Introduction

Intimate partner violence and abuse (IPVA) is defined as psychological harm with physical or sexual violence, including controlling behaviour, acts of aggression, sexual coercion and psychological abuse.1 The impact of IPVA is substantial, with an estimated 30% of UK women expected to be affected within their lifetime.2 The Crime Survey for England and Wales has reported a 14.4% increase in domestic abuse-related crimes since March 2020, affecting an estimated 2.1 million people.3,4

IPVA also shares risk factors with child abuse,5 and the presence of either form of violence increases the risk of the other, meaning that early identification of patients experiencing IPVA may benefit family issues.6,7

The vast majority of IPVA-related physical trauma results in head and neck injuries.8,9 This makes dentists well-placed to identify vulnerable patients. National Institute for Clinical Excellence and General Dental Council (GDC) guidance states that dentists have an obligation to make sure they can recognise, assess and signpost these patients to appropriate services to the best of their abilities.10,11

There is, however, a wealth of evidence that suggests this is not happening within healthcare settings in the UK. Of the 40% of patients who reported IPVA to their general practitioner, only 17% had this reported in their medical records.12 The majority (87%) of dentists surveyed in the USA did not screen for IPVA, even when tell-tale head and neck-related injuries were present,13 while only 5.7% of French primary care dentists systematically looked for signs of abuse or neglect.14 Similar issues have been found in Saudi Arabia and India.13,15,16 As of 2012, only 45% of dental schools in the UK provided formal teaching on recognising and managing IPVA, while 82% of healthcare workers surveyed in Oxfordshire would personally welcome further training on IPVA.17,18

Early identification of vulnerable patients and signposting are key to improving this public health crisis alongside its associated health and social consequences, and it is therefore important to understand the barriers that dentists experience when supporting IPVA patients.

Aim

The aim of this study is to explore whether dentists and dental students are prepared to support patients with lived experience of IPVA.

Objectives

  • Explore dental students' perceptions of their preparedness to treat patients who have experienced IPVA

  • Explore dentists' views and experiences of treating patients who have experienced IPVA

  • Explore dentists' and dental students' perceptions of their training opportunities

  • Identify facilitators and barriers to provision of care

  • Compare and contrast the views of students and dentists.

Methods

Study design

This study adopted a qualitative cross-sectional research design; focus groups and interviews were conducted between November 2022 and April 2023.

Sample and recruitment

Participants were recruited using the following inclusion criteria:

  • Third- to fifth-year dental students studying at Newcastle University

  • Dental practitioners currently working in primary care.

Dental students at Newcastle University were recruited through university email. Dentists were recruited via email through UK local dental committees.

Interested participants were sent a participant information leaflet, consent form and a screening questionnaire. Participants were able to withdraw their consent to participate at any time. Recruitment continued until data saturation was reached. It was envisaged that data saturation would occur at around 25-30 interviews, as per Guest et al.19 This study was approved by the Faculty of Medical Sciences Research Ethics Committee, part of Newcastle University's Research Ethics Committee, Ref 2363/24445.

Data collection

Data generation followed the principles of grounded theory.20 A combination of online and in-person focus groups were offered to accommodate participant preferences. In-person focus groups and interviews were conducted at Newcastle University School of Dental Sciences. Due to the sensitive nature of the subject, participants were offered the opportunity to request a one-to-one interview. Participants were fully debriefed and offered referral to appropriate safeguarding services if necessary, as per Department of Education guidelines.21

A semi-structured topic guide informed interviews to be able to address key topics while allowing space for participants to explore areas of interest. This included questions concerning awareness, training and sociological links, such as shared risk factors with child abuse.

The focus groups were digitally recorded and transcribed with consent. Participants were assigned a code to maintain anonymity, made up of either ‘Dʹ for dentist or ‘DS' for dental student, sex and a value dependent on order of recruitment. Thematic analysis was used to analyse the data and identify recurrent themes using the model proposed by Braun and Clarke.22

Results

In total, 14 dentists (six interviews, three focus groups), and 22 dental students (four interviews, four focus groups) participated. The main themes are discussed below.

Awareness of IPVA issues

All participants indicated an awareness of physical abuse as an aspect of IPVA. Most participants understood that abuse is complex and often multifaceted, with emotional, financial and psychological abuse being highlighted as characteristics of IPVA:

  • ‘This is such an important subject in everybody's day-to-day life that, unless we have more knowledge, we don't know there is a problem […] if you don't understand the definition of the abuse'- D17, interview, female.

The majority of dentists were not aware of the link between child abuse and IPVA:

  • ‘I didn't really think about the link between domestic violence and child abuse in the same home. That's quite bad, but it's pretty obvious isn't it, I guess […] if they've got kids. So, then it would maybe make me think about reporting it more'- D15, interview, female.

Willingness to help

Appropriateness

All participants felt that dentists could play a role in helping patients who have experienced or were experiencing IPVA:

  • ‘We could identify it, and it's a really good place for somebody to be able to go and open up, and because obviously, they can come alone quite often' - D15, interview, female.

