Ethics & Law · patient case with 2 questions
Two Patients, Two Bruises
Patient: An 8-year-old boy in the morning, and an 82-year-old woman in the afternoon
Chief Complaint: Boy: toothache. Woman: routine denture review.
Background: The boy attends with his mother. While in the chair he lifts his shirt to show the dentist a large bruise on his abdomen; his mother sharply tells him to stop and pull his shirt down. — The woman attends with her adult son, who answers most questions for her. She has a fingertip-pattern bruise on the dorsum of her hand and a healing bruise on the forearm.
Medications: Boy: none. Woman: amlodipine, levothyroxine.
Vital Signs: Both within normal limits
Findings: Boy: caries in tooth #S. Bruise is on the trunk, an area not typically injured in ordinary play. — Woman: well-fitting dentures, healthy mucosa. She is alert and oriented, but defers to her son and appears reluctant to speak while he is in the room.
Question 1
What should the dentist do about the child?
Show answer and explanation
Correct answer: A. Report the suspicion to child protective services after the patient has left
- A. CORRECT. Dentists are MANDATED REPORTERS in every US jurisdiction. The threshold is REASONABLE SUSPICION, not proof — you are not required to investigate, confirm or identify a perpetrator, and you do not need the caregiver's permission. Making the report after the family has left, from a private location, protects the child: reporting in front of a possible abuser can escalate the risk to the child once they go home.
- B. Asking is reasonable as part of history-taking, but simply accepting the explanation and stopping there does not discharge the mandated duty when the injury pattern is suspicious.
- C. Waiting for disclosure is not the standard. Children rarely disclose, and the duty is triggered by suspicion, not by a statement.
- D. The action is right but the timing is dangerous. Reporting audibly in front of the accompanying adult may trigger retaliation against the child and can cause the family to disappear.
Note: Injury patterns that raise suspicion: bruises on the trunk, ears, neck, buttocks or in a patterned shape; injuries in a non-ambulatory infant; an explanation inconsistent with the injury or with the child's developmental stage; and delayed presentation. Roughly 65% of physical abuse injuries involve the head, face, mouth or neck — which is why dentists are so often the ones who notice.
Question 2
What is the most appropriate action regarding the elderly patient?
Show answer and explanation
Correct answer: A. Report the suspicion to Adult Protective Services
- A. CORRECT. Suspected abuse or neglect of a vulnerable adult is REPORTABLE in most jurisdictions, and dentists are mandated reporters of elder abuse in the majority of states. The threshold is again reasonable suspicion. A grip-pattern bruise, a companion who answers for the patient, and the patient's evident reluctance to speak freely together constitute a recognised concern pattern.
- B. Questioning the potential abuser risks the same escalation as in the paediatric case and is likely to yield a rehearsed answer. Interviewing the PATIENT alone, without the companion, is the correct clinical step — but it supplements the report rather than replacing it.
- C. A six-month review leaves a vulnerable person in a potentially unsafe situation for half a year.
- D. Age-related skin thinning and anticoagulants do cause easy bruising, and that is a genuine differential. But a FINGERTIP-PATTERN bruise is a grip mark, and the accompanying behavioural signs are not explained by fragile skin.
Note: Elder abuse red flags: unexplained or patterned injuries, poor hygiene or malnutrition, a caregiver who dominates the interaction or refuses to leave the room, missed appointments, and unexplained financial changes. Interview the patient ALONE whenever you can arrange it naturally.