Review article

Forensic Dentistry-what a dentist should know

Srinivasa Prasad*, G Sujatha**, G Sivakumar, J Muruganandhan**

Abstract
Teeth with their physiologic variation and effects of therapy remain to record information throughout their life time. They also act as a weapon under certain circumstances and leave the identity of the biter. Dentistry has much to offer the field of law in identifying and solving the civil and criminal cases. This paper gives the readers an understanding of the role of a dentist as a forensic odontologist and also emphasizes the need for good quality and accurate dental records. Key words: Forensic, dentist, DNA

orensic Odontology can be defined as a branch of dentistry, which deals with the proper handling and examination of dental evidence and with the proper evaluation and presentation of dental findings in the interest of the dentist.1 A forensic odontologist assists the legal authorities by examining dental evidence in different situations. There are three major areas of activity currently in forensic odontology namely: 1. The examination and evaluation of injuries to teeth, jaws, and oral tissues resulting from various causes (abuse, assault, mass disasters and crime related injuries). 2. The examination of marks with a view to subsequent elimination or possible identification of a suspect as the perpetrator. 3. The examination of dental remains (whether fragmentary or complete, and including all types of dental restorations) from unknown persons or bodies with a view to the possible identification of the latter.2 This branch has been utilized for many years for the identification of victims and suspects in mass disaster, abuse and organized crimes.3 Forensic odontology involves the management, examination, evaluation

and presentation of dental evidence in civil or criminal proceedings along with research.4 A working classification is been proposed by Shamim T involving all dental specialties( Table 1).5 Dental identification has played a very important role in natural as well as manmade disasters. Identification is based on comparison between known characteristics of a missing individual (termed ante-mortem data) with recovered characteristics from an unknown body (termed post-mortem data). When they have no clue of the identity or no antemortem records are present, a detailed postmortem record is compiled for further use and a forensic anthropologist is used for contributing information such as age, sex and ancestry of the deceased, which is known as postmortem dental profiling.6 An antemortem dental record will contain written notes, charts, diagrams, dental and medical histories, radiographs, clinical photographs, study models, results of specific tests, prescriptions, and referral letters and other information. Their accuracy and availability have a huge impact on the speed and efficacy of identification. Problems are encountered when the dental records are incomplete, irregular, lost or damaged and have poor quality radiographs.7 Good quality dental records are an essential part of patient care, a medico-legal requirement, and are necessary for dental identification.8 A forensic dentist records the postmortem records completely by charting down the dental findings and taking photographs and radiographs. On completion a comparison between the two is carried out, similarities and discrepancies are noted on the comparison and a result is established. 443

*Prof and Head, Dept. of Oral and Maxillofacial Surgery **Senior Lecturer Prof and Head Dept. of Oral and Maxillofacial Pathology Sri Venkateswara Dental College and Hospital Address for correspondence Dr. G Sujatha E-mail: gsuja@rediffmail.com

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Table 1. Working classification proposed for forensic odontology based on its relation with other dental specialities.
Oral pathology and Microbiology
1. Age estimation using ground sections

Oral medicine and Radiolgoy

1. Age estimation using radiographic method

Pedodontics
1. Age estimation

(histological method)

Gustafsons technique Incremental lines of Retzius Perkymata Prenatal and postnatal lie formation Racemization of collagen in dentin Cemental incremental lines Translucency of dentin Developmental disturbances of teeth Regressive alterations of teeth Tumours and cysts of oral acvity DNA profiling from teeth

Secondary dentin formation Changes in the orientation of mental foreamenand interior alveolar canal Eruption and formation of mandibular third molar Trabecular pattern in jaws Pulp/tooth area ratio of teeth Pattern of lamina dura Maintenance of dental records Dental charting Comparative dental identification Cheiloscopy

Eruption sequence Schour and Massler chart Demirjians methods using dental maturation chart Nollas calcification stages Child abuse

Orthodontics
1. Age estimation i. ii.

