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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

These summaries are not intended to, and do not, express, imply, or summarize standards of care, but rather provide a concise reference for dentists to aid in understanding and applying evidence from the referenced systematic review in making clinically sound decisions as guided by their clinical judgment and by patient needs. American Dental Association ©

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