pattern of oral-maxillofacial trauma stemming from interpersonal physical violence and determinant...

Pattern of oral–maxillofacial traumastemming from interpersonal physicalviolence and determinant factors

Meire Coelho Ferreira1, AnneMargareth Batista1, Fernanda deOliveira Ferreira2, Maria Let�ıciaRamos-Jorge1, Leandro SilvaMarques1

1Dentistry Department, School of Biological and

Health Sciences, Universidade Federal dos

Vales do Jequitinhonha e Mucuri; 2Department

of Basic Sciences, Federal University of

Jequitinhonha and Mucuri Valleys, Diamantina,

Brazil

Key words: maxillofacial injuries; soft tissuesinjuries; tooth injuries; violence; risk factors

Correspondence to: Meire Coelho Ferreira,R Doze, 648, Governador Valadares, MinasGerais 35.020-690, BrazilTel.: +55 (33) 9123 0118Fax: +55 (38) 3532 6099e-mail: [email protected]

Accepted 21 March, 2013

Abstract – Background/Aim: Facial trauma is among the most commontypes of injury. The aim of the present study was to assess the prevalenceand pattern of oral–maxillofacial trauma stemming from interpersonalphysical violence (IPV) and determine whether IPV is factor associatedwith oral–maxillofacial trauma. Materials and methods: A retrospectiveanalysis was conducted of 790 complete patient charts for data on the typeof IPV for the gender, area of residence (urban or rural), age and type oftrauma. Statistical analysis involved the chi-squared test (P < 0.05), univar-iate/multivariate Poisson, and logistic regression (P < 0.20). Type of oral–maxillofacial trauma was the dependent variable. Socio-demographic statusand type of IPV were the independent variables. Results: One hundredforty (17.7%) individuals had oral–maxillofacial injuries stemming fromIPV [80 (10.1%) due to urban violence (UV) and 42 (5.3%) due to domes-tic violence (DV)]. DV was more prevalent among females (69%), and UVwas more prevalent among males (67.5%). The most common types oftrauma were facial contusion and laceration, dental concussion, and man-dibular fracture. Age and UV were explanatory factors for mandibularfracture. Females from rural areas and who suffered DV were more likelyto exhibit facial contusion and dental concussion. Conclusions: Interper-sonal physical violence was identified as a factor associated with oral–max-illofacial trauma, specifically mandibular fracture, facial contusion, anddental concussion.

Worldwide, the number of deaths due to physicaltrauma was estimated at 8.5 million in 2010, with headand facial injuries accounting for 50% of cases (1).These types of injury represent 7.4–8.7% of cases ofemergency and urgent care in hospitals (2). The largenumber of injuries involving the face is due to the ana-tomic vulnerability of this part of the body, whichoften leads to serious trauma (3). Multidisciplinarytreatment is required, involving different medical anddental specialties.

Maxillofacial trauma has a varied etiology. Recentstudies report interpersonal physical violence (IPV) asone of the main causes of this form of trauma, especiallyin developed countries, with prevalence rates rangingfrom 9.3 to 52% (1, 4–8). Moreover, alcohol and drugabuse are involved in most cases of IPV (7–10).

Interpersonal violence is defined as behavior thatcauses harm to another individual, invading his/herautonomy, physical or psychological integrity, andoccurring most often through the use of excessive force(11), including acts of violence and intimidationbetween family members, intimate partners, acquain-tances, or strangers (12). Interpersonal violence is

recognized by society as transgressing human rightsdue to the harm caused to the victim and the fact thatit occurs throughout the world, regardless of socioeco-nomic class, culture, race, and religion (13–15).

