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 Table of Contents  
REVIEW ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 2  |  Page : 126-131

Forensic odontology for general dentists


Department of Oral Pathology and Microbiology, Dr. D. Y. Patil Dental College and Hospital, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India

Date of Submission23-Oct-2020
Date of Acceptance18-Jan-2021
Date of Web Publication16-Jul-2021

Correspondence Address:
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdrr.jdrr_147_20

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  Abstract 


Forensic odontology is the application of knowledge of dentistry for legal causes. Although Forensic odontology as a subject is new to the Indian scenario, its importance has been very well documented in global literature. Teeth are the hardest structures in the human body and they resist the challenges posed by nature very well. Furthermore, teeth are unique for each individual. Dr. Oscar Amoedo identified many victims of the Paris Charity Bazaar fire disaster with the help of dentition. Since then Dr. Oscar Amoedo is recognized as the 'Father of Forensic Odontology.' A general dental practitioner is central to many aspects of forensic odontology such as disaster victim identification, identification of recovered human remains, denture marking, and detecting abuse cases.

Keywords: Disaster victim identification, forensic odontology, general dental practitioners, general dentists, India


How to cite this article:
Gawali RA. Forensic odontology for general dentists. J Dent Res Rev 2021;8:126-31

How to cite this URL:
Gawali RA. Forensic odontology for general dentists. J Dent Res Rev [serial online] 2021 [cited 2021 Aug 1];8:126-31. Available from: https://www.jdrr.org/text.asp?2021/8/2/126/321528




  Introduction Top


Forensic odontology is defined by Keiser and Nielsen as "that branch of dentistry which in the interest of justice, deals with the proper handling and examination of dental evidence."[1] In simple terms forensic odontology is the application of knowledge of dentistry for legal causes. It is one of the most upcoming and promising sub-disciplines of forensic science as well as dentistry. Some authors[2],[3] describe it as a sub-discipline of forensic medicine, but forensic odontology has its roots in dentistry. Although forensic odontology as a subject is new to the Indian scenario, its importance has been very well documented in global literature.

Teeth are the hardest structures in the human body and they resist the challenges posed by nature very well. They are the last tissues of the body to disintegrate, if at all. These attributes makes teeth available and suitable for any forensic analysis. Dental identification, which is one of the most important aspects of forensic odontology is highly useful in the identification of victims of various disasters and mass casualties. Dental identification is enlisted in Interpol's scientific techniques of identification along with fingerprints, medical identification, and deoxyribose nucleic acid (DNA).[4] The fact that dental identification is swift, certain, and cost-efficient, makes it the method of choice in many circumstances.


  History of Forensic Odontology Top


The formal history of forensic odontology begins with a mass disaster at Paris. In the year 1897, at the annual Bazar De La Charite (Charity Bazaar) in Paris, a fire broke and resulted in 126 deaths. Dr. Oscar Amoedo was a Cuban born dentist practising in Paris at the time. He took a personal interest in the case and contemplated that the records of dental treatment were useful for the identification of the charred bodies of the victims or at least exclusion of the otherwise. He interviewed many dentist who were involved in the identification efforts. Dr Amoedo later in the year 1898 published a treatise describing the method used for dental identification of the victims. This treatise was called "L'Art Dentaire Medicine Legale"[5] and it is the first scientific text on forensic odontology. Since then Dr. Oscar Amoedo is recognized as the "Father of Forensic Odontology."

Before the Paris incident, the history of forensic odontology is spread across many centuries involving individual cases of dental identification; such as the identification of Lollia Paulina by Agrippina in AD 49;[6] the identification of First Earl of Shrewsbury by his Herald in 1453,[7] and many more.

The first case of dental identification by a dentist occurred in Boston in 1776. Dr. Joseph Warren was an American revolutionary who died of a gunshot wound to the head during the battle for Breed Hill against the British army. Later, when his friend and silversmith-cum-dentist, Paul Revere learned that Warren is buried in a mass grave, he exhumed the body and identified it with the help of unique dental prosthesis he had fabricated for him.

One historically important case of dental identification is that of Adolf Hitler. On April 30, 1945, Hitler committed suicide inside his Führer bunker by shooting his head. Those days, there were a lot of speculations and rumors that the Führer had survived the enemy invasion and managed to escape. All the speculations were put to rest when the soviets procured Hitler's dental records from his dentist Hugo Johannes Blaschke. One of the radiographs confirmed to be of Hitler, depicting the peculiar "Telephone Bridge" matched exactly with the post mortem remains and their radiographs, resulting in positive dental identification. Later studies in 2017[8] reiterated the dental identification of Adolf Hitler in the scientific and public domain.

