legaljustice4john.com
The Shaken Baby Syndrome Myth
renamed "Abusive Head Trauma" or "Non-Accidental Injury"

WAS

SBS: EVERTHING IS BROKEN

* SBS began as an unproven theory and medical opinions, now discredited by biomechanical engineering studies
* No DIFFERENTIAL DIAGNOSIS done to eliminate other causes, abuse assumed without evidence
* Shaken Baby diagnostic symptoms not caused by shaking
* Child protective agencies snatch children, destroy families based on medical accusations without proof of wrong-doing
*Poor or deceptive police investigations, falsified reports, perjured testimony threaten legal rights, due process
* Prosecutors seek "victory", over justice; defense attorneys guilty of ineffective counsel, ignorance, lack of effort
* Care-takers threatened, manipulated, in order to force plea bargains, false confessions
* A fractured criminal justice system--a big piece for the rich, a small piece for the poor, and none for alleged SBS cases.

1. SBS "MYTH" WEBSITE SUMMARY 
2. ARTICLE ABOUT PEDIATRIC ACADEMY SBS FRAUD

3. SUMMARIZED HISTORY OF THE SHAKEN BABY SYNDROME THEORY
4. POLICE ASSAULT: PROTESTING FOR A POLYGRAPH --DJT


Related websites/ important people and projects ShakenBabySyndrome/Vaccines/YurkoProject
CHRISTINA ENGLAND: BOOK
"Shaken Baby Syndrome or Vaccine Induced Encephalitis-- Are Parents Being Falsely Accused?" by Dr Harold Buttram, with Christina England (WEBSITE)
Evidence Based Medicine and Social Investigation:
EBMSI conferences, resources and information Articles and Reports
VacTruth: Jeffry Aufderheide; The SBS conection and other dangerous or deadly side effects of vaccination 

Vaccinefraud.com/The true, suppressed history of the smallpox vaccine fraud and other books:
Patrick Jordan
On SBS:
Sue Luttner, must-read articles and information on Shaken Baby Syndrome: her resources link
The Amanda Truth Project: Amanda's mother speaks out at symposium
Tonya Sadowsky


SUBJECT:

TORN LABIAL FRENULUM
(Skin Connecting Upper Lip To Gum)
Not Exclusively Characteristic (Pathognomonic) Of Abuse


  1. First part of Baby Casey history summary
  2. Forensic photos
  3. Forensic report, falsified
  4. Medical studies on torn labial frenum, "not exclusively characteristic of abuse without other signs"

Baby Casey Laverty was born to a mother who lived on coffee, sugar, junk food and cigarettes during her pregnancy, took no pre-natal vitamins and was obsessed about "getting fat" and only gained 10lbs, then hemorrhaged for 2 days after giving birth, suggesting the possibility of a bleeding disorder. Casey was illegally forced to have a Hep B vaccination after birth, and 3 days later almost died and spent nearly a week in the hospital, was found to have jaundice, high bilirubin, a "serious blood disease" (sepsis, it's believed) followed by 3 days of dangerous IV antibiotics, as well as other symptoms. When the blood infection wasn't found after treatment, doctors claimed it might have been a "hospital error" but were unable to do a cerebral-spinal tap to verify that while there was no infection in the blood after treatment, that it hadn't gone to the brain. Lethargy and other symptoms that followed suggest otherwise. In fact, fluctuations in her heart and breathing monitors so concerned one doctor that he wondered if the equipment had become "unhooked" but the pediatrician who did an exit report minimized everything and suggested that the parents had over-reacted when the baby quit breathing temporarily, or imagined it.

Casey went into a decline over the next 3 weeks. Her skull seemed to change shape which resumed a normal structure after her sleeping position was altered, indicating an abnormally soft skull. She remained lethargic, didn't like to be held or moved and held her legs in a flexed "frog leg" posture, and then developed a respiratory infection that made breathing difficult. Casey's parents continually consulted a nursing hotline associated with the hospital that treated her (a phone nursing service company under contract to the hospital, not hospital nurses), who talked them through the Baby Heimlich maneuver, which was repeated all night until she coughed up a plug of mucus and was able to breath freely and sleep peacefully.

The next day, unusual crying episodes began--"high-pitched, inconsolable crying" which is a description of the kind of cry associated with brain inflammation, such as from encephalitis or meningitis. Her eyes became bloodshot, and the lids reddened from hemorrhage. Soon after, a brown "stain" spread over her chin area and then disappeared when 4 skin eruptions similar to cold sores broke out around her lower lip. Hotline nurses insisted she just had "a bad cold, colic, red eyes and eyelids from crying, and cold sores" and "didn't need to see a doctor".

The Friday before a scheduled pediatric appointment, her father was sitting on a bed and bouncing her in his hands to make her laugh when she slipped from his grasp. Her short fall  was broken by his hands, a padded laundry basket on to a carpeted floor. She stopped crying as soon as he picked her up and hugged her to his chest in a panic, but he called the nursing service to ask what to do and after going through a lengthy checklist for signs and symptoms of injury, the nurse determined that she was unhurt and didn't need to be taken to the doctor or hospital. There was no bump on the head, no bruising, no nothing. She went to sleep and seemed to be fine, as his stepfather described her the next day when the grandparents came to visit.

That weekend Casey developed diarrhea, but otherwise seemed to be better. John noticed a little red spot on her cheek when he got home from work Sunday night (which was later seen in photos as a pimple or whitehead), but when he took mother and baby to the pediatric clinic the next day, she was quiet and peaceful until they got to the clinic and she was being handled. After being stripped and laid on a table to be examined and weighed, she let out a piercing scream and the "inconsolable crying" began again which alarmed the physician's assistant who had already spent more than an hour with the parents who wanted answers about the health issues, poor feeding history (mostly soy formula), and talked about the horrendous experience with the local children's hospital earlier.