2. Identification

2. Identification

Cephalometrics Orthopantomograph (OPG) X-ray and handwrist

iii. X-ray to determine pubertal state

2. Identification
i. ii.

Community dentistry
1. Identification

Tooth rotation and malposition Orthodontic applicances

Oral and maxillofacial Surgery

1. Identification

Endemic fluorosis Socioeconomic grouping

i. ii.

iii. Orthodontic reconstruction

3. Sexual dimorphism
i.

Dental caries, Periodontal disease Oral cancer

Maxillomandibular and dentoalveolar fractures Surgical repairs and implants LeFort I osteotomy procedure in autopsy

Mandibular canine index and mandibular first molar index Caphalic index

4. Race identification
i.

Mass disasters

2. Dental fraud and malpractice 3. Elderly abuse Periodontics

1. Age estimation

5. Craniofacial superimposition

Conservative dentistry
1. Identification and endodontics

Periodontosis (gum recession) Root transparency and root length Gingival morphology and pathology Thickness and widening of periodontal ligament

Restorations Endodontic treatment Root canal treated restorations Radiolucent and radio opaque restorative materials

2. Identification

2. Identification using radiographic method (Periapical radiograph)

3. Effect of heat on restorative materials

The American Board of Forensic Odontology recommends that these be limited to the following four conclusions.9 Positive identification: The antemortem and postmortem data match in sufficient detail, with no unexplainable discrepancies, to establish that they are from the same individual. Possible identification: the antemortem and postmortem data have consistent features but, because of the quality of either the postmortem remains or the antemortem evidence, it is not 444

possible to establish identity positively.

Insufficient evidence: The available information is insufficient to form the basis for a conclusion. Exclusion: the antemortem and postmortem data are clearly inconsistent.

Dental Profiling When dental records are unavailable and other methods also become impossible, a picture of the general features of the individual is produced and this is known as post

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mortem dental profiling which includes information on the age, sex, socioeconomic status and ancestry background of the deceased. Additional informations such as habits, dietary pattern and occupation may also be provided.10 Race Dentists with the help of a forensic anthropologist can determine the sex and ancestry from skull shape and form. A forensic dentist can determine race within the three major groups: Caucasoid, Mongoloid and Negroid based on the skull appearance. Additional characteristics, such as cusps of Carabelli, shovelshaped incisors and multi-cusped premolars, can also assist in determination of ancestry.11 Sex Sex determination is usually based on cranial appearance, as no sex differences are apparent in the morphology of teeth. Discriminant function analysis, a statistical method used for determination of sex based on tooth measurements showed a success rate of 92.5%.12 Minute quantities of DNA even from very old tooth specimens are helpful in determining the sex. Ameloblasts of the enamel secrete amelogenin (AMEL gene) which is present in the X and Y chromosomes of humans, females have two identical AMEL genes (XX) and males have two non identical AMEL genes (XY).Discrimination of male and female is based on the length of the base pairs of the gene which is 106 and 112 for X and Y gene respectively. A sample which shows two discrete bands of 106 and 112 is identified as male and a female sample appears as a single band of 106 for the AMEL gene.13,14 Age Teeth act a reliable tool in estimation of age. Eruption sequence, neonatal line formation, Incremental lines of Retzius, Schour and Massler chart and Gutafssons method are parameters used for age estimation.15 The use of radiographs is ideal to determine the stages of mineralization, degree of formation of root and crown structures, and stages of eruption which are reliable and helpful in predicting the age of an individual.16 Habits Habits such as smoking or betel nut chewing are found by the presence of stains and presence of erosion suggest alcohol or substance abuse.17,18 Pipe stems, cigarette holders, hairpins, carpet tacks or previous orthodontic treatment show unusual wear pattern.19 Socioeconomic status is assessed by the quality, quantity and presence or absence of dental treatment.6 DNA Teeth present as an excellent source as DNA material 20 and its sources are pulp, dentine, cementum and periodontal ligament fibers. DNA from teeth and bone are preserved for many years even after putrefaction of remains.21 The other sources include saliva and mucosal swabs. Saliva may also be isolated from various sources in the crime scene, for example, postage stamps and envelopes, glasses, cigarettes, straws, food and chewing gum, toothbrushes and dental floss, and dental impressions.22,23 Use of DNA for human identification is proved to be very effective and has been documented.24 Polymerase chain reaction (PCR) technique allows amplification of DNA from even negligible amounts of source material.25 The amplified DNA is then compared with antemortem samples such as stored blood, hairbrush, clothing, cervical smear, biopsy specimens. Other methods include Restriction fragment length polymorphism (RFLP), single nucleotide polymorphism-based (SNP) and micro-assays.21 DNA can also help in identification of a parent or sibling. Most of these techniques involve nuclear DNA but mitochondrial (mt) DNA is more abundant, and can be identified in cases when nuclear DNA is insufficient. Dental tissues like dentin and cementum are rich in mtDNA.26 Bite Marks Bite mark is vital evidence in case of crime and abuse and can go unnoticed by untrained individuals. Recording, comparing and determining whether the mark is truly a result of biting is important for a forensic odontologist. Knowledge on the arch alignments and specific tooth morphology of animals is also required for a forensic odontologist to distinguish human bites from non human. Bite marks are usually documented taking photographs or taking impressions. Measuring the size of the tooth 445