India too has its fare share in the history of forensic odontology. One of the documented and highly cited case in forensic literature is of Raja (King) Jaichand. He fell in the battle of Chandwar against Muslim invader Mohammad Ghori. He was killed by Qutb al-Din Aibak, a commander of the Ghorid army. The body of Jaichand was identified by Ghori based on his peculiar teeth, which according to historians were "gold plated."


  Forensic Odontology Casework Top


Forensic odontologist's casework and fieldwork involves[9]

  1. Disaster victim identification (DVI)
  2. Identification of recovered human remains
  3. Age estimation
  4. Sex determination
  5. Bite mark analysis
  6. Opinion on dental trauma with respect to section 320 Indian Penal Code (IPC)
  7. Dental jurisprudence-Expert witness in the court involving other dentists, such as Consumer Protection Act (CPA) related claims
  8. Abuse cases


Disaster victim identification

A disaster is a sudden, calamitous event that seriously disrupts the functioning of a community or society and causes human, material, and economic or environmental losses that exceed the community's or society's ability to cope using its own resources.[10] Disasters can be natural, anthropogenic or a combination of the two. Despite all the technological advances India has achieved, it still finds its position in the ten most vulnerable and disaster-prone countries of the world, with both natural as well as anthropogenic disasters making a high impact on the development and economy of the country apart from causing a huge number of human casualties.[11] The various natural disasters India faces include floods, droughts, cyclones, earthquakes, landslides, and tsunami. Various anthropogenic disasters India has witnessed include industrial accidents, transportation accidents, structural collapse and fires, and many more. Apart from the great economic losses, the major issue to be addressed in any mass disaster is victim identification. Dental identification forms an important component of DVI globally and also as per the Interpol guidelines.[4] Various challenges faced during a DVI effort include:

  1. The remains are highly mutilated
  2. The remains may be charred
  3. The remains are fragmented
  4. The remains are commingled.


All these factors pose a unique challenge in the whole identification process. As teeth are highly resistant to various hostile post mortem environments, thanks to their unique structure; dental identification becomes the method of choice in such circumstances. India, as of date, does not have any concrete plans about DVI.[12]

Identification of recovered human remains

For a case of homicide, the indispensable element of investigation is the identification of the body or the remains, without which new leads in the case do not develop. Many a times, the perpetrators intentionally disfigure and maim the body, so that it will not be identified and the investigation comes to a halt. Teeth have very well demonstrated their ability to resist extreme forensic environments. Teeth have survived the high impact and mutilation,[13] incineration,[13] burials,[14] immersion in water,[14] and acid attacks.[15] Owing to these characteristics and also the fact that each person has a unique set of dentition, dental identification becomes the method of choice in such circumstances. We already know that different occupations, personal habits, medications, systemic or local diseases can leave typical signatures on the teeth. These can be of immense help in reconstructing the identity and creating a profile of the deceased, even if antemortem dental records are not available for direct comparison. Later on, when a list of presumed dead is made based on dental profiling and other corroborative evidence, ante-mortem records can then be procured and comparative dental identification achieved. Moreover, a person can be conclusively excluded from the list of presumed dead based on dental comparative identification.

Age estimation

Age is an important aspect of our day to day life. Age is the bar at many of the activities we undertake in society. Age is also an important part of the biological profile of an individual. Attaining a specific age bestows certain rights and responsibilities upon the individual, such as driving a vehicle, the right to vote, right to compete in an election, etc. The age of majority is the yardstick which defines a juvenile from an adult and the punishment awarded in case of an offense. The fact that many births in India occur outside the hospital and the date of birth (DOB) are not reported accurately to the authorities, makes the DOB proof documents suspicious in the court of law. Hence, the age of an individual, living or dead, assumes paramount importance in various civil and criminal issues.

Age can be estimated based on somatic growth, skeletal development, dental development, and sexual development. Dental development is robust and least affected by any fluctuations in external factors such as nutrition, physical activity, infectious diseases, or any internal factors such as hormonal variations, genetic variations, etc. Thus, dental age estimation and skeletal age estimation are routinely preferred over the other two.

