FORENSIC ODONTOLOGY knowledge in clinical dentistry

Medicolegal problem solving by forensic odontology

1. FORENSIC ODONTOLOGY “Bridging dentistry and justice” Dr. Sreeja Junior resident Public Health Dentistry

2. contents What kind of JC is this ? Why was this topic chosen ? Source of article About the journal Introduction Materials and methods Results Discussion Conclusion Dentist as forensic expert References

3. What kind of JC is this? 1. JOURNAL CLUB AIMED AT UPDATING KNOWLEDGE RELATED TO A FIELD OF INTEREST. 2. JOURNAL CLUB AIMED AT UPDATING CLINICAL PRACTICE. 3. JOURNAL CLUB WHICH AIM AT TEACHING AND LEARNING CRITICAL APPRAISAL TECHNIQUES WITH EVIDENCE BASED MEDICINE AND DENTISTRY. 4. PROBLEM BASED JOURNAL CLUB- CENTERED ON A PROBLEM. 5. ALTERNATIVE JOURNAL CLUB- VIDEO, BOOK, REVIEW AND STORYTELLING 6. INNOVATIVE JOURNAL CLUBS

4. WHY was this topic CHOSEN? Forensic dentistry plays an important role in the identification of victims following mass disasters . In developing countries such as India , forensic dentistry is not developed up to the mark. Unawareness is one of the major reasons for this situation. Maintenance of dental records is still not proper enough, and services of forensic dentists are not being utilized. Forensic odontology should be properly educated and trained among dental curriculum.

5. Source of article Journal of Indian Academy of Oral Medicine & Radiology Year : 2019 | Volume : 31 Page no : 239-45 Published: 30-09-2019 DOI: 10.4103/jiaomr.jiaomr_108_19

6. About the Journal

7. ABOUT THE JOURNAL Title : Journal of Indian Academy of Oral Medicine & Radiology Editor-in-Chief : Dr. Avinash Tejasvi.M.L ISSN(P) : 0972-1363 eISSN : 0975-1572 Publication Frequency : Quarterly Impact Factor : 0.3

8. introduction Forensic is derived from the Latin word forum , which means Court of Law . Forensic odontology as defined by the FDI is that branch of Forensic medicine which in the interest of justice deals with the proper handling and examination of dental evidence and proper evaluation and presentation of dental findings. The first case of identification using dentition, in India , was that of King Canouj , Jayachandra Rathore in 1911, who died in a war and his body was recognized by his false anterior teeth. Forensic odontology plays an important part in criminal, marital, monetary, social, burial disputes, and identification of individuals missing for a prolonged period of time. Identification is important in civil cases like insurance claims, matrimonial and property disputes, impersonation and issue of passports and licenses.

9. Human dentition is considered as hard tissue analog to the fingerprint . The identification of remains by dental evidence is possible because, the hard tissues are preserved after death and can even withstand a temperature of 1600°C when heated without appreciable loss of microstructure.

10. Materials and methods Objective A cross‑sectional study was conducted to determine the knowledge and awareness of forensic odontology among the dentists in the rural and urban areas of Punjab . Selection criteria for study Selection for study was done on the basis of following inclusion criteria‑ 1. UG students, BDS, PG students, MDS were included in the study. 2. Subjects were included from both urban and rural areas of Punjab. • A total of 738 dentists in the urban and rural areas of Punjab were approached out of which 644 of them responded back with complete questionnaires . The incomplete questionnaires were excluded. • The study was conducted over a period of 6 months . The approval for the study was taken from the ethical community of Baba Jaswant Singh Dental College and Research Centre, Ludhiana; Punjab .

11. Questionnaire 1. A self‑administered, well‑structured questionnaire written in English language with both open and closed end questions was prepared. 2. A pilot assessment was done on 15 dental practitioners to ensure the lucidity and appropriateness of the questions. This panel of 15 dentists was excluded from the study . Most of the contributors found the questionnaire to be uncomplicated and precise. 3. The questionnaire consisted of 15 questions dealing with‑ • Patient dental record maintenance and its importance. • Attitude and knowledge of dentists toward forensic odontology. • Career preferences of dentists in the field of forensic odontology. 4. All the participants were asked to respond to each item. Confidentiality and ambiguity of contributors was ensured .

