In the ninth of our 16 blogs for 16 days, Professor Paul Coulthard, Dean of Dental School at Barts and The London School of Medicine and Dentistry, talks about the role that dentist can play in identification and referral.
The face is a common target in assault and consequently dental professionals have a part to play in identifying domestic violence and abuse in patients that present to them. The role of the dental team is to identify domestic violence and refer their patient for specialist help.
Many dentists and dental care professionals do not however consider that this is their responsibility because they assume that the patients GP or social services or the police will be doing something. We know that other services may not have been approached and even if they have, it is better for the individual to be asked on numerous occasions rather than not asked at all.
THE DENTAL ENVIRONMENT
Some dentists may think that this role is more appropriate for the general medical practitioner rather than themselves, not recognising the importance of their own role and the opportunities that general dental practice provides. A large proportion of the population attend their dentist on a regular basis who do not need to attend their GP. Also, GPs receive minimal training in oral health and dental injury and may not detect dental aspects of abuse.
It is useful to take advantage of working in the dental environment, which is likely to be considered less stigmatising than some other statutory services, to create an opportunity for the patient to disclose domestic violence and ask for help. Patients are often unaccompanied during examination and treatment sessions as part of routine practice and somembers of the dental team are in a unique and advantageous position to undertake enquiry about domestic violence and abuse.
Asking about domestic violence
The dental professional should be confident and supportive in their approach, expressing concern as necessary. The appropriate time to ask is probably as part of taking the social history. Later, when examining the patient, if injuries are found that do not appear to be consistent with the stated aetiology, then the dental professional should explain this concern to the patient.
All dental care professionals in contact with patients should be aware of the risks of domestic violence and alert to the possible indicators which include frequently missed appointments, injuries inconsistent with explanations of accidental causation, evidence of multiple injuries and if the woman or man appears frightened or excessively anxious.
If the dentist and team only focus on treating injuries, without asking about their cause, then they will be doing little to help the patient experiencing domestic violence. If there are signs suggesting that a patient may be experiencing domestic violence, then the dentist or dental care professional should ask direct and specific questions, and try to obtain evidence, if possible photographic.
Before asking direct questions, the dental professional should begin with some indirect ones to help establish a relationship with the patient and develop empathy. Examples include: ‘Is everything alright at home?’ or ‘Are you ever afraid at home?’
It may be helpful to explain why the questions are being asked by explaining, “I am sorry if someone has already asked you about this, and I don’t wish to cause you any offence, but we know that throughout the country 1 in 4 women experiences violence at some time during their life and so we are asking all women about this issue.’
If responding to dental or facial injury then it may be helpful to suggest, ‘Your partner seems very concerned and anxious about you. Sometimes people react like that when they feel guilty, was he responsible for your injuries?’
The purpose of identification of domestic violence is referral on to the appropriate agency and so this process must be considered prior to enquiry. The referral to agencies providing direct help can be done by providing leaflets and cards with contact details to take away. The dental team should have access to the appropriate information, and be responsible for ensuring that such information is widely available for patients, relatives and friends of women experiencing domestic violence.
Displaying posters in the waiting room with a contact telephone is also useful. It provides a signal to encourage patients to disclose their domestic violence experience.
TRAINING FOR DENTISTS AND DENTAL CARE PROFESSIONALS
Many dental professionals lack the fundamental knowledge about domestic violence as well as the necessary skills to identify and discuss violence with women. Training should involve working alongside key voluntary sector agencies as well as different professional groups involved in responding to violence. Dental professionals also need to understand the issues around confidentiality and child safeguarding and record keeping.
We have been undertaking some research to look at an intervention to educate, and hopefully change the behaviour of dentists and members of their team, so that they are informed and confident to ask patients about domestic violence when they present to them with injury potentially as a consequence of DVA. They are also connected to local agencies for effective referral.
Dentists and dental care professionals should be aware of how domestic violence impacts on dentistry. They should be confident in the identification of domestic violence when a patient presents routine dental care in addition to when they present with dental or facial injury. The identification of individuals experiencing domestic violence is the first step towards ensuring appropriate care. Dentists should be prepared to refer the patient to the appropriate agencies that can offer direct help.
Inadequate training prevents professionals identifying and responding appropriately to domestic violence.
Professor Paul Coulthard is Dean of Dental School at Barts and The London School of Medicine and Dentistry.