Intra-oral injury and occult trauma — branching viva

Opening

Examiner: A 5-month-old infant presents with a torn upper labial frenum and a small bruise behind the ear. The carer says the baby fell from a bed. What is your immediate clinical interpretation? ^[5]

Candidate: A torn labial frenum in a non-mobile infant is a sentinel oral injury — the American Academy of Pediatrics (Kellogg 2005) recognises oral injuries, particularly a torn frenum, as a manifestation of physical abuse that every physician must actively look for. A 5-month-old who does not yet crawl cannot sustain a frenum tear from a fall. The ear bruise is another red flag. I apply the TEN-4 FACES-B bruising rule: the frenum tear is an "F" item and the ear bruise is an "E" item, and any bruise under 4 months is a "4" item (this child is 5 months, but the bruising on the ear and the frenum tear are both positive). This is abuse until excluded, and I proceed to a full safeguarding workup. ^{[5] [7]}