When the abnormal crying began, the PA became alarmed and called in the doctor who disappeared with Casey for less than  5 minutes and then came back and said he was sending the baby to the hospital. He told the parents "for further testing" but after John argued because of their previous nightmare experience with the hospital, the lack of trust and the fact that this doctor was the one who wrote the report and ignored the medical findings, and was overheard saying it was just "for the money" --this doctor contacted the hospital and told them he suspected child abuse and targeted the father "because in his experience mothers don't harm their children". He also called the police, but admitted it was just to make certain the parents didn't interfere with Casey being admitted to the hospital, which they didn't. In fact, they met the ambulance and the mother carried Casey in to Admittance and told them the doctor wanted her there for further testing.

What happened afterward was a parent's nightmare. For once thing, once a doctor suggests "child abuse" all concerned medically set out to prove it, including "interpreting" everything in terms of inflicted injury without looking at alternative causes. The skin sores became "burns" to start with. And then as Casey was handled by medical professionals, she started to develop bruising that wasn't there when she was admitted--all blamed on the parents, in a story which snowballed as it went along. The PA documented in a report that she had no bruises when examined at the clinic, but by the time this case hit it's peak, she was "covered with bruises when she came to the hospital and the parents did it."  She did develop some bruising as testing and examinations continued, suggesting a bleeding disorder, but wasn't admitted that way.

As an example of how extreme the suggestion of "child abuse" becomes, one need only look at the forensic report with exaggerated and false statements. The forensic photos he took with the report were replaced with later photos when more bruising had been inflicted at the hospital. The photo doesn't match the report. He describes the 4 skin lesions in terms that sound like battery--not even "burns" the doctors tried to make them out to be earlier. The story gets worse. Much worse. --djt

A pediatrician angry at a distrustful, confrontational father demanding to know what was wrong with his child, critical of prior medical care at a hospital when she stopped breathing temporarily, and overheard insulting the doctor's motives in wanting to send her back to the hospital after assurances that she only had a "bad cold, cold sores, colic and red eyes and eyelids, contacted the hospital where she was being sent and claimed he suspected child abuse. He later faudulently altered a clinic report and wrote a falsified medical report, among other things claiming symptoms that never existed and adding findings that only occurred later after she was hospitalized. Among later findings was a "torn frenulum" --the tiny piece of skin that connects the upper lip to the gums. It could have happened at any time, including during intubation during her previous hospitalization, or during mouth examinations. There was no sign of impact to her lip, mouth or gums nearly always associated with violent  non-accidental injury to suggest abuse.

Once the suggestion of abuse was made, EVERYTHING was interpreted in terms of abuse by medical professionals, law enforcement, and the criminal justice system. That included the forensic officer who took photos of Baby Casey and wrote a forensic report. His first photos were switched with later photos when medical handling caused bruising (suggesting an abnormal bruising condition--hemorrhagic) so that the photos on file no longer matched the report, but the report still demonstrates how the facts were altered to fit the theory of the case. This officer described 4 cold-sore type lesions rimming Casey's lower lip as "a severe cut or laceration to victim's chin, just below her lower lip, which covered most of this area....".   The written description makes it sounds like blows to the mouth area. That would make a "torn frenulum" a sign of abuse.The photo shows something very different--Skin lesions with no abrasions of any kind to the lips or mouth area. Without an indication of assault to the mouth area, a torn frena as a sign of abuse would make no sense.

The parents weren't even told about the finding of a "torn frenulum" and were never questioned by doctors or law enforcement about this"injury", but it was used against them as a sign of violent abuse.

 

 

 

 

 

 

 

The above photo purports to show a "torn frenum", (frenulum) that tiny piece of skin connecting the upper lip to the gum. This condition was not observed at the well baby examination that morning, and could have been caused by medical personel in the course of examining inside Baby Casey's mouth, or in handling by medics anywhere between ambulance pickup and the time these photos were taken several hours later. However, after the pediatrician told the hospital that this was a case of abuse, and particularly after doctors inadvertantly caused bruising on her face which was blamed on the parents, everything was interpreted in terms of abuse.

ICU Dr. McCravey suggested that the torn frenum was a sign of abuse, which was an assumption not supported by scientific studies and medical findings in other cases, and when found in abuse cases was caused by a blow to the mouth which would leave signs of the abuse not in evidence here.


http://www.bmj.com/cgi/eletters/333/7560/160 A torn labial frenum has long been held as a strong indicator of physical abuse. The entire published evidence around this topic amounts to 28 case reports of torn frenum in abuse. Most cases are of severely abused children under the age of five. Although accidental torn frena are mentioned in the literature, there are no published comparative studies. The probability that a torn frenum is abusive is impossible to calculate from the literature and a prospective comparative study is called for.

Emerg Med J 2005; 22:125
© 2005 BMJ Publishing Group Ltd, British Association for Accident & Emergency Medicine, & Faculty of Accident & Emergency Medicine
BEST EVIDENCE TOPIC REPORT
Torn frenulum and non-accidental injury in children
Stewart Teece, Clinical Research Fellow, Ian Crawford, Senior Clinical Fellow

Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK; kevin.mackway-jones@man.ac.uk

Report by Stewart Teece, Clinical Research Fellow
Checked by Ian Crawford, Senior Clinical Fellow

ABSTRACT
A short cut review was carried out to establish whether a torn frenulum in a child is indicative of non-accidental injury. Altogether 104 papers were found using the reported search, of which none presented any evidence to answer the clinical question. It is concluded that there is no evidence available to answer this question. Further research is needed.

http://adc.bmj.com/cgi/content/abstract/adc.2006.113001v1Objective: A torn labial frenum is widely regarded as "pathognomonic" of abuse.We systematically reviewed the evidence for this, and to define other intra-oral injuries found in physical abuse.

Methods: An all language literature search of primary studies, conference abstracts and references from 1950 to June 2006. Each study underwent independent reviews by two of 31 reviewers, drawn from paediatrics and paediatric or forensic dentistry. Standardised critical appraisal, and data extraction was performed. Studies were ranked by study design, and confirmation of abuse.

