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Breaking the Cycle

DOTSOne in three women will be abused in her lifetime, and dentists are in a position to save lives.


A mother and her two children began coming to Tufts for dental care on a regular basis. Having recently left an abusive relationship, the woman was working hard to put her family's lives back on track. One day, the trio missed their appointment, never to be heard from again.

Stories like this are why Dr. Kanchan Ganda, professor of general dentistry, and Dr. Gülsün Gül, assistant professor of general dentistry, founded Tufts' Dental Outreach to Survivors (DOTS) program. Aided by Cynthia Yered Mclaughlin, D90, clinical assistant professor of general dentistry, and Patricia DiAngelis, general dentistry department administrator, the DOTS team devotes much of its time to procuring free and confidential dental care for victims of abuse.

Established in 2003 with a grant from Delta Dental of Massachusetts, DOTS has provided care to 234 patients-including 20 children-referred to Tufts by 46 shelters, hospitals and community centers in Greater Boston. Free dental care means no bills-and no paper trail. The money saved can become the rent money or down payment that helps a woman leave her abuser for good. And her new smile can help her regain at least a little of her lost self-esteem.

Uniquely poised

Domestic violence survivors referred to DOTS already have left or started the process of leaving their abusers. Gül is working to ensure that the next generation of dentists will not just deal with the consequences of partner abuse but actually intervene: "The idea here is to save lives."

"The idea here is to save lives."

— Dr. Gülsün Gül

Because abusers often control their victims' contact with the outside world, dental neglect may be a key indicator of domestic violence. Indeed, neglect is by far the most common condition seen among the DOTS patients, more than half of whom required restorative care.

However, dentists may best identify patients who are being abused simply by asking the question. Dental professionals are uniquely poised to raise the issue with patients who spend, on an average visit, 30 to 60 minutes with hygienists and dentists, compared to just seven to 10 minutes with physicians. Research indicates survivors of abuse overwhelmingly want their health-care providers to ask about intimate partner violence. Yet in 2001, a national survey conducted by the University of California at San Francisco School of Dentistry found that most U.S. dentists don't ask their patients about abuse.

Because the vast majority of domestic violence injuries involve the head, neck or mouth, dentists can take the lead in identifying, treating and intervening in abuse cases. "If you can intervene in just one case," Gül says, "then you have made a huge difference. We're trying to give dentists another tool to add to their mental checklist for patient assessment."

DOTS


Just by documenting signs of abuse, dentists can be of enormous support to victims. Dental records can serve as key evidence in criminal or divorce cases or restraining order hearings. Equally as important, dentists should have lists of local agencies, shelters, hotlines and other community resources to give patients who may not know where to go for help. By letting patients know they do not deserve to be abused and that there is a way out, dentists may be able to help their patients break the cycle of abuse.

Commissioned by the Family Violence Prevention Foundation, Gül and her colleagues collaborated on a publication [PDF] that gives dental professionals a crash course in recognizing and responding to domestic violence. The brochure includes common signs of abuse and tips on broaching the subject with patients.

Staggering statistics

Abuse can take many forms. It can be a physical assault on a spouse, an elderly parent or a child; it can be controlling or intimidating behavior; it can be forced sexual contact. Even though denial, shame and fear prevent many victims from reporting the violence, the statistics are staggering. One in three adult women is physically or sexually abused by a boyfriend or husband in her lifetime, and one in four gay men and lesbian women will suffer the same at the hands of their partners.

"No dentist should think this doesn't happen in his or her patient population. Often, older dentists come to me and say, 'I wish I'd known what to look for.'"

— Dr. Gülsün Gül

Intimate partner violence (IPV) training has been part of the Tufts Dental curriculum since 2000. Students receive 15 hours of instruction from experts in the Boston Public Health Commission and the Asian Task Force as well as survivors of abuse. In their clinic work, students learn to look for and document the common signs of domestic violence-injuries inside the mouth or on the neck, face or arms or fractured teeth. Just as often, dental neglect, missed appointments and unpaid bills can signal domestic violence, and so dental students learn to ask patients directly about possible abuse.

Last November, Gül and Joanne Brewer, assistant director of the Boston Public Health Commission's Domestic Violence Program, presented the dental school's first continuing education course on domestic violence. It was not long into the course before one participant told her classmates that she is a survivor of abuse. Another dentist spoke of a patient who died at her husband's hands. "I always remember that patient," he said.

What's next?

The DOTS team is working to secure additional funding and expand the scope of the program by collaborating with other schools on Tufts' health sciences campus. Gül has met with Dr. Mary Lee, dean for educational affairs at the School of Medicine, and Eileen Kennedy, dean of the Friedman School of Nutrition Science and Policy, to propose creating a similar curriculum for Tufts' medical and nutrition students. "They could join us in assessing the patients," Gül says. "And we at the dental school would help them create customized training for their students."

Gül also envisions sending a multidisciplinary team of volunteer dental, medical and nutrition students into shelters and community centers to offer a range of health services to survivors of abuse. Such a comprehensive program would require more funding and more volunteers. Gül says that educating dental professionals about domestic violence might be the most economical way to serve the most patients.

"It doesn't only occur in underserved populations," Gül says. "More and more often it's happening in affluent communities. No dentist should think this doesn't happen in his or her patient population. Often, older dentists come to me and say, 'I wish I'd known what to look for.'"


Profile written by Jacqueline Mitchell

Jacqueline Mitchell is a staff writer for Tufts Dental Medicine. The complete version of this story first appeared in the Winter 2006 issue. It ran online on Feb. 20, 2006.

Photos by Christopher Harting