Dental students talked about the consistency in the patient-dentist relationship. Benefits included noticing changes in behaviour over time and developing a trusting environment where patients feel comfortable ‘opening up':

  • ‘You might see a different GP [general practitioner] every time but with a dentist, you're in like, a position to be able to sort of spot patterns in behaviour if you've seen someone for a prolonged period of time' - DS6, focus group, male.

Preparedness

Perceptions of training

Both groups indicated that the undergraduate education they received did not prepare them to assist patients affected by IPVA. Some stated that they had received no training:

  • ‘There was nothing, absolutely nothing. This wasn't even on the teaching radar, I would say. The whole idea of safeguarding in general wasn't really on the radar'- D6, male, interview

  • ‘Like education on the signs of domestic abuse, what to do if you suspect someone's suffering domestic abuse […] I'd say we've had very little to no education on that' - DS1, female, interview.

While some did remember receiving training, there was a general feeling that this did not sufficiently bolster their confidence or preparedness in any meaningful way:

  • ‘I don't know how you guys felt, but what I learned wouldn't have helped me' - D8, focus group, female.

Although the government guidelines Safeguarding in general practice: a toolkit for the dental team23 are available, the majority of participants were not familiar with this guidance. This suggests a need for more effective dissemination and awareness.

Confidence

All of the dental students stated they felt uncomfortable thinking about acting on their suspicions. All but one dentist indicated a lack of confidence when it came to speaking to patients about challenging and sensitive topics:

  • ‘I think I'd be able to detect if something was off […] but I don't know if I'd be able to like put my finger on what was going on. And I don't know if that would […] if I would have enough confidence to take that further on just a feeling' - DS5, focus group, female.

Participants noted that bringing up IPVA with a patient is more challenging when they are uncertain of what to do next to safeguard the patient. Many indicated this would discourage them from enquiring despite their suspicions, potentially resulting in missed opportunities to provide support to affected patients:

  • ‘But yeah, we've all kind of said like having the conviction in bringing something up when you don't know what to do next [is difficult]'- DS7, focus group, female.

Both groups expressed hesitations about assuming the responsibility of reporting. Many assumed that GPs would be better trained in this area and therefore would likely delegate responsibility:

  • ‘I think […] I kind of, a lot of the time, already assume, wrongly, that somebody else is taking care of it when that might not be the case at all […] I think it comes back to like lack of training and understanding' -D3, focus group, female.

Desire for more training/resources

All participants felt they could benefit from further training and accessible, specific resources:

  • ‘It has to be something part of curriculum. It has to be a part of postgraduate training and it has to be updated as we explore different worlds. Emotional abuse have to be taken seriously. And controlling abuse has to be taken seriously. So don't look just for bruises in your patient's face,[the] typical dental attributes we have, but look at the body language when she comes in with a partner' - D17, interview, female.

A few dental students did recall some training on IPVA but unanimously stated that the teaching hadn't been useful:

  • ‘I've just like done the quizzes, got the training done, like been to the lecture, ticked the box, but like we have so much stuff to learn, and that it's not really stuck in my head' - DS11, focus group, female.

Both cohorts brought up the complex role that cultural differences (eg nationality, religious beliefs) play in how certain behaviours might present and how this can be challenging. There seemed to be a specific desire for training to include cultural nuances:

  • ‘I think also an awareness of what is culturally acceptable in like different areas and what is deemed normal. Because I think that is a range and I don't think it is a one size fits all approach, so I think we need to have more teaching on where that line lies really' - DS4, focus group, female.

Barriers to care

Worry

Many participants expressed reluctance in trying to help patients over fear of doing the wrong thing. There was a worry that despite good intentions, their lack of training and confidence in their abilities may inadvertently heighten risk and worsen their patient's situation:

  • ‘I think you only get one chance to be there with them and have that conversation, that difficult conversation. And if you get it wrong, that could change their trajectory as to how they end up, where they end up' - D16, interview, female.

There was also an apprehension about making a patient feel rushed. Participants expressed concern that time pressures within dental appointments might impact their ability to identify and help patients:

  • ‘I'm worried that I wouldn't notice in such a short amount of time, or they wouldn't feel that comfortable with me at that sort of time to start to then approach me' - DS11, focus group, female.

Participants also worried that a patient might react negatively should they attempt to communicate their concerns:

  • ‘I think it's a very difficult situation to be in. Just […] you don't know what way they're going to take it. Some people might be like “oh, who's this?” like they, they might just react in anger, but they like might just break down' - DS3, focus group, female.

Dentists identified additional barriers, such as the presence of a partner and gender dynamics. Providing succinct, easy-to-follow protocols may help to alleviate this:

  • ‘I think that, okay, I'm a six-foot-tall man with a beard and most people that experience domestic violence are going to be women who are potentially going to be quite intimidated by six-foot-tall me' - D6, interview, male.

Resilience

Around half of all participants identified a lack of resilience training as a barrier to engaging with patients. This highlights the complexity of the link between professional responsibilities and the mental wellbeing of practitioners:

  • ‘I find it [...] sort of boundaries and things quite difficult. You know, going home. If someone, when, well, when people have sort of disclosed things. You can't help but go home and think about it, and that's where you think let's have a lot better training […] switching off to that isn't the easiest' - D16, interview, female.