Results: 19 of 154 studies reviewed were included, representing 591 children. There were no comparative studies of accidental and abusive torn labial frenum to enable a probability of abuse to be determined. Nine studies documented abusive torn labial frena in 27 children, 22 were less than five years old and 24 fatally abused. Only a direct blow to the face was substantiated as a mechanism of injury. Two studies noted accidentally torn labial frena, both from intubation. Abusive intra-oral injuries were widely distributed to the lips, gums, tongue and palate and included fractures, intrusion and extraction of the dentition, bites and contusions.

Conclusions: Current literature does not support the diagnosis of abuse based on a torn labial frenum in isolation. The intra-oral hard and soft tissue should be examined in all suspected abuse cases, and a dental opinion sought where abnormalities are found.


(FULL ARTICLE BELOW)

http://adc.bmj.com/content/92/12/1113
Arch Dis Child 2007;92:1113-1117 doi:10.1136/adc.2006.113001
Original article

Diagnosing abuse: a systematic review of torn frenum and other intra-oral injuries

Sabine Maguire1,
Bruce Hunter2,
Lindsay Hunter2,
Jo Richard Sibert1,
Mala Mann3,
Alison Mary Kemp1

1
Department of Child Health, Cardiff University, Cardiff, UK
2
Dental School, University of Wales Hospital, Cardiff University, Cardiff, UK
3
Support Unit for Research Evidence, Cardiff University, Cardiff, UK

Sabine Maguire, Department of Child Health, Cardiff University, Cardiff, UK; sabinemaguire@yahoo.co.uk

Accepted 21 April 2007
Published Online First 27 April 2007


Abstract

Introduction: A torn labial frenum is widely regarded as pathognomonic of abuse. (Pathognomonic=exclusively characteristic of)

Methods: We systematically reviewed the evidence for this, and to define other intra-oral injuries found in physical abuse. Nine studies documented abusive torn labial frena in 30 children and 27 were fatally abused: 22 were less than 5 years old. Only a direct blow to the face was substantiated as a mechanism of injury.

Results: Two studies noted accidentally torn labial frena, both from intubation. Abusive intra-oral injuries were widely distributed to the lips, gums, tongue and palate and included fractures, intrusion and extraction of the dentition, bites and contusions.

Conclusions: Current literature does not support the diagnosis of abuse based on a torn labial frenum in isolation. The intra-oral hard and soft tissue should be examined in all suspected abuse cases, and a dental opinion sought where abnormalities are found.


RESPONSES

Torn labial frenum -pathognomonic in some circumstances?

ian k mecrow

It would be churlish to write expressing criticism of the recent study by the Welsh Child Protection Systematic Review Group (1) without first acknowledging the important contribution they have made to bringing an evidence base to the practice of child protection. However, I was surprised that the study group should make the statement that a torn frenum is widely regarded as pathognomonic and note there is only one article cited to support this statement. This article did not present any data but was an educational review of the responsibilities of dentists in notifying child abuse.

My own experience leads me to believe firmly that a torn labial frenum may occur accidentally in older infants. I have previously been involved in a case where a 12 month infant who had recently started cruising, had been standing exploring the top of a coffee table with her mouth and gums in the way that small infants often do. She had unexpectedly lost her balance whilst her mouth was still in contact with the edge of the table and had been reported by her parents as falling. She had immediately cried, had been noted to have blood in her mouth and parents attended the Accident and Emergency Department where they gave this plausible and consistent history for the injury.

In an attempt to clarify whether my personal experience of this injury was unusual, I recently asked a group of 30 paediatricians whether there was support for the proposition that a torn labial frenulum is pathognomonic of child abuse. No one was prepared to support this and two other consultant paediatricians cited examples of accidental trauma involving a similar mechanism to that described above – one in his own child.

However, my concern is that whilst the possibility of accidental causation in the older child appears to be widely accepted, the same may not be so for babies.

The literature supports the idea that non-mobile infants are unlikely to bruise accidentally. (2,3,4). The presence of a torn labial frenulum in an non-mobile infant (where a previous history of general anaesthetic and intubation have been excluded) is highly suggestive (and even, dare I say, possibly pathognomonic) of non accidental injury.

My belief is that the courts would follow and support the logic inherent in the proposition that babies who are non-mobile do not generate sufficient forces to bruise the skin spontaneously and are similarly exceedingly unlikely to occasion accidental tears to the labial frenum.

REFERENCES: 1. Maguire S, Hunter B, Hunter L et al Diagnosing abuse:a systematic review of torn frenum and other oral injuries. Archives of Disease in Childhood. 2007; 92: 1113-1117 2. Sugar N F, Taylor J A and Feldman K W. Bruises in Infants and Toddlers: those who don’t cruise rarely bruise. Archives of Paediatric and Adolescent Medicine 1999, April 153 (4): 399-403. 3. Mortimer P E and Freeman M. Are Facial Bruises in Babies Ever Accidental? Archives of Disease in Childhood 1983; 58: 75-80 4. Labbè J, Caouette G. Recent Skin Injuries in Normal Children. Paediatrics, 2001 (August) 108(2): 271-276.

Torn labial frenum - always abusive?

Leena Menon, GP Registrar, Cardiff University
S Maguire, B Hunter, J Sibert, A Kemp

We read with interest the systematic review on torn labial frenum and intraoral injuries by Maguire et al. Systematic review of the world literature1 found no studies comparing accidental versus non-accidental torn frenum. Diagnosing child abuse is challenging to both Paediatricians and Dentists2.A torn labial frenum is a trivial dental injury, rarely presenting to dental or A/E departments.

To illustrate the point further we set out to survey the prevalence of accidental torn labial frenum in a small cohort of children, and if possible define the characteristics of intentional and accidental torn labial frenum.

