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• Torn labial frenum - always abusive?
  Leena Menon
  Published on: 22 March 2016
• Is a torn frenum diagnostic of child abuse?
  Sandra S Mascarenhas
  Published on: 22 March 2016
• Torn labial frenum -pathognomonic in some circumstances?
  ian k mecrow
  Published on: 22 March 2016

• Published on: 22 March 2016

  Torn labial frenum - always abusive?

  • Leena Menon, GP Registrar, Cardiff University
  • Other Contributors:
    • 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...

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  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

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  Conflict of Interest:
  None declared.

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• Published on: 22 March 2016

  Is a torn frenum diagnostic of child abuse?

  • Sandra S Mascarenhas, Specialist Registrar,Paediatrics
  • Other Contributors:
    • Dr.Aszkenasy M,Consultant Community Paediatrician

  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 desi...

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  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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  Conflict of Interest:
  None declared.

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• Published on: 22 March 2016

  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 art...

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  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.

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  Conflict of Interest:
  None declared.

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