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of the suspect and comparing it with bite mark can be done with metric analysis.27 The amount of details recorded on the surface may vary in each case. When a good impression of the bite is left behind the physical characteristics like distance from cuspid to cuspid, shape of the arch, evidence of malalignment, spacing, teeth width and thickness, missing teeth and wear patterns are taken into consideration for comparing bite mark wound and suspects teeth. Dentists should be in a position to explain the obstacles which interfere with accurate analysis and apply the bite mark evidence consistent with scientific principles while reporting bite mark evidence.28 Chelioscopy and Rugoscopy Chelioscopy is the study of lip prints. Although unique to an individual like fingerprints, it is not as reliable because of its deformable nature. Susuki and Tsuchihasi have classified lip prints into many types depending on the pattern of grooves as type I (vertical), type II (branched), type III (intersected), type IV (reticular) and type V (other).29 Studies have found gender differences with certain types predominant in females (I and II) and in males (III and IV).30 Rugoscopy is the study of palatal rugae patterns. They are ridges in the anterior hard palate and are unique among individuals. They can be classified as primary (>5 mm), secondary (3-5 mm) and fragmentary (<3 mm) and can be straight, curved, circular or wavy.31 They are useful as they are the best protected soft tissue and can be easily accessed during life and after. Awareness among Dental Surgeons There is increased need for dental surgeons to have a good knowledge about forensic odontology as it is useful in identification of an individual and also discover abuse among all ages. Dentists are the health care professionals who routinely assess the head and neck of the patients and have a great chance in identifying the signs of abuse and neglect. Every dentist has to understand the forensic implications associated with their practice. There is always a lack of involvement among dentists because of lack of training and experience, and due to their limited knowledge in this branch of dentistry. There is also a fear of litigation among dentist which 446 commonly discourages them. Any physician who fails to identify and report a child with historical, physical and radiological findings that indicate abuse is guilty of professional negligence.33 There is always a lack in availability and accuracy of dental records which has a great influence in determining the success of identification. Given the advantage that dental tissues can be preserved for a long period of time, dentists should have their own kit for forensic identification.34 The kit includes: Dental explorers Dental mirrors Periodontal probes Bite blocks Tissue scissors Osteotome Cotton swabs Gauze

Head lamp

Dental Records It is essential to maintain good quality dental records as they are important for patient care, identification and for medico legal cases. Well recorded information improves the accuracy and efficacy of identification. Dentists should not only know the importance of preparing an accurate dental record but also the importance of preserving these records. The ante mortem records should provide information from written notes, medical and dental histories, charts and diagrams, radiographs, clinical photographs, study models, reference letters, results of lab investigations and prescriptions.7 When dental records are inaccurate, incomplete with poor quality radiographs problems are encountered during identification. A problem also arises when records are lost and damaged. Denture labeling is recommended in most of the international dental associations as identification of the denture provides vital clue of the wearer. Denture can be coded or marked at the denture base. Requirements for denture markers are being biologically inert when incorporated, inexpensive, easy and quick to apply, retrieve after accident, acid resistant and survive increased temperatures.35

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Conclusion Knowledge and importance of forensic dentistry is required for every dentist in injury and abuse cases for proper recording of findings to help investigating and legal officers. As forensic odontologists have a major role to play in identification of victims in mass disasters, a good quality of dental records makes the identification process easier. Teeth are unique and resistant to destruction and their records when well maintained have a major impact in identification process. Dentists should also be aware of the legal aspects involved in forensic investigations and report to the concerned authorities to help in obtaining legal remedies to the victims. References
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