12. RESULTS Data analysis The results have been shown in the graphs 1-15 which were analyzed statistically by using Analysis of variance test, T‑test, Chi‑square test. P value was calculated for all the results of the study. P value ≤0.05 was considered as the level of significance.

13. discussion Forensic odontology is a challenging and fascinating branch of forensic medicine . According to our study, the ratio of contributors who have studied forensic odontology is highest amongst the UG students followed by MDS and PG students and BDS. The dentist should be aware of child, elderly, or spousal abuse and bite marks when confronted with unusual oral injuries, especially in cases of persons with accompanying body injuries. Kenney and Clark have cited numerous researches that suggest approximately 50% of injury in child abuse cases occur in the oral and perioral region. According to our study, PG students presented better level of knowledge and skill to identify the physical abuse of a child followed by UG students, MDS graduates and BDS graduates.

14. Age is one of the essential factors in establishing the identity of a person . According to the present study nearly 26% of BDS graduates did not know how to estimate the dental age by examining the teeth. These findings were in contrary to the Preethi et al. study where nearly half of the dental practitioners did not know how to estimate the dental age. Bite mark analysis is one aspect of forensic dentistry requiring an immediate response by the forensic dentist. In our study, majority of the contributors (around 90%) from all the strata were confident of bite mark analysis of teeth. More than 40% of contributors were unaware of the role of dentist in the event of mass disaster , which happens to be an important field of action for a forensic odontologist and more than 30% of the contributors were unaware of the methods of gender identification of a deceased .

15. The dental record serves a purpose of future reference for the practitioners when needed and is not always maintained for a forensic purpose. According to the present study around 60% of UG students, 71% of BDS, 84% of PG students, and 82% of MDS maintained dental records. Very few practitioners knew the duration of dental record maintenance as stated by the law , which is a minimum of 7 years to a maximum of 10 years .

16. conclusion Within the scope of present study, it was concluded that there is lack of knowledge, awareness, and practice of forensic dentistry amongst the dentists of Punjab. There is willingness among the dental professionals to further enhance their knowledge and pursue forensic odontology as a career option. There have been few instances where forensic odontology has been highlighted to its full potential and hence, it can be concluded that this branch will create an impact in the future .

17. What is impact factor of journal?

18. What is H index ?

19. Historical evidences Dr. Oscar Amoedo , Paris, is considered as "Father of Forensic Odontology". Dental evidence played a vital role in historical case of identification of Adolf Hitler . His dental findings were compared with antemortem dental records and radiographs . Dentition was an important lead in the identification of remains of various leaders, who were killed, like Zia Ul Haq, former Pakistani President and Rajiv Gandhi , former Indian Prime Minister . Federation Dentair International in 1968 has recommended to include forensic odontology in the curriculum of teaching institutions. First formal instructional programme in forensic dentistry was given in United States at the Armed Forces Institute of Pathology.

20. SCOPE AND PURPOSE : Management and maintenance of dental records that comply with legal requirements Identification of human remains by comparing antemortem and postmortem dental information. Collection and analysis of patterned marks (bite marks) on inanimate material or injured tissue. Recognition of the signs and symptoms of human abuse . Assessment of the age of the person Determination of sex of a person

21. TECHNIQUES OF IDENTIFICATION: 1) COMPARATIVE DENTAL IDENTIFICATION : Attempts conclusive identification by comparing the dead individuals teeth with presumed dental records of the individual. ORAL AUTOPSY OBTAINING DENTAL RECORDS COMPARING POST AND ANTEMORTEM DENTAL DATA WRITING A REPORT AND DRAWING CONCLUSIONS 2) RECONSTRUCTIVE GROUPS: Attempts are made to elicit age, sex, race, occupation etc leading to a probable identification. 3) DNA PROFILING : This method is used when dental record is not available for comparison. The technique uses modern forensic DNA profiling methods to oral tissues to establish identity .