Oral–maxillofacial involvement in cases of IPVoccurs due to the accessibility of the face (16) and canlead to emotional, social, and behavioral problems onthe part of the victim (17). Maxillofacial injuries stem-ming from IPV are difficult to investigate, as legal und-erreporting is common due to the associations withalcohol abuse, illicit drug use, firearms, and acts of vio-lence against women, children, and the elderly, whichgenerate fear, shame, low self-esteem, and a sense ofpowerlessness (18). The recognition of the injury pat-tern caused by IPV is important to the diagnosis ofcases as well as decision-making processes regardinghealth policies, the evaluation of the needs ofhealth-care services, and the development of preventionprograms aimed at minimizing the occurrence of IPV.

The aim of the present study was to assess the prev-alence and pattern of oral–maxillofacial injuries stem-ming from IPV and determine whether IPV is a factorassociated with oral–maxillofacial trauma.

© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 15

Dental Traumatology 2014; 30: 15–21; doi: 10.1111/edt.12047

Materials and methods

A retrospective study was carried out involving the anal-ysis of the charts of 1121 patients with oral–maxillofacial trauma treated at the Urgent Care andEmergency Ward of regional hospital in the city of Gua-nh~aes (state of Minas Gerais, Brazil) between January2005 and December 2007. The hospital in question is areference center for 23 municipalities in the Rio DoceValley and offers care to patients from both urbanand rural areas, encompassing a population of approxi-mately 238 797 inhabitants in an area covering12 745.1 km2. The inclusion criterion was a completerecord of oral–maxillofacial trauma.

The sample size calculation was carried out consider-ing the study design. The study presented anexploratory objective (to determine the prevalence oforal–maxillofacial trauma) and an analytical aim (todetermine whether IPV is a factor associated with oral–maxillofacial trauma).

To determine the prevalence of oral–maxillofacialtrauma, it was necessary to calculate the sample sizeappropriate to this study design (the sample size calcu-lation to estimate prevalence). The sample size was esti-mated based on a 50% prevalence rate of IPV, a 4%level of precision, and 95% confidence interval (CI).The minimum sample size was estimated at 600patients. To compensate for loses during the evaluationof the patient charts (incomplete data), 790 recordswere evaluated.

Considering the analytical aim, we performed thesample size calculation for the analytical cross-sectionalstudy, considering the type I and type II errors. It wascarried out the sample size calculation to compare pro-portions between groups (trauma′s prevalence in thosewho suffered physical violence and trauma′s prevalencein those who did not suffer physical violence). It wasconsidered P = 50%, as it was unknown the trauma′sprevalence in those who suffered and those who did notsuffer physical violence. Moreover, using P = 50% inthe calculation, we obtained a greater sample size thanusing other values, which ensures that this sample sizewould be enough for all the independent variables. Thecalculation was performed adopting 95% significancelevel, 80% of statistical power, and assuming a mini-mum difference to be detected of 10% of trauma occur-rence between who suffered and who did not sufferviolence, resulting in a sample size of 784 individuals.Then, the sample size of the study (790 individuals) isappropriate, considering both sample size calculations.

Soft tissue injuries were categorized as abrasion, lac-eration and contusion. Fractures were classified basedon the anatomic site: mandible, zygomatic bone, nose,and more than one facial bone. Dentoalveolar traumawas categorized as concussion, luxation, enamel frac-ture, enamel dentin/fracture, enamel dentin/fracturewith pulp involvement, and avulsion. IPV was classifiedas domestic violence (DV) and urban violence (UV).

In the present study, the dependent variable was thetype of oral–maxillofacial trauma (soft tissue injury,facial bone fracture, and dentoalveolar trauma). Theindependent variables were socio-demographic statusand type of IPV.

Descriptive statistics were performed for the socio-demographic data, oral–maxillofacial trauma, and typeof IPV. The chi-squared test was employed to deter-mine associations among the socio-demographic vari-ables, types of trauma, and type of IPV, with the levelof significance set to 5%. Univariate/multivariate Pois-son and logistic regression analyses were performed toinvestigate the explicative factors of the types of oral–maxillofacial trauma related to IPV. To avoid the over-estimation of the odds ratio (OR), Poisson analyseswere performed when the occurrence of the type oftrauma was greater than 10% in the population stud-ied. When the outcome frequency was <10%, logisticregression analysis was performed (19). Independentvariables that achieved a P-value < 0.05 in thechi-squared test were submitted to univariate regressionmodel. Independent variables that achieved aP-value < 0.20 in the univariate analysis were incorpo-rated into the multivariate regression model. The Sta-tistical Package for Social Sciences (SPSS forWindows, version 17.0; SPSS Inc. Chicago, IL, USA)was used for the analyses.

