommend universal screening for domestic violence. "But dentists must be enabled to recognize and respond appropriately to signs of abuse," Gerbert said.
The most hopeful finding from the study was that domestic violence education increased the likelihood that dentists would screen for abuse and intervene. Dentists with domestic violence education were more likely to make a note in the patient's chart, express concern for the patient's safety, give referrals and/or arrange for the patient's safety. In addition, more than half of the dentists surveyed reported that they would like more training in this area. These data support the recent efforts of the American Dental Association to enact domestic violence educational programs for dentists. To address the barriers uncovered in the study, Gerbert suggested that this type of education focus on specific intervention behaviors, become standardized and incorporated into dental school and continuing education classes.
The Gerbert study offers a model for intervening called AVDR. This limits the dentist's tasks to the following areas:
- Asking patients about abuse;
- GivingValidating messages which acknowledge that battering is wrong and confirm the patient's worth;
- Documenting presenting signs, symptoms and disclosures in writing and with photographs; and
- Referring victims to domestic violence specialists in the community.
Survivors of domestic violence have described how validation from a provider had not only provided "relief" and comfort" but also had "started the wheels turning" toward realizing the seriousness of their situation and changing it.
When documenting abuse, dentists should follow the guidelines endorsed by Physicians for a Violence-free Society, said Gerbert. They should specifically chart the patient's injuries and disclosures, using direct quotes and full names and locations. The provider also may need to complete body maps and take photographs to document specific injuries. Regarding referrals, dentists should keep an information sheet of domestic violence resources on hand, and, if possible, connect the patient with a community advocate.
"The AVDR approach would standardize dentists' intervention behaviors and leave the vast majority of follow-up in the hands of domestic violence advocates," Gerbert said.
The UCSF study encourages further research. The data generated could inform policy making and educational efforts in domestic violence and dentistry, Gerbert said.
Co-authors of the study, all from the UCSF School of Dentistry, include Candace Love, PhD, staff research associate; Nona Caspers, MFA, senior editor; Amy Bronstone, PhD, staff research associate; Dorothy Perry, PhD, associate professor; and William Bird, DDS, DPH, clinical professor.
Funding for this study was provided by the National Institute of Mental Health.
Journal
The Journal of the American Dental Association