Responsibilities and Intervention Techniques for Dental Professionals
Dental professionals must understand their obligations to report when they suspect someone may be a victim of IPV or EM. One proven approach to having this conversation is known as “ask, validate, document, and refer/report if required by law” or AVDR.23 The AVDR model provides a framework for dental professionals responding to any kind of family violence. It also helps ensure that victims are offered resources that may be needed as well as fulfill a dental professional’s legal and ethical obligations.
Before even engaging in the ADVR method, there are some baseline steps dental professionals should take to be prepared to appropriately respond to a patient reporting or showing signs of abuse. Dental professionals should establish and maintain a professional therapeutic relationship with the patient. They should also become familiar with the signs of IPV and EM and the state reporting requirements for each type of abuse. The ADVR method includes:
ASK: This includes not only actively asking questions, but also listening closely and observing suspicious evidence that can be ascertained during a dental patient’s office visit (or anyone accompanying them). Be free of distractions and sit in a position that is comfortable for the patient. Ideally, it helps to ask these questions when the patient is alone with the dental professional so that they can be asked in a non-threatening and non-judgmental way. If the patient is a non-English speaking patient, use a professional interpreter instead of the person who they brought to the appointment in order to circumvent the partner trying to control the patient.14 If the patient asks why such questions are necessary, it may help to explain that they are routine screening questions that may not appear to have a relationship with the mouth, but in actuality, they have a significant relationship with oral health.14 Personal safety and well-being are some of those important things. If you live in a state with mandatory reporting requirements, make the patient aware of these before full disclosure. Please note that you need to be prepared to hear the patient’s answers. Caring, empathetic questions may open the door for later disclosure as you build rapport. Also, refrain from using language with stigmatizing words, like “rape,” “abuse,” “battered,” or violence” in your questions.14
Do you feel safe at home?
You seem stressed and I noticed you missed your last appointment. Are you ok? Is there anything I can do to help?
I don’t know if this is a problem for you, but many of our patients have been dealing with domestic violence, so I started to ask all my patients routinely.
I see that you are grinding your teeth regularly (or insert intraoral/extra oral finding). What in your life could cause that?
VALIDATE: Respond to patient’s feelings and take time to acknowledge that disclosure is scary. Assure the patient that he or she is doing the right thing in telling you and acknowledge their courage to disclose such personal information. Take anything the patient reports seriously and assure patients of confidentiality to the extent allowed under the state’s mandatory reporting laws. It is also important to remember that dental professionals without counseling credentials must avoid offering advice or telling the patient what to do. There are many strategies that you can practice in role-playing activities to become comfortable validating patient reports.
Common responses could be:
“I am sorry you have been hurt.”
“I am concerned about you and your safety.”
“There are resources out there that can help you.”
DOCUMENT: Record or document any evidence that may be helpful, including physical evidence and any verbal comments. If at all possible, it is recommended to use direct quotes from the patient when documenting the conversation. If you report the abusive situation due to the mandatory reporting laws in your state, document a case number into your notes if the state provides one. Consider asking the patient if you can photograph visible injuries, if possible, or make sure to describe orofacial injuries in detail. It is helpful to hold something up to document the extent of the injuries (e.g., if intraoral lesions, place the probe beside it to document how big the lesion is). Finally, use neutral language in your documentation. Instead of “alleges,” use the word “reports.” Words that have a negative connotation can be used against the victim by the defense counsel (alleges, refuses, etc). This detailed information could be very beneficial information if the victim decides to pursue any legal action against the perpetrator.
REFER AND REPORT: Treat injuries within the expertise of the office and refer to other healthcare providers for other injuries. Provide patients with options and resources for next steps, including referrals to domestic abuse advocacy organizations. Consider having small, easy to conceal cards or other resource information already available for patients that contain information for local resources. Even having these resources available in privately accessible areas like restrooms is helpful, especially if the victim is not ready to disclose to you.14 Developing relationships with local domestic abuse programs can help professionals in a dental office make the referral process even more effective and provide dental professionals with ongoing training. Document the referral information given to the patient and file mandatory reports if needed. Schedule a follow-up visit.18
Sample Documentation Language (to be used in addition to your normal dental progress notes:
Patient reports physical abuse by significant other on 8/7/22. Pt states "he pushed me up against the wall, grabbed me around the neck and punched me in the face." A contusion noted to left side of face, round, light purple in color. Intraorally, bilateral lacerations in healing stages on buccal mucosa and patient reports biting self when being grabbed. Extra and Intra-oral photographs taken after approval from patient. Referrals provided for local IPV services and patient took local shelter business card. Patient asked if she would like to report incident to police. Patient declines reporting at this time.
**Add report number if your state qualifies for mandatory reporting, such as: “Report made to APS. Report number 65432. Patient informed of APS report.”
Key parts: Reports (instead of alleges), Declines (instead of refuses), and direct quote from patient.