We conducted a questionnaire based survey among Paediatricians to determine numbers and characteristics of accidental torn labial frenum among their own children. The survey was sent via email to all members of the RCPCH Wales (twice) and then repeated to all the Specialist Registrar trainees in the Wales region in 2004. We chose health professionals as they are most likely to have correctly diagnosed this injury in their child, even if it were not brought for medical attention. This was compared with data on 7 children sustaining an intentional torn labial frenum, with abuse confirmed at Case Conference. The abuse data was ascertained from a study on children with subdural haemorrhages and those undergoing brain CT scan3

We had 90 replies from a group of 521 doctors representing 188 children. This represents a response rate of 15%. 18 children (9.5%) sustained an accidental torn frenum. The following boxes show the details of all the children with their injuries.

• • • • • • • •

This small study indicates that an accidental torn labial frenum is not rare (9.5%). Although the accidental group had a wider age range, and the level of non-responders may indicate an overestimate of prevalence, likewise the abuse group were highly selected as undergoing neuroradiological imaging, yet some differences emerge, which merit further study: accidental torn frenum occurred in older and more independently mobile children. Abusive torn frenum was found in younger infants, with associated injuries, intracranial haemorrhage, fractures and bruising. In conclusion, torn labial frenum in isolation may occur accidentally, but when it does so it tends to be in independently mobile children, is an episode that should be easily recalled by parents due to the apparently profuse bleeding ( mixed saliva and blood), and most commonly is the result of a blunt injury. Abusive torn frena in contrast, occurred in younger children with multiple severe co-existent injury. This study highlights the need for a large scale prospective case control study to accurately define the characteristics of this injury in both settings.

References 1 Sabine Maguire, Bruce Hunter, Lindsay Hunter, Jo Richard Sibert, Mala Mann, Alison Mary Kemp for the Welsh Child Protection Systematic Review Group. Diagnosing abuse: a systematic review of torn frenum and other intraoral injuries. Arch Dis Child 2007; 92:1113-1117

2Woolridge E D. Legal problems of the forensic odontologist. J Forensic Sci 1973; 18; 1:40-46

3Kemp A M, Stoodley N, Cobley C, Coles L, Kemp K W. Apnoea and brain swelling in non accidental head injury. Arch Dis Child 2003; 88(6):472-6

Published 7 February 2008


Is a torn frenum diagnostic of child abuse?

Sandra S Mascarenhas, Specialist Registrar,Paediatrics
Dr.Aszkenasy M,Consultant Community Paediatrician

James Cook University Hospital,Middlesborough

We read with interest the article by Maguire et al 1, reporting the results of a systematic review of torn frenum and other intraoral injuries in diagnosing abuse. We do accept that in the absence of case control studies, the most appropriate study design to answer a diagnostic clinical question, the authors had to settle for case series or case studies. However, when none of the included case series were specifically designed to look for a torn frenum, any firm conclusion based on such studies is weak. It was also surprising to note that some of the studies that were given a rank of one for abuse (highly suggestive of abuse), were case reports based on a single child. Also, we thought it would be useful to point that the number of patients (in Table 4 and 5) do not add up and tally with the total number described in the text. Finally, we do agree that the best way forward is to conduct a well-designed comparative study involving our dental colleagues.

Competing interests: None declared

Reference

1 Maguire et al, Diagnosing abuse: a systematic review of torn frenum and other intra-oral injuries. Arch Dis Child.2007; 92: 1113-1117
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Published 13 December 2007

A torn frenum should prompt assessment for potential child abuse
Critical Summary Prepared by: James Bader DDS, MPH

OVERVIEW

Systematic Review Conclusion:

A torn frenum alone does not necessarily signal child abuse, but should signal the need for further examination.
Critical Summary Assessment:

A thorough review shows the evidence is insufficient for definitive diagnosis, but sufficient for concern.
Evidence Quality Rating: Poor

A Critical Summary of:

Diagnosing abuse: a systematic review of torn frenum and other intra-oral injuries

Maguire S, Hunter B, Hunter L, Sibert JR, Mann M, Kemp AM. Arch Dis Child. 2007;92(12):1113-7

Clinical Questions:

a) Does a torn labial frenum in a child indicate that abuse has occurred?
b) What is the pattern of oral injuries associated with child abuse?
Review Methods:

A thorough search of several databases for studies of intraoral injuries in 0-18 year olds yielded 154 studies, of which 19 met inclusion criteria as determined independently by two expert reviewers. Studies were assessed for strength of study design, and certainty that abuse had occurred.
Main Results:

The 19 included studies represented 591 children. Nine of these studies documented torn labial frena in 30 abused children, 27 of whom did not survive. Only one was a case control study, and it did not isolate on this particular injury. Frena tears were considered to be minor, and not assessed separately in several studies. The most frequent non-sexual child abuse oral injuries were laceration or bruising to the lips. Other oral injuries associated with abuse included mucosal lacerations, dental trauma, tongue injuries, and gingival lesions.
Conclusion:

The literature on frenum tears is sparse, and includes mostly fatal cases. Thus it is difficult to generalize to patients seen in dental practices. The evidence does not support the oft-cited observation that a torn labial frenum is indicative of child abuse. Certainly, such a finding should be followed up with a more thorough examination of the oral cavity for other indications of possible abuse.
Source of funding:

National Society for the Prevention of Cruelty to Children (London, England)

A torn frenum should prompt assessment for potential child abuse
Critical Summary Prepared by: James Bader DDS, MPH

OVERVIEW

Systematic Review Conclusion:

A torn frenum alone does not necessarily signal child abuse, but should signal the need for further examination.