The present study received approval from theHuman Research Ethics Committee of the publichospital at which it was carried out.

Results

In the period analyzed, 790 patient charts containedcomplete data on cases of oral–maxillofacial trauma.Among this total, 140 individuals (17.7%) has injuriesstemming from IPV [80 (10.1%) due to UV and 42(5.3%) due to DV]. No report on the type of occur-rence was given in 18 cases (2.3%) of IPV. Table 1displays the distribution of the type of IPV accordingto gender, area of residence (urban or rural), and age.Table 2 displays the distribution of the type of oral–maxillofacial trauma stemming from the different typesof IPV.

With regard to UV, the most common types ofinjury were facial contusion and dental concussion(n = 70; 87.5%), facial laceration (n = 46; 57.5%), andmandibular fracture (n = 26; 32.5%). For DV, themost frequent types of injury were facial contusion(n = 41; 97.6%), facial laceration (n = 16; 38.1%), andmandible fracture (n = 10; 23.8%).

In both the univariate and multivariate analyses,age and UV were factors associated with mandibularfracture. For the zygomatic bone, age was the onlyexplanatory factor. Age, area of residence (urban orrural), and type of violence were not factors associatedwith maxillary fracture. The rural area was a protectorfactor, and type of violence was not a predictor ofnose fracture. The female gender was a protectorfactor, and both age and type of violence were notassociated with fracture of more than one facial bone(Table 3).

The female gender was a factor associated withfacial contusion, demonstrating a 1.076-fold greaterlikelihood of exhibiting contusion than the male gen-der. Facial contusion was more prevalent among indi-viduals in rural areas (PR = 1.109; CI = 1.043–1.180)and more prevalent among cases of DV (PR = 1.216;

© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

16 Ferreira et al.

CI = 1.144–1.292). These explanatory variables becameeven stronger in the multivariate analysis (Table 4).

In the univariate analysis, gender, area of residence,and type of violence were explanatory factors fordental concussion. In the multivariate analysis, individ-uals of female gender, residing in rural areas, and thosewho suffered DV were more likely to exhibit dentalconcussion (Table 5).

Discussion

Urban violence is a transgression practiced on thestreet associated with criminal behavior, such asmuggings, fights, kidnapping, murder, lynching, drugtrafficking, and gunfire. UV is a systematic disre-spect for the norms of social conduct established bylegal codes or customs (20). DV involves physical,

Table 1. Distribution of type of interpersonal physical violence (IPV) according to gender, area of residence, and age, Guanh~aes,Brazil, 2005–2007 (n = 790)

Type of IPV

Gender

Male

n (%)

Female

n (%)

Total

(%) P-value*

Did not suffer IPV 454 (69.8) 196 (30.2) 650 (100) <0.001Did suffer IPV

Domestic violence 13 (31.0) 29 (69.0) 42 (100)

Urban violence 54 (67.5) 26 (32.5) 80 (100)

Area of residence

Urban area

n (%)

Rural area

n (%)

Total

n (%) P-value*

Did not suffer IPV 428 (65.8) 222 (34.2) 650 (100) 0.004

Did suffer IPV

Domestic violence 38 (90.5) 4 (9.5) 42 (100)

Urban violence 54 (67.5) 26 (32.5) 80 (100)

Age

<13 years

n (%)

13–19 years

n (%)

20–29 years

n (%)

� 30 years

n (%)

Total

(%) P-value*

Did not suffer IPV 79 (12.2) 171 (26.3) 249 (38.3) 151 (23.2) 650 (100) 0.001

Did suffer IPV

Domestic violence 1 (2.4) 6 (14.3) 18 (42.9) 17 (40.5) 42 (100)

Urban violence 2 (2.5) 25 (31.3) 40 (50.0) 13 (16.3) 80 (100)

Eighteen individuals did not report the type of IPV suffered.

*Chi-squared test.

Table 2. Distribution of oral–maxillofacial trauma stemming from IPV, Guanh~aes, Brazil, 2005–2007 (n = 790)

Type of trauma

Type of IPV

Did not suffer IPV

n (%)

Domestic violence

n (%)

Urban violence

n (%)

Total

(%) P-value*

Mandibular fracture 102 (73.9) 10 (7.2) 26 (18.8) 138 (100) 0.001

Maxillary fracture 39 (92.9) 1 (2.4) 2 (4.8) 42 (100) 0.286

Zygomatic bone fracture 84 (82.4) 5 (4.9) 13 (12.7) 102 (100) 0.686

Nose fracture 55 (79.7) 5 (7.2) 9 (13.0) 69 (100) 0.560

Fracture of more than one facial bone 29 (85.3) 1 (2.9) 4 (11.8) 34 (100) 0.786

Facial abrasion 442 (100) 0 (.0) 0 (0.0) 442 (100) <0.001Facial laceration 378 (85.9) 16 (3.6) 46 (10.5) 440 (100) 0.039

Facial contusion 522 (82.5) 41 (6.5) 70 (11.1) 633 (100) 0.007

Dental concussion 487 (81.4) 41 (6.9) 70 (11.7) 598 (100) 0.000

Dental luxation 49 (100) 0 (0.0) 0 (0.0) 49 (100) 0.007

Dental fracture1

157 (99.4) 0 (0.0) 1 (0.6) 158 (100) <0.001Dental avulsion 67 (100) 0 (0.0) 0 (0.0) 67 (100) 0.001

Eighteen individuals did not report the type of IPV suffered.

*Chi-squared test.1Dental fracture: pooled data on enamel fracture, enamel/dentin fracture, and enamel/dentin fracture with pulp involvement.


Facial injuries and interpersonal violence 17

emotional, and psychological abuse used by theaggressor to control a partner (21), child, or elderlyindividual (22).

In the sample analyzed, 140 individuals had oral–maxillofacial injuries stemming from IPV, the most fre-quent of which were facial contusion and laceration,

dental concussion and mandibular fracture. The inde-pendent variables age, gender, and type of IPV werepredictors of soft tissue injuries, facial bone fractures,and dentoalveolar trauma.

Injuries to the head, neck and face seems to besensitive but not specific markers of DV (23–25),

Table 3. Univariate/multivariate Poisson and logistic regression for facial bone fractures, Guanh~aes, Brazil, 2005-2007 (n = 790)(a) Univariate and multivariate Poisson regression for mandibular and zygomatic bone fractures and (b) Univariate andmultivariate logistic regression for fracture of the maxilla, nose, and more than one facial bone

Dependent variable Independent variable Unadjusted PR 95% CI P Adjusted PR 95% CI P

(a)

Mandibular fracture Age

<13 years 1 1

13–19 years 2.429 0.976–6.046 0.056 2.150 0.869–5.323 0.098

20–29 years 3.875 1.619–9.276 0.002 3.413 1.427–8.163 0.006

� 30 years 2.961 1.199–7.314 0.019 2.789 1.140–6.823 0.025

Type of IPV

Absent 1 1

Domestic violence 1.517 0.858–2.682 0.151 1.372 0.777–2.423 0.276

Urban violence 2.071 1.441–2.976 0.000 1.916 1.312–2.798 0.001

Zygomatic bone fracture Age

<13 years 1 1

13–19 years 4.049 1.270–12.904 0.018 4.000 1.256–12.744 0.019

20–29 years 3.666 1.165–11.532 0.026 3.697 1.174–11.637 0.025

� 30 years 4.038 1.260–12. 937 0.019 4.093 1.273–13.162 0.018

Type of IPV

Absent 1 1


Urban violence 1.257 0.736–2.149 0.402 1.175 0.688–2.007 0.554

Dependent variable Independent variable Unadjusted OR 95% CI P Adjusted OR 95% CI P