22. ORAL AUTOPSY Autopsy is a highly specialized surgical procedure that consists of a thorough examination of a corpse to determine the cause and manner of death and to evaluate any disease or injury that may be present. Performed for either legal or medical purposes TYPES: Forensic Clinical or pathological Anatomical virtual

23. Obtaining dental records Dental records contain information of treatment undergone and dental status of a person during his/her life time and constitute the antemortem dental data. Content of all available records should be transcribed on to the standard ‘ interpol antemortem form’ which is colour coded in yellow.

24. MODIFIED INTERPOL POSTMORTEM ODONTOGRAPH INTERPOL ANTEMORTEM ODONTOGRAPH

25. Comparing post mortem and ante mortem dental records Features compared include tooth morphology and associated bony structures, pathology and restorations An individual with multiple dental treatment and unusual features has a better likelihood of being identified than someone with no extraordinary dental characteristics.

26. interpretation : Positive identification : sufficient uniqueness among the comparable items. Probable identification : high level of concordance among data, may lack radiograph support. Presumptive (possible) identification : enough information may be missing from either source. Insufficient identification : insufficient supportive evidence. Exclusion of identification : clearly inconsistent.

27. Identification in mass disaster The term "mass disaster" evokes images of a chaotic event. The process of dental identification is same except the magnitude of event is far greater. Mass disasters can be classified in one of three ways: I . Natural 2. Accidental 3. Criminal World trade center attack in 2001

28. Reconstructive post mortem (dental profiling) Dental profiling includes extracting a triad of information- race, gender, occupation & age. According to Sweet and pretty - “The information from this process will enable a more focused search for ante mortem records”.

29. IDENTIFICATION FROM DENTAL DNA: Teeth can resist extreme condition. Pretty and Sweet state that teeth are an excellent source of DNA Applied technique → polymerase chain reaction- allows amplification of highly degraded DNA. This facilitates comparison with a known biological antemortem sample of the decedent such as hair from a comb, epithelial cells from a toothbrush or biopsy specimen. Advantage: - DNA pattern can be compared to the parents or siblings, thus facilitating positive identification.

30. Extraction of dental DNA: Tooth pulp is considered as the best source of dental DNA. Ajayprakash and co-workers isolated DNA from dental pulp and accurately determined personal identity using HLA-DQ amplification. Cytogenic grinding: Advocated by Sweet and Hildebrand. Technique: cooling the whole tooth to extremely low temperatures using liquid nitrogen mechanically grinding it to fine powder. sufficient amount of DNA (intact, carious as well root-filled teeth). Disadvantage: - tooth needs to be completely crushed

31. PALATAL RUGAE IN IDENTIFICATION: Palatal rugae are ridges on the anterior part of the palatal mucosa on each side of the mid-palatal raphe behind the incisive papilla A useful method of identification in edentate individuals. The rugae pattern on the deceased’s maxilla or maxillary denture may be compared to old dentures well protected by lips, check, tongue, buccal pad of fat and teeth in incident of fire and high impact trauma. Can resist decomposition to an extent Unique to an individual. Seldom change shape with age and reappear after trauma or surgical procedures.

32. Classification of palatal rugae: Acc to lysell , Primary rugae (>5mm) Secondary rugae (3-5 mm) Fragmentary rugae (2<3 mm) (Rugae <2 mm is not taken into consideration). Patterns of palatal rugae: (a) curved, (b) wavy, (c) straight, (d) undetermined

33. DENTAL PROFILING The study of teeth and the surrounding tissues of the oral cavity for the purpose of establishing the identity of a victim is called dental profiling. What can be determined Age Gender Race Socioeconomic Status Personal Habits Oral And Systemic Health Occupation Diet Familial Relationship Psychological Characteristics.

34. SEX DETERMINATION BY DNA ANALYSIS Amelogenin (AMEL) –Major matrix proteins secreted by the ameloblasts of the enamel AMEL gene coding → located on the X chromosome and the Y chromosomes in humans. Females (XX) have two identical AMEL genes but the males (XY) have two non identical genes. Preparing DNA from teeth authors obtained 100% success in determining sex of the individual.

35. Dental age estimation Dental age is one of the few measures of physiologic development that is uniformly applicable from infancy to late adolescence Age estimation using the dentition may be grouped into 3 phases. 1. Aging in prenatal, neonatal and early post natal 2. Age estimation in children and adolescents and 3. Age estimation in adults

36. