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Oral healthcare reform is critical for addressing a hidden, often overlooked trauma of domestic and family violence

Introduction by Croakey: Inequities in access to oral healthcare, as highlighted by a recent #CroakeyLIVE webinar, are exacerbating the traumas of women who experience violence, according to a dental expert.

Dr Shalinie King, a Senior Lecturer with the University of Sydney Dental School, has seen young women wait up to four years for treatment to replace teeth lost due to violence.

In the article below, King calls for policy reform to ensure violence survivors have access to oral healthcare, improved education and training for oral health professionals in working with survivors , and better data collection.

“Domestic or family violence that results in a broken arm, leg or jaw-bone is managed within the Australian health system; however, if that same person breaks or loses a tooth as a result of the assault, they are unable to access the health system unless they have a HealthCare Card and even then, they may wait years to access care,” she writes.


Shalinie King writes:

Violence against women has been in the spotlight again recently, triggered by reports such as the fact that, according to 2021-22 figures, more than one in four reported having experienced domestic or family violence since the age of 15.

These rates of violence are unacceptable. An often-hidden consequence is the impact this violence has on the teeth and oral health of the individual.

Perpetrators of physical violence against women often target the face, in part because the face and mouth are vulnerable targets of violence with little protection but also because they may have the intention of disfiguring and humiliating their victims.

A recent systematic review involving studies from around the world on the prevalence of orofacial trauma among survivors of domestic violence reports that more than 50 percent of assaults involve trauma to the dental, and orofacial region. However, rates as high as 90.6 percent have been reported at a major trauma centre in the United Kingdom.

The physical consequences include soft tissue injuries such as bruising and lacerations, broken teeth, loosening or complete loss of teeth, fractures of the facial bones including the upper or lower jaws, and the nose. Importantly, it is often the front teeth that are most likely to be damaged or lost impacting self-esteem, confidence and physical appearance.

However, there are longer-term consequences related to the economic impact of domestic and family violence on survivors which can translate into poor oral health outcomes and reduced oral health related quality of life.

Trauma to the oro-facial region is quite confronting. The public health system provides emergency and follow-up care for all soft tissue injuries and for all injuries involving broken facial bones.

However, the public system does not provide any ongoing care for injuries to the teeth apart from emergency relief of pain, which often involves removal of the teeth.

Long waits

Any costs related to the rehabilitation of lost or broken teeth must be borne by the survivor of domestic violence, or if they are eligible for public dental treatment, they can access care through the public system. This can involve long waiting lists where they may wait several years for treatment.

A few years ago, I worked as a clinical educator in a university student dental clinic in western Sydney where we provided dental care for women who had experienced  domestic or family violence, mostly this involved replacing teeth lost due to violence or poor oral health.

Many of our patients had been waiting between two to four years for treatment, some without any teeth at all. Many were young women with school age children.

Once we had restored their missing teeth, patients told us of the significant impact on their lives. They would be able to pick up their kids from school without feeling embarrassed, they could go for job interviews without being judged, and they could smile again.

The cost of rehabilitating lost or missing teeth is unaffordable for many survivors of domestic or family violence.

Accessing the public system is also particularly hard – the survivor is required to register with the public dental clinic in their local health district. If they move to a different area they will have to re-register with the new dental clinic. The waiting lists between local health districts are not integrated, this means that they will then go to the bottom of the list in their new local health district.

Many women who experience domestic or family violence do not have stable accommodation, some move frequently to evade violent partners. The result is they spend years on public hospital waiting lists, and some give up even trying to access the system.

Reform priorities

As a first step, we need to make the public dental system easier to access with a national or, at the very least, state-based waiting list for survivors of domestic violence.

Introducing a funding model for urgent repair or replacement of any broken front teeth would have enormous impacts on the self-esteem and emotional well-being of survivors.

In the longer term, we should work towards integrating dental care with other support services for survivors of domestic and family violence.

Given the extent of oro-facial trauma in domestic and family violence, oral health professionals, including dentists, oral health therapists and dental hygienists, have an important role in identifying signs of violence.

However, many oral health professionals lack the skills and training to confidently recognise and respond to domestic and family  violence.

There is therefore a need to improve the education and training of oral health professionals.

Inclusion of survivors of domestic and family violence as a priority group in Australia’s National Oral Health Plan could help promote strategies to improve the training and education of oral health professionals as well as the integration of the dental care into the broader health system.

Finally, we need national data collection on dental and oro-facial injuries to better understand the nature and extent of this trauma related to domestic violence in Australia.

Domestic or family violence that results in a broken arm, leg or jaw-bone is managed within the Australian health system; however, if that same person breaks or loses a tooth as a result of the assault, they are unable to access the health system unless they have a HealthCare Card and even then, they may wait years to access care.

Although dental trauma may not be life threatening, supporting survivors of domestic violence to restore their teeth will enhance their self-confidence and  rebuild their self-esteem.

This will not only improve their quality of life and their economic productivity but will give them the dignity, care and respect they deserve.

Author

Dr Shalinie King is a Senior Lecturer with the University of Sydney Dental School, and a postdoctoral research associate with the Westmead Applied Research Centre (WARC) where she leads the oral health research stream. The goals of her work at WARC are to improve awareness of the importance of good oral health in contributing to better heart health outcomes, with a broader focus on improving the integration of oral health care into chronic disease management. Ultimately, she aims to build the evidence to support better access to basic preventive oral health care as part of the general health system.

She is a practising clinician with experience working in both the public and private sectors of dentistry and is a Fellow of the Royal Australasian College of Dental Surgeons. As senior lecturer in the Sydney Dental School she has extensive teaching experience and in 2020 implemented and coordinated a clinical placement programme in collaboration with a corporate partner. In 2023 she was invited to give evidence at the Parliamentary Select Committee enquiry into the Provision Of And Access To Dental Services.


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