Discussion

This study aimed to explore the views of practising dentists and dental students on their preparedness to help patients with lived experience of IPVA. The results of this study show that most dentists and dental students felt that their knowledge of IPVA and their confidence of how to help patients was inadequate, and that most would like to expand their knowledge on the subject.

Appropriateness

All participants felt that they were in a good position to be able to identify and help patients experiencing IPVA. The reasons for this were: a perceived good continuity of care, thereby being able to notice behavioural or physical changes in patients; accessibility, due to biannual appointments; and the opportunities dentists have to build patient rapport over time. These factors were thought to make an individual feel more comfortable disclosing their experience of abuse to a dentist over other healthcare professionals. Support for this theory can be seen in studies showing that better continuity of care with general practitioners can lead to better healthcare outcomes.24,25,26 This also aligns to evidence suggesting that women with lived experience of IPVA would trust their dentist to act appropriately after disclosure of violence.27

Training

Many dentists felt that they had received little to no training on IPVA before graduating. While this could be explained by a longitudinal decline of knowledge, dental students felt similarly about their levels of preparedness. This would seem to suggest a need for improved undergraduate training, perhaps alongside enhanced postgraduate continuing professional development requirements.

This raises questions about the efficacy of the current education model regarding safeguarding IPVA patients and its fitness for purpose. Several studies have praised the benefits of additional training by one-off teaching seminars and online content, and perhaps this needs to be explored further within the safeguarding framework.28 However, there is no literature to confirm the most effective way of teaching this subject that translates into the practical demands of safeguarding in practice.

Many participants assumed that GPs would have more extensive training in comparison to dentists. However, studies demonstrate that GPs also feel that they lack support, training and guidance.29,30,31,32 As the long-term management of patients who have experienced IPVA is likely to be multidisciplinary, it might be beneficial to look towards an interprofessional learning model, including interdisciplinary curriculum integration to ensure that all students receive consistent and comprehensive teaching.

Barriers

Both cohorts expressed concerns that, despite their best intentions, their perceived lack of adequate training, guidance and resources might worsen their patients' situations by re-traumatisation or escalation of abuse. This indicates the need for improved training to give dentists the skills to navigate these sensitive situations.

Communicating with patients who have experienced trauma is complex and necessitates careful navigation. Trauma-informed practice is an approach to healthcare which acknowledges that exposure to trauma can affect a person's neurological, biological, psychological and social development.33 This includes an individual's ability to develop relationships with healthcare staff and access treatment. This is supported by studies that show that women are more likely to disclose IPVA to health professionals who enquire in a validating, supportive, non-judgemental way.29,34 A systematic analysis showed that trauma-informed, organisational interventions may improve the readiness of practitioners and improve patient outcomes.35 Additionally, studies show that ineffective communication with dental patients can lead to adverse outcomes, such as anxiety in the clinician and patient, and breakdown in the patient-clinical relationship.36

Moving forwards

Currently, all dental school programmes in the UK are working to the learning outcomes in the GDC document Preparing for practice. This states that practitioners must be able to ‘identify the signs of abuse or neglect, explain local and national systems that safeguard welfare and understand how to raise concerns and act accordingly'. 37

As of September 2025, students entering dental programmes will have to deliver the following learning outcome, which is subtly different: ‘identify the signs of abuse, neglect or emotional trauma, explain local and national systems that safeguard the welfare of children and adults and understand how to raise concerns and act accordingly'.38

In neither version of the learning outcomes are students expected to be able to apply their knowledge. This is likely because it would be impossible to give every dental student the opportunity to see a ‘real world' patient in this situation; nonetheless, simulated teaching and assessment could be beneficial.

Currently, dental educators are limited by the capacity of their curriculum and there may not be the resources to have a significant portion of training directed at a new topic. Enhancing the pre-existing safeguarding training may be the most appropriate way forwards. Improving awareness that dentists will encounter IPVA patients in practice may be a logical place to start, as well as introducing the concept that adult patients experiencing violence can be considered vulnerable adults. This would allow the introduction of evidence-based, trauma-informed interviewing techniques into the curriculum and would support GDC communication learning outcomes.10

Examples of good practice do exist. The Identification and Referral to Improve Safety system (IRIS) is a specialist domestic violence and abuse training, support and referral programme for general medical practices that encourages ongoing education and consultancy. This system has been shown to improve GP response to IPVA and thereby improve the safety, quality of life and wellbeing of survivors.39,40 This improved understanding led to better usage of specialist services. A recent study showed that dentists who experienced an IPVA disclosure felt IRIS was a valuable resource.41 This shows that interventional strategies could be welcomed by general dental practitioners, but increasing knowledge, confidence and training would be key to increase willingness to use it. Future research could focus on the type of training required in dental schools to be able to make this feasible.

Conclusion

This study found that both cohorts of participants did not feel they were adequately prepared to help manage patients who have lived experience of IPVA, especially in terms of the training they had received through their formal education. Within the limitations of a qualitative exploratory study, there were no discernible differences between the perceptions of the two cohorts, meaning that experience in primary care does not make up for inadequate preparation at undergraduate level.