The age of an individual can be estimated by studying various developmental stages when teeth are in the process of development and by studying the regressive changes when the teeth are completely formed. Various researchers have given formulas and charts for age estimation. Schour and Massler  Atlas More Details,[16],[17] Ubelaker atlas,[18] and London atlas[19] are a few atlases available which allow for age estimation by direct comparison of the radiograph with the developmental stage given in the atlas. Formula-based techniques such as Demirjian's method,[20] Gustafson's method,[21] and Cameriere's method[22] require the odontologist to assign a developmental score or make measurements which are later substituted in the formula to arrive at the estimated age.

Sex determination

Along with age, sex is also an important part of the biological profile of an individual. Just such as age, the sex of an individual dictates the social behavior and the rights assigned to any specific sex. Sex determination is an essential requirement in the process of identification of a mutilated, decomposed, skeletonized body or remains. Conclusive evidence about the sex will lessen the burden on investigators to almost half.

Sex determination can be a requirement in living individuals as well. There have been instances in past wherein individuals have faked their gender to gain unfair advantage in terms of profession, sports, legal outcome, social status, etc.[23] According to the World Health Organization regional office for Europe, sex is dictated by biological characteristics, whereas gender is dictated by socially constructed features and norms such as clothing, etc.[24] However, the legal system of most nations recognizes only biological sex. Hence, there is a potential for conflict when individuals, who's sex and gender are not congruent, come across the law and legal system.

Sex determination is not only a requirement in forensic cases, but it's also relevant in historical, archaeological, and anthropological contexts. Many mysteries are solved and rumours put to rest because of sex determination of such ancient specimens.[25]

Sex determination in forensics can be done by various techniques such as histological (Barr Bodies),[26] DNA based techniques[27] or anthropological methods.[28] Odontological sex determination is possible since teeth, jaw bones and skull show metric[29],[30] and nonmetric sexual dimorphism.[31]

Bite mark analysis

Biting is a basic human instinct in cases of physical assault. Occasionally, they are inflicted during sporting events[32] in heat of the moment and amorous biting also exists between couples. Biting is also very common in assaults of sexual nature wherein bite marks can be found both on the victim as well as the perpetrator. Bite marks on the perpetrator explain the struggle and defense offered by the victim, whereas bite marks on the victim explain the viciousness of the crime and the morbid mentality to overpower and take control over the victim. Bite marks can also be found at theft or robbery scenes on food items such as an apple, piece of cheese, or a chocolate bar.

Bite marks, which are essentially tool marks or patterned injuries vary greatly in their appearance and severity.[33] Bite mark injuries can range from mild teeth indentations with or without abrasion and contusion to severe laceration and avulsion. Bite marks are physical evidence and its analysis involves seeking answers to critical questions in a systematic manner. The most likely questions are,

  1. Is it a bite mark injury or something else?
  2. If it's a bite mark injury, is it caused by human or any animal?
  3. If it's a human bite mark, is it caused by an adult or a child?
  4. If its a bite mark injury caused by adult human dentition, who caused it?


Identification of the biter is a process of comparison of the known exhibit (K) (bite mark injury) with the questioned sample (Q) (represented by the dentition of suspected biter). The bite mark analysis guidelines and protocols vary with different countries and associations.[34],[35] Bite mark evidence has varied acceptance among different courts across the globe.

Opinion on dental trauma with respect to section 320 IPC

One of the widely used classifications of dental trauma is Ellis and Davey's classification.[36]

Ellis and Davey categorized dental trauma into eight classes.

Class 1: Simple fracture of the crown-involving little or no dentine

Class 2: Extensive fracture of the crown– involving considerable dentine, but not the pulp

Class 3: Extensive fracture of the crown– involving considerable dentine, and exposing the dental pulp

Class 4: The traumatized tooth which becomes non-vital with or without loss of crown structure

Class 5: Teeth lost as a result of trauma

Class 6: Fracture of the root-with or without loss of crown structure

Class 7: Displacement of the tooth-without fracture of crown or root

Class 8: Fracture of the crown en masse and its displacement

Section 320 of IPC deals with "Grievous Hurt." According to section 320 of the IPC, the following kinds of hurt are designated as "Grievous:"

  1. Emasculation
  2. Permanent privation of the sight of either eye
  3. Permanent privation of the hearing of either ear
  4. Privation of any member or joint
  5. Destruction or permanent impairing of the powers of any member or joint
  6. Permanent disfiguration of the head or face
  7. Fracture or dislocation of a bone or tooth
  8. Any hurt which endangers life or which causes the sufferer to be during the space of 20 days in severe bodily pain, or unable to follow his ordinary pursuits.


So, according to IPC 320 point no. 7, virtually any class of dental trauma is a grievous hurt. Hence, the applicability of IPC 320 is based on circumstances of injury and the intention of the accused. Detailed history of the injury is critical in such case. Thus, the role of a dentist is very crucial.

Dental jurisprudence-Expert witness in the court involving other dentists, such as Consumer Protection Act related claims

With the increased acceptance of information technology and widespread use of social media, the world has shrunken. A vast amount of information is now available at the click of a button. The television, print media, social media, etc., constantly bombard different products and services to its viewers. All of this has ignited a sense of consumerism in the public's mind, which even extends to medical and dental treatment.

Consumer Protection Act (CPA) was introduced in the year 1986 and it initiated a lot of debate regarding the applicability of CPA to doctors and its subsequent repercussions on the healthcare delivery system. The amended version, Consumer Protection Act 2019, came into effect recently on July 20, 2020. Since implementation, there have been numerous instances of doctors including dentists dragged to courts for alleged negligence in their care. Courts do not expect doctors to be 100% flawless in their treatment, but it expects a minimum standard of care to be exercised, which any other average doctor trained in the respective subject would deliver.

In many cases, doctors have successfully proved their innocence, primarily because they did the right thing and secondarily because they had the records to prove they did the right thing. Although delivering the appropriate diagnosis and treatment in the most ethical manner is the best defense against a CPA claim, many a times dentists fail to document the difficulties associated with the treatment and its progress in records, especially any expected and unexpected complications. The underlying reason in the majority of CPA claims on dentists is noncommunication or miscommunication of the complications to the patient. Another common mistake is not taking an informed consent which clearly describes the expected risks and complications associated with the treatment. With advanced treatment modalities such as dental implants, grafting procedures, cosmetic veneers, clear aligners, etc., coming to the mainstream of dental practice, use and misuse of CPA against dentists is steadily on the rise too. A respective specialist or a forensic odontologist may be called upon to opine in such cases.

Abuse cases

India is a vast nation with diverse traditions. The cultural threads are tight and the communities are closely knit. Issues such as child, spouse, and geriatric abuse, which were once considered issues of the western world, are increasingly coming forward. The social menace of abuse, honor killings, rapes, etc., are considered taboo and are not addressed in the way they should be.

The majority of the physical injuries associated with these gruesome acts are in the face, head, and neck region, the expertise of a dentist! In many cases, dentists can recognize signs of emotional abuse and neglect too with the help of careful examination, history taking, and observation of behavior.

Dentists should be clear with their roles in such cases. The only detection of abuse is not enough, but reporting and early intervention is the goal to be achieved. Bite marks or injuries that resemble bite marks are a possibility in abuse cases, analysis of which is an expert's job.


  Conclusion Top


Dental records are one of the most important yet highly underrated components of patient's care. The dentist's obligation of standard care toward his/her patients is not limited to the clinical duties of correct diagnosis and treatment. The practice of forensic odontology lies on the foundation of (presence of) ante mortem dental treatment records. Good records are not only great for identification, but they also can save a lot of potential trouble when things go southwards. Treatment records are the strongest form of defense in case of any litigation against the dentist, be it criminal, civil, or in consumer court.

Dental Council of India (DCI) in its latest revised Dentist Regulations 2014 mandates every dentist to maintain the dental records for at least three years.[37] However, DCI does not specify the retention period of dental records for pedodontists, orthodontists, and implantologists whose treatments usually extend over a long period.

Digital records offer convenience over the physical records because they can be retrieved faster, they do not occupy physical place, they can be stored indefinitely and they can be transmitted electronically.

When a patient is completely edentulous, the pattern of rugae helps in the process of identification. Dentures also play a key role in identification in such cases. Thus, dentists have a significant role in this process, if they have incorporated some unique identifiers in the denture.

As dentists are not trained on the legal aspects of oral, para-oral injuries and dental trauma, cases of intentional violence such as child or spouse abuse often go unnoticed. The orientation of dental practitioners toward these issues will certainly be beneficial to society. A prudent dentist is not expected to confront the relatives (parents or spouse) of the abuse victim. Whether the dentist should counsel the patient and their relatives is a matter of debate, since the possibility of aggravating the situation cannot be ruled out. A safer way is to be discrete and report the possibility of abuse to local Non-Governmental Organisations working in the welfare of the vulnerable group.

In this way, a general dental practitioner has a crucial role in many aspects of forensic odontology such as DVI, identification of recovered human remains, denture marking, detecting abuse and dental trauma cases, etc.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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