Data source: Searches were made for studies using Applied Social Sciences Index and Abstracts, Caredata (the social work and social care knowledge base), Child Data (the National Children's Bureau Database), the Cumulative Index to Nursing and Allied Health, Embase, Medline, the System for Information on Grey Literature in Europe, the TRIP database (www.tripdatabase.com), Sciences Citation Index, and ISI Proceedings (covers conference papers in all scientific and technical fields). Authors were contacted where necessary.
Study selection: All studies of children 0-18 years with intra-oral injuries because of physical child abuse, and torn labial frena of any aetiology, in live and fatal cases were included. Review articles, expert opinion or guidelines that did not include primary evidence, studies with mixed adult and child data where the children's data could not be extracted, studies that addressed complications or management of abusive injuries, intra-oral injuries because of sexual abuse, thermal injuries or dental neglect were excluded.
Data extraction and synthesis: Studies were reviewed by the Welsh Child Protection Systematic Review Group. Standardised data extraction and appraisal forms were used and a qualitative synthesis undertaken.
Results: Nineteen out of 154 studies reviewed were included, representing 591 children. There were no comparative studies of accidental and abusive torn labial frenum to enable a probability of abuse to be determined. Nine studies documented abusive torn labial frena in 27 children, of whom 22 were younger than 5 years old and 24 had been fatally abused. Only a direct blow to the face was substantiated as a mechanism of injury. Two studies noted accidentally torn labial frena, both from intubation. Abusive intra-oral injuries were widely distributed to the lips, gums, tongue and palate and included fractures, intrusion and extraction of the dentition, bites and contusions.
Conclusions: Current literature does not support the diagnosis of abuse based on a torn labial frenum in isolation. The intra-oral hard and soft tissue should be examined in all suspected abuse cases, and a dental opinion sought where abnormalities are found.ome of the traditional and normative predictors of successful outcomes.