(b)

Maxillary fracture Age

<13 years 1 1

13–19 years 0.943 0.238–3.737 0.933 0.969 0.243–3.867 0.965

20–29 years 1.417 0.403–4.985 0.587 1.508 0.425–5.357 0.525

� 30 years 2.525 0.715–8.914 0.150 2.643 0.742–9.415 0.134

Area of residence

Urban 1 1

Rural 1.607 0.856–3.018 0.140 1.475 0.778–2.798 0.234

Type of IPV

Absent 1 1


Urban violence 0.402 0.095–1.696 0.215 0.412 0.097–1.754 0.230

Nose fracture Area of residence

Urban 1 1

Rural 0.466 0.255–0.851 0.013 0.457 0.244–0.854 0.014

Type of IPV

Absent 1 1


Urban violence 1.371 0.650–2.893 0.407 1.360 0.642–2.879 0.422

Fracture of more than one facial bone Gender

Male 1 1

Female 0.271 0.095–0.779 0.015 0.298 0.102–0.872 0.027

Age

<13 years 1 1

13–19 years 0.806 0.145–4.487 0.805 0.681 0.121–3.850 0.664

20–29 years 1.319 0.283–6.140 0.724 1.196 0.253–5.655 0.822

� 30 years 4.365 0.989–19.268 0.052 3.845 0.860–17.199 0.078

Type of IPV

Absent 1 1


Urban violence 1.127 0.386–3.293 0.827 1.402 0.464–4.233 0.549

PR, prevalence ratio; CI, confidence interval; OR, odds ratio.


18 Ferreira et al.

demonstrating that a thorough patient history is funda-mental in the investigation of the causal factor. Whenthe victim is a woman, the case should be investigatedregardless of the site of the injury (26), as there is agreater possibility of being the victim of physical aggres-sion due to the vulnerability of the gender. In the presentstudy, women were victims in 29 (69%) of the 42 cases ofDV.

In 15 cases, the occurrence of DV was not the firstepisode, suggesting that the women in these cases maybe victims of chronic physical abuse. In one case, thevictim returned to the emergency ward four times in a1-year period. These findings are consistent with datadescribed in previous studies (9, 11, 14, 23), whichreport that DV suffered by women tends to be recur-ring. In the present study, there were no reports of com-pulsory notification to police authorities. According tothe hospital staff, there have been cases in which the vic-tims of DV refused police involvement and body examsby legal experts, which would lead to a crime report.This behavior may be due to fear that their partnerswould discover the report, which could lead to furtheracts of violence, and underscores the difficulty femalevictims of DV have with regard to leaving an abusiverelationship (13). There are often cases of emotionaldependence, the hope that the partner will change his

behavior, no financial alternatives for survival, and alack of support from family and friends (27). Gettingout an abusive relationship and recovering one’s effectsinvolves repeated attempts at leaving and returning (13).

Interpersonal physical violence was predominantamong the male gender (59.3%), especially in cases ofUV (67.5%). A retrospective epidemiological studyaddressing mandibular fractures found that physicalaggression was the second most prevalent etiologicalfactor, with a predominance of the male gender (2). Aprospective evaluation of mandibular fractures carriedout by Desai et al. (28) revealed that the vast majority(86%) resulted from IPV. In the present study, mandib-ular fractures were the most prevalent outcomes of IPVin general as well as UV and DV, which is in agreementwith findings reported in previous studies (1, 7, 18).Moreover, UV was a predictor of mandibular fracture.

Soft tissue injuries, such as lacerations and contu-sions, were the most prevalent, respectively, accountingfor 49.3 and 92.1%. This pattern is similar to thatreported by Saddki et al. (11), who investigated inti-mate partner violence. The high prevalence of contu-sions is likely due to the impact of the aggression, theoccurrence of falls after an act of aggression, and thechoice of a blunt weapon. Although the proportion ofmale individuals in the sample was nearly double that

Table 4. Univariate and multivariate Poisson regression for facial contusion, Guanh~aes, Brazil, 2005–2007 (n = 790)


Facial contusion Gender

Male 1 1

Female 1.076 1.009–1.147 0.025 1.084 1.013–1.160 0.020

Area of residence

Urban 1 1

Rural 1.109 1.043–1.180 0.001 1.142 1.069–1.221 <0.001

Type of IPV

Absent 1 1

Domestic violence 1.216 1.144–1.292 0.000 1.219 1.138–1.305 <0.001

Urban violence 1.090 0.995–1.194 0.065 1.090 0.994–1.195 0.067

PR, prevalence ratio; CI, confidence interval.

Table 5. Univariate and multivariate Poisson regression for dental concussion, Guanh~aes, Brazil, 2005–2007 (n = 790)


Dental concussion Gender

Male 1 1

Female 1.114 1.036–1.198 0.004 1.112 1.030–1.201 0.007

Age

<13 years 1 1

13–19 years 1.073 0.935–1.232 0.314 1.053 0.917–1.208 0.466

20–29 years 1.043 0.913–1.192 0.536 0.997 0.870–1.142 0.967

� 30 years 0.961 0.828–1.117 0.606 0.927 0.795–1.081 0.335

Area of residence

Urban 1 1

Rural 1.095 1.017–1.178 0.016 1.141 1.055–1.233 0.001

Type of IPV

Absent 1 1

Domestic violence 1.303 1.221–1.390 0.000 1.317 1.214–1.430 <0.001

Urban violence 1.168 1.063–1.283 0.001 1.160 1.053–1.277 0.003

PR, prevalence ratio; CI, confidence interval.



of females, the proportion of women who sufferedfacial contusions was half that of males who sufferedthis type of injury. According to Shepherd et al. (29),when aggression against a woman is practiced by aman, there is a tendency for him to choose a bluntweapon, because he either does not wish to cause per-manent disability or believes he does not need a moreharmful weapon, since he considers himself to be stron-ger. In the present study, the female gender, rural area,and DV were factors associated with facial contusion.

Regarding age group, IPV was more prevalentbetween 20 and 29 years of age, which is in agreementwith findings described in previous studies (3, 7, 11).The greater occurrence in this age group is likely dueto greater involvement with violence (30). The samepattern was seen with both UV and DV.

The reasons for why the face is the target for mostacts of physical aggression may be the fact that it iseasily reached, as it is located at height of the aggres-sor’s raised arm. It has also been suggested that theaggressor either consciously or unconsciously wishes toaffect the victim’s self-esteem (11). A study addressingvictims of intimate partner violence found that 50.4%of the women suffered maxillofacial injuries (11). Across-sectional study involving 127 individuals (81 menand 46 women) treated at an emergency care centerfound that 17 of the 18 victims of DV had facial, head,and neck injuries, and the authors concluded that thehead, neck and face are markers of DV with a highdegree of sensitivity (95%) (24).

Interpersonal physical violence is often associatedwith alcohol abuse (7). In the present study, however,few victims (n = 43; 5.4%) reported such an associa-tion. It is likely that this number would have beenhigher if there had been a more detailed investigationinto the event that triggered the act of physical aggres-sion. Investigating maxillofacial injuries associated withDV, Le et al. (9) found that 33% of the victims hadconsumed alcohol at the time of the aggression. In astudy involving 65 victims of maxillofacial injuriesrelated to aggression, Eggensperger et al. (10) foundthat alcohol and drug abuse were associated with 23%of the victims. Just as the victim may abuse alcoholand illicit drugs, the aggressor generally does so aswell. A study assessing the prevalence of maxillofacialfractures due to DV found that one-third of the hus-bands of the victims were addicted to drugs (18).

Although the World Health Organization (WHO)considers the response of health-care services to victimsof violence to be an international priority (31), healthprofessionals are generally not qualified to identify, andcouncil victims and are restricted to treating the inju-ries. The role of health professionals is to identify theetiology of the injury and, in cases of the occurrence ofphysical aggression, provide the victim with informationon where to seek help (32). With regard to DV, a num-ber of studies have shown that dentists, nurses, andphysicians generally do not have the necessary knowl-edge for the adequate identification and referral of suchcases (15, 33). Moreover, health professionals do notconsider themselves skilled enough to ask sensitivequestions, are unaware of the victim-support institu-

tions, and are often limited by institutional barriers,such as the lack of an established protocol, a lack oftime in emergency wards and a lack of adequate physi-cal space to allow privacy during the care of such cases(15). In Brazil, the notification of cases of IPV to thepolice is mandatory in cases of both DV and UV.

It should be pointed out that the number of casestreated at the Urgent and Emergency Care Service dur-ing the 2-year period does not correspond to the totalnumber of cases of IPV in the region. Underreportingmay occur in cases of less severe occurrences, for whichbasic health-care services and private clinics are capableof treating the injuries.

It is likely that the Urgent and Emergency Care Ser-vice has a greater number of victims of IPV than thepolice due to the fact that the injuries require immediatemedical assistance and the possibility of overlooking thecausal factors, as seeking the Public Safety Agency leadsto an official report of the case. Especially in cases ofDV, the victims feel uncomfortable, exposed, ashamed,and fearful of retaliation on the part of the aggressor.Moreover, for cases in which the aggressor is the sexualpartner, he often feels guilty and shows remorse, whichinvariably sensitizes the emotionally involved victim,who believes that the acts of aggression will cease andtherefore refuses to press charges.

The findings of the present study underscore theimportant role health units play in providing reliabledata on IPV. Thus, there should be a standardized chartfor the emergency treatment of such victims. The find-ings also call the attention of health-care professionalsto the possibility that patients with oral–maxillofacial,head, and neck injuries may be the victims of physicalaggression. Orientation should therefore be given tohealth professionals regarding the use of standard pro-tocols. Considering the frequency of maxillofacialtrauma related to IPV, oral–maxillofacial surgeons maybe the first and even the only health professionals toprovide care to the victims. Therefore, the diagnosisand establishment of effective treatment for cases ofIPV are of utmost importance, as such violence can leadto a significant reduction in the quality of life of theindividuals involved.

Besides offering medical care, health professionalsshould be prepared to ask victims about the type ofIPV suffered, should be aware of organizations thatoffer assistance to both the victim and aggressor, andshould not demonstrate any attitudes that may intimi-date the victim. In a study addressing the conduct ofhealth professionals with regard to DV, less than halfknew what non-governmental organizations offersupport to victims, whereas 93% believed that theassistance from a social worker is fundamental to themanagement of this type of violence (15).

The use of secondary data is a limitation of the pres-ent study, as the precision, reliability, and integrity ofthe patient records are uncertain, which is a commonproblem in retrospective studies. Moreover, althoughthe emergency ward at the hospital in question is a refe-rence center for 23 municipalities, the findings are repre-sentative only of the region studied and therefore maynot be applicable to other regions of Brazil.


20 Ferreira et al.

Conclusion

Interpersonal physical violence was identified as a fac-tor associated with oral–maxillofacial trauma, specifi-cally mandibular fracture, facial contusion, and dentalconcussion.

Acknowledgments

This study was supported by the Brazilian Coordinationof Higher Education (CAPES), Ministry of Education,the National Council for Scientific and TechnologicalDevelopment (CNPq), Ministry of Science and Tech-nology, and the State of Minas Gerais ResearchFoundation (FAPEMIG), Brazil.

Conflict of interest

The authors declare they have no conflicts of interestin relation to the present study.

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pattern of oral-maxillofacial trauma stemming from interpersonal physical violence and determinant...

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