Critical Summary Assessment: A thorough review shows the evidence is insufficient for definitive diagnosis, but sufficient for concern.
Evidence Quality Rating: Poor

A Critical Summary of:

Diagnosing abuse: a systematic review of torn frenum and other intra-oral injuries

Maguire S, Hunter B, Hunter L, Sibert JR, Mann M, Kemp AM. Arch Dis Child. 2007;92(12):1113-7

Clinical Questions:

a) Does a torn labial frenum in a child indicate that abuse has occurred?
b) What is the pattern of oral injuries associated with child abuse?
Review Methods:

A thorough search of several databases for studies of intraoral injuries in 0-18 year olds yielded 154 studies, of which 19 met inclusion criteria as determined independently by two expert reviewers. Studies were assessed for strength of study design, and certainty that abuse had occurred.
Main Results:

The 19 included studies represented 591 children. Nine of these studies documented torn labial frena in 30 abused children, 27 of whom did not survive. Only one was a case control study, and it did not isolate on this particular injury. Frena tears were considered to be minor, and not assessed separately in several studies. The most frequent non-sexual child abuse oral injuries were laceration or bruising to the lips. Other oral injuries associated with abuse included mucosal lacerations, dental trauma, tongue injuries, and gingival lesions.
Conclusion:

The literature on frenum tears is sparse, and includes mostly fatal cases. Thus it is difficult to generalize to patients seen in dental practices. The evidence does not support the oft-cited observation that a torn labial frenum is indicative of child abuse. Certainly, such a finding should be followed up with a more thorough examination of the oral cavity for other indications of possible abuse.
Source of funding:

National Society for the Prevention of Cruelty to Children (London, England)

Commentary:

Importance and Context:

This review attempts to answer a clinical question about the association between labial frenum tears and child abuse, and also seeks to identify patterns of oral injuries indicative of child abuse. Differentiating abuse from accident is difficult at best, but the review suggests that a torn frenum is regarded among pediatricians as “pathognomonic” of child abuse. Dentists should be attuned to the possible implication of such an injury, as well as the possible patterns of oral injuries associated with child abuse.

Strengths and Weaknesses of the Systematic Review:

This review used accepted methods to identify, select, and abstract the literature, and produced a sound evidence summary. The methods directly addressed one difficulty in this type of research, i.e. assessing the certainty that the study populations consisted of abuse victims rather than accident victims. However, the review excluded studies where children were victims of sexual abuse, which may also have intraoral consequences. Also, the review included case studies, which cannot be used to establish causal associations.

Strengths and Weaknesses of the Evidence:

There were a limited number of studies, and most of these studies that documented torn frena involved children with substantial abuse leading to death. Thus, the patterns of injuries described are unlikely to be encountered in dental practice. Whether torn frena may be indicative of less severe abuse cannot be resolved by the available evidence. Because data describing the frequency of frenum tears in a non-abused population have not been reported, no estimate of the probability of a frenum tear in an ambulatory dental patient signaling abuse could be calculated.

Implications for Dental Practice:

This review was prepared for physicians. It concludes by calling for dental consults when there is doubt concerning the cause of perioral and intraoral injuries. Dentists should be prepared to respond to such requests, as well as initiate investigations when oral conditions raise suspicion. They should be aware, however, that there is no good evidence for frenum tears indicating abuse in the absence of any other injuries.

Critical Summary Publication Date: 3/5/2009



http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2066066/

Arch Dis Child. 2007 December; 92(12): 1113–1117.
Published online 2007 April 27. doi: 10.1136/adc.2006.113001

Diagnosing abuse: a systematic review of torn frenum and other intra-oral injuries
Sabine Maguire, Bruce Hunter, Lindsay Hunter, Jo Richard Sibert, Mala Mann, and Alison Mary Kemp, for the Welsh Child Protection Systematic Review Group

Sabine Maguire, Jo Richard Sibert, Alison Mary Kemp, Department of Child Health, Cardiff University, Cardiff, UK
Bruce Hunter, Lindsay Hunter, Dental School, University of Wales Hospital, Cardiff University, Cardiff, UK
Mala Mann, Support Unit for Research Evidence, Cardiff University, Cardiff, UK
Correspondence to: Sabine Maguire
Department of Child Health, Cardiff University, Cardiff, UK; sabinemaguire@yahoo.co.uk
Accepted April 21, 2007.

ABSTRACT

Introduction

A torn labial frenum is widely regarded as pathognomonic of abuse.

Methods
We systematically reviewed the evidence for this, and to define other intra-oral injuries found in physical abuse. Nine studies documented abusive torn labial frena in 30 children and 27 were fatally abused: 22 were less than 5 years old. Only a direct blow to the face was substantiated as a mechanism of injury.

Results
Two studies noted accidentally torn labial frena, both from intubation. Abusive intra-oral injuries were widely distributed to the lips, gums, tongue and palate and included fractures, intrusion and extraction of the dentition, bites and contusions.

Conclusions
Current literature does not support the diagnosis of abuse based on a torn labial frenum in isolation. The intra-oral hard and soft tissue should be examined in all suspected abuse cases, and a dental opinion sought where abnormalities are found.

Keywords: abuse, frenum, intra-oral injury, torn labial frenum, systematic review.......

Facial and intra-oral trauma has been described in up to 49% of infants and 38% of toddlers who have been physically abused.1,2 A torn labial frenum (often referred to as frenulum or phrenum) is widely believed by paediatricians to be pathognomonic of abuse,3 and has been described as the most common abusive injury to the mouth.4,5 Several abusive mechanisms have been proposed and include forced feeding,6 gagging, gripping and violent rubbing of, or a direct blow to, the upper lip.7,8 A torn labial frenum, however, is regarded as a trivial intra-oral injury by dental practitioners, as it is likely to heal spontaneously with minimal complications, and is not reported in large-scale dental trauma surveys.9
It is estimated that up to 50% of all school-age children sustain accidental dental injuries,10 challenging clinicians to distinguish between abusive and non-abusive injuries to the mouth.

We systematically reviewed the literature to establish the probability of a torn labial frenum being caused by physical child abuse and to define what other intra-oral injuries are found in physical abuse.

METHOD

Data sources and participants
We carried out an all-language literature search of research articles, conference abstracts, websites and references in all articles identified, including review articles and relevant textbooks from 1950 to June 2006. The key words and details of databases searched can be found in tables 1 and 2, respectively. Articles were scanned for duplication and relevance. Authors were contacted where necessary. The resulting studies were reviewed by members of the Welsh Child Protection Systematic Review Group, a panel of 31 people who were paediatricians, child health professionals with child protection expertise, or paediatric or forensic dentists. Each study was subjected to two independent reviews and a third if disputed. Standardised criteria for study definition, data extraction and critical appraisal were used.11 Full critical appraisal and data extraction forms are available at http://www.core-info.cf.ac.uk

Table 1) Keywords and phrases used for the electronic search

Child abuse
avulsion injur:.
child protection
intraoral adj3 burn:
(battered child or shaken baby or battered baby)
lip scars
intraoral adj3 lesion:
.(child maltreatment lip or lips).
(child adj3 maltreatment) scars
adj3 lip
(child adj3 physical abuse)
vermilion border.
non-accidental injur:
tongue.mp.
soft tissue injur:
floor of mouth.
physical abuse
Luxation injury or luxated tooth
physical punishment.
lateral luxation.
oral dental trau
displaced tooth or intruded tooth or oral facial injur:
extruded tooth or avulsed tooth
(oral or dental injur:)
intrusion injury or extrusion injury
(abrasion: or lesion: or laceration:).
subluxated tooth
(frenum or freanum or Frenulum).
Crown fract: or root fract:
(torn lingual or labial frenu:).
Crown adj3 fracture) or labial frenum/ root) adj3 fracture
lingual frenum/ Alveolar injury or alveolar fracture
(lingual frenum or freanum or dental traumatology.
fraenum or phrenum).
oral traumatology.
(labial frenum or freanum).
Periodontal injury or gingival injury

Table 2) Databases used for the search strategy


Database                                        Information
ASSIA 1987–June 2006               ASSIA: Applied Social Sciences Index and Abstracts on the Web is an indexing and abstracting tool covering                                                                        health, social  services, economics, politics, race relations and education
CareData 1980–June 2006          Social work and social care knowledge base
ChildData 1958–June 2006          National Children's Bureau database
CINAHL 1982–June 2006             The Cumulative Index to Nursing and Allied Health (CINAHL) database provides authoritative coverage of the literature                                                           related to nursing and allied health
EMBASE 1980–June 2006          The EMBASE family consists of three separate databases: (1) EMBASE: Excerpta Medica Database, and its subsets, 2 EMBASE Drugs and
Pharmacology, and 3
EMBASE Psychiatry
MEDLINE 1950–June 2006           Biomedicine, allied health, biological and physical sciences, humanities and information science as they relate to                                                               medicine and health care, communication disorders, population biology and reproductive biology
Ovid MEDLINE June 2006             In-process and other non-indexed citations
SIGLE 1980–June 2006                System for Information on Grey Literature in Europe is a bibliographic database covering European non-                                                                                   conventional (so-called grey) literature in the fields of pure and applied natural sciences and technology, economics,                                                            social sciences and humanities
TRIP Database 1997
–June 2006                                      The TRIP Database searches over 55 sites of high-quality medical information. It gives direct, hyperlinked access to                                                               the  largest collection of “evidence-based” material on the web as well as articles from premier on-line journals
Sciences Citation Index
1981–June 2006                             Sciences Citation Index is a multidisciplinary database, covering the journal literature of the social sciences
ISI Proceedings
1990–June 2006                             Covers conference papers in all scientific and technical fields

Data extraction
We included all studies of children aged 0–18 years with intra-oral injuries due to physical child abuse, and torn labial frena of any aetiology, in live and fatal cases. We defined intra-oral as the area between the vermilion border of the lips and the hypopharynx.

We excluded review articles, expert opinion or guidelines that did not include primary evidence, studies with mixed adult and child data where the children's data could not be extracted, studies that addressed complications or management of abusive injuries, intra-oral injuries due to sexual abuse, or thermal injuries (as these will be encompassed in separate reviews) or dental neglect.

Studies were ranked by study design and by the likelihood that abuse had taken place in the “abused” population. We used our own ranking of abuse, as previously described, where a ranking of 1 gave the highest security of diagnosis that abuse had taken place, and a ranking of 5 the least confidence (table 3).12 We included studies with a ranking of 1–4. In the case of non-abusive injuries, we only included studies where authors had described methods to ensure that abuse had been excluded.

Table 3) Ranking of the definitions of child abuse


Ranking    Criteria used to define abuse

1       Abuse confirmed at case conference or civil or criminal court proceedings or admitted by perpetrator
2       Abuse confirmed by stated criteria including multi-disciplinary assessment
3       Diagnosis of abuse defined by stated criteria
4       Abuse stated as occurring, but no supporting detail given as to how it was determined
5       Abuse stated simply as “suspected”, no details on whether it was confirmed or not

RESULTS

Of 154 studies reviewed, 19 met the inclusion criteria.1,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30 These represented data on 591 children. There were no comparative cross-sectional or case-control studies of torn labial frena to enable a probability of abuse to be determined for this injury. The only mechanism described for an abusive torn frenum was a direct blow to the face, recorded in two children. No details of mechanisms were given in other cases. Likewise, there were no comparative studies to compare the characteristics of other abusive and non-abusive intra-oral injuries.

Abusive torn labial frenum
Nine studies documented torn labial frena in abused children (table 4?4):): seven were case series or case studies,14,16,17,18,20,28,29 and one was a case-control study.23 None of these studies were designed to address torn frena specifically; the case-control evaluated blunt abdominal trauma in association with cardiopulmonary resuscitation.

These studies represented data on 30 children, of whom 27 (90%) were fatally abused. Twenty two were 5 years of age or younger. The age range given was 0–10 years for five children in one study.23 Four of these studies ranked 1 for abuse, three ranked 3 and two ranked 4.

Cameron was the first to report a torn labial frenum as a consequence of physical abuse in 1966.14 In a retrospective study of 29 fatally abused children between birth and 4.5 years, he noted “the presence in nearly half of the cases of laceration of the mucosa of the inner aspect of the upper lip near the phrenum [sic], sometimes with tearing of the lip from the alveolar margin of the gum was a striking feature of possible significance”.14 Later the same year, Tate29 reported six cases with abusive facial injury, three of whom had a torn frenum. The mechanism was described as a direct blow in two cases: a 2.5-year-old child with a torn frenum of the upper and lower lips was shaken and her head struck against a fireplace several times, and a 23-month-old child with a torn upper labial frenum was struck about the face. Two of the three children were fatally abused with associated head injuries; multiple bruises and fractures were found in all three.

Of the remaining 11 reported cases, nine were fatally abused with associated head injury16,28,30 (personal correspondence with authors), five had fatal abdominal injuries and one had co-existent ano-genital sexual abuse with multiple fractures.18 The remaining two had other intra-oral injuries, and one later sustained an intracranial injury.17,20

Non-abusive torn labial frenum
Two separate case studies documented a torn upper labial frenum occurring as a consequence of an intubation, both in fatally injured children.22,23 No further details were offered. When contacted, the authors of the larger series of dental trauma in children21 replied that they did not record a torn frenum as they regarded this as a trivial dental injury.

Abusive intra-oral injuries
Fourteen studies documented other types of abusive intra-oral injuries.1,13,15,17,19,20,21,24,25,26,27,28,29,30 They were all case series or studies, and 11/14 had a higher abuse ranking of 1 or 2. They represented data on 579 children (table 5).). The most commonly recorded abusive injuries to the mouth were lacerations or bruising to the lips. The remaining injuries included mucosal lacerations, dental trauma (including fractures, intrusion and forced extraction), tongue injuries and gingival lesions. No characteristics of these lesions were specific to an abusive aetiology, apart from an adult bite to a child's tongue.19

Table 5      Abusive intra-oral injury


Authors/year    Abuse rank    Number of children (age)    Orofacial injuries found
Tate, 1971 (29)               1       2 (23 months and 4 years)       Case 1, chipped upper incisor, also torn frenum and fractures, killed 3 weeks later
                                                                                                      Case 2, severe laceration of upper lip and loose tooth. Multiple other soft tissue injuries
Becker et al, 1978 (1)    4        260 (not given by authors)       49% orofacial trauma, 14 intra-oral, 4 dental trauma, no other detail on location
Swann and Glasgow,
1982 (27)                       2        1 (7 weeks)                               Oral bleeding, bruise and ulcer to fauces, abrasions and bruising to gingiva and around tongue
Schuman, 1987 (24)      1        1 (10 years)                               Midroot fracture of maxillary incisor
Sobel, 1983 (25)            1        1 (4 years)                                 Facial abrasions/bruises, bruising of upper and lower lip, laceration of gingival and
                                                                                                       alveolar mucosa, intrusion of one incisor and avulsion of incisor, fractured mandible
Grace and Grace,
1987 (17)                        1         3 (10–18 months)                    Abrasions of hard palate with associated trauma to ear in one case, two cases of laceration
                                                                                                      to pharyngeal wall, one with associated intracranial injury and one trauma to ear
Symons et al,
1987 (28)                        4         1 (3 years)                                Fatally abused, abrasion of upper lip, laceration of frenum of upper lip, intracranial haemorrhage
Manning et al,
1990 (20)                        1         1 (4 months)                              Recurrent oral bleeding, abrasions and lacerations of upper gum, hard palate, floor of mouth and frenum.
                                                                                                       Retropharyngeal abscess
Carrotte, 1990
(15)                                   1         3 (13 years, n/a)                      Dental extraction of permanent teeth by parents as a punishment
Barrett and Debelle,
1995 (13)                          2        1                                                 Tear on posterior pharyngeal wall, forcible removal of an impacted dummy
Naidoo, 2000
(21)                                    2        300 (1 month–14.25 years)    22 lacerations to lips, 6 injuries to oral mucosa, 5 to teeth, 5 to gingiva, 3 to tongue. Also unspecified                                                                                   number of loose or missing teeth. Seven fractures of mandible/maxilla
Lee et al,
2002 (19)                          1        1 (10 months)                           Adult bite to the infants tongue, herpetic lesions perioral and intra-oral, also multiple fractures,
                                                                                                       skin lesions and lacerations to ear and neck
Stricker et al,
2002 (26)                          1        1 (9 days)                                  Bleeding lesion on hard palate, discharged, returned at 4 weeks with multiple fractures
                                                                                                       and intracranial haemorrhage
Phillips and van               3        4                                                 Bruised lips, lacerated lips, bruised alveolar mucosa, avulsed teeth. All fatal cases,
der Heyde, 2006 (30)       (20 months, 2.5 years,                      co-existent lacerations, bruises, burns, fractures, sexual abuse (one case) and
                                          3 years, 5 years)                                scars to body, with fatal visceral and head injuries

Becker recorded orofacial trauma in 49% of 260 abused children, 14 (6%) of whom had intra-oral injuries.1 The largest series, by Naidoo, showed that 59% of 300 physically abused children had facial injuries, 11% of whom had intra-oral injuries.21 The most common injuries recorded were to the lips (22 children). There were also seven fractured mandibles, and six injuries to oral mucosa, five to teeth, five to gingiva and three to the tongue. Torn frena were not recorded specifically. The children were selected from those with known physical abuse and orofacial injury. No child was examined by a dentist in any of these studies, and the data were collected retrospectively from chart reviews, raising the question of how often the mouth was actually examined.
Injuries to the tongue included an adult bite to an infant's tongue in a 10-month-old child, with the arc of the bite pointing towards the lips, confirming it could not have been self inflicted, with multiple fractures, bruises and subdural haemorrhages19 and abrasions and bruising.

In three studies oral bleeding was a presenting symptom.20,26,27 In one case the infant re-presented five times from the age of 4 months,20 and was found to have a laceration of the uvula with several abrasions and lacerations of the upper gum, hard palate, floor of mouth and lingual frenum; the child developed a retropharyngeal abscess.

Injuries to teeth included displacement, chips, avulsions, intrusion and fractures.1,21,24,25,29,30 One bizarre case series included three siblings who had endured forced dental extraction of permanent incisors as a form of punishment.15

DISCUSSION

This study confirms that intra-oral injury occurs in a significant number of children who have been physically abused. Injuries are widely distributed to the lips, gums, tongue and palate and include fractures, intrusion and extraction of the dentition, bruising, lacerations and bites.

There is a paucity of published scientific literature about the torn labial frenum. There are no studies defining the incidence of torn labial frena in abuse and none that compare the injury in abused and non-abused children. It is impossible, therefore, to ascribe a probability of abuse for a torn labial frenum. Published studies are limited to 30 highly selected cases where a torn labial frenum is described in predominantly pre-school children who had suffered serious abuse, and where the majority of cases were fatal with extensive associated injuries. The only substantiated cause of an abusive torn labial frenum was a direct blow. There were no recorded cases of forced feeding, twisting or rubbing causing this injury. The literature includes mention of torn labial frena that were not abusive, and therefore a torn frenum in isolation cannot be described as pathognomonic of physical abuse. Clearly the finding of an unexplained torn labial frenum in a young child warrants full investigation, but the paucity of data in the literature and the highly selected nature of cases reported precludes defining an age band where concern would be highest. A diagnosis of physical abuse should not be based on a single injury in isolation, but arrived at in the context of the child's medical, social and developmental history and the explanation offered for the injury.

Some of the largest series in the literature31,32 were not eligible for inclusion as they were only ranked 5 for abuse. They included cases of suspected abuse, with no separation of data on those cases where abuse was actually confirmed.

It is important when assessing a possible torn labial frenum to consider rarer congenital abnormalities of the labial frena such as midline diastema,33,34 hypertrophic frenum in association with hypoplastic left heart syndrome,35 and multiple frena in other congenital heart syndromes such as Ellis-van Creveld or Pallister-Hall33, 76, as possible explanations of the abnormality.

The most frequently reported abusive injury to the mouth is not a torn labial frenum, as has been suggested,4 but injury to the lips. This assumes that the mouths of all abused children in the various series were fully examined. As these were retrospective studies of case notes,1,21 this is far from clear. None of the described abusive intra-oral injuries had any diagnostic characteristics, except for a bitten tongue.1,13,15,17,19,20,21,24,25,26,27,28,29,31 It is clear that paediatricians should always examine a child's mouth when assessing a child for suspected abuse. As it is doubtful whether non-dental specialists would recognise the significance of grey discolouration of the teeth as a micro-fracture or previous injury,38 or whether they would be able confidently to distinguish this from the characteristic yellow-brown to grey discoloration found in dentinogenesis imperfecta, it is important to involve dental colleagues. This would be particularly pertinent if co-existent skeletal fractures were found, as may be the case with combined osteogenesis imperfecta and dentinogenesis imperfecta.39 It is important that paediatricians are aware of the appropriate primary and secondary dentition expected at a given age, in order to question the absence of permanent teeth, as described by Carrotte.15

Many of the intra-oral injuries described in abused children are likely to be seen by general dental practitioners, yet dentists make very few child protection referrals. This is highlighted by Cotton,40 who noted that of 20 000 child abuse investigations only 12 were initiated by dentists. A survey by Becker et al of 1332 dentists in the USA, where there was mandatory reporting with a response rate of 40%, noted that 22 cases of child abuse were seen but only four (18%) were referred to social services,1 despite a legal requirement to report suspected abuse. A similar study by Malecz41 showed that not only did few dentists report abuse cases, but 7% of 155 respondents said that under no circumstances would they report child abuse. Reasons cited included uncertainty about diagnosis and fear of litigation, although practitioners making a referral “in good faith” are protected from litigation in the United States.3 Even 12 years later, a survey of 250 dentists, 157 of whom responded, showed that 50% of dentists had suspected abuse but one third did not refer the case,42 and similar reluctance has recently been documented in the UK where 21% of dentists did not refer cases they suspected of having been abused.43 There have been a number of initiatives in the United States to tackle this issue,44,45 and Welbury et al have developed a computer-assisted learning programme for general dental practitioners in the United Kingdom,46 and the British Dental Council have recently published guidance.47
There is no legal mandatory reporting of child abuse in the UK, but the British Dental Association has made it clear that dentists do have an ethical responsibility to report child abuse.48 Clearly, those responsible for child protection training in each region must include dental practitioners and hygienists in such programmes, and offer ongoing support.

As in previous reviews,12,49 children with disability were not represented. This is particularly disappointing as disabled children are recorded as being three times more likely to be abused than their able-bodied counterparts.50

Whilst this review did not deal with dental neglect, a notable number of cases presented co-existing neglect with resulting dental caries, likely to cause severe pain to the child.25,28 Dental neglect while variably defined,38 should be considered in any child with extensive dental caries or early childhood caries where appropriate dental care has not been sought.51,52 This subject merits a review in its own right, in view of the potential implications in relation to pain, morbidity and faltering growth.53

Future research should be directed at determining the sensitivity and specificity of intra-oral injuries in abuse by well designed comparative studies. It is clear that we need to define those children who sustain accidental torn frena, in isolation or otherwise, by age, developmental stage and co-existent injury and cause, in order to aid the distinction from abusive torn frena. Attention should be given specifically to documenting the full extent of intra-oral injuries in physically abused children and their co-existent injuries, and this should include disabled children

Acknowledgements

The authors wish to thank the following: NSPCC for their financial support of this systematic review; our reviewers: C Adams, M Barber, P Barnes, R Brooks, L Coles, P Davis, R Evans, L Hunter, R Frost, C Graham, M James-Ellison, B Hunter, R Jenkins, N John, A Kemp, K Kontas, H Lewis, A Maddocks, S Maguire, A Mott, A Naughton, C Norton, M Obaid, M Parry, H Payne, L Price, I Prosser, B Ellaway, J Sibert, E Webb, C Woolley; and Kim Rolfe for technical help with database management and editing of the paper.

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Dianne Jacobs Thompson  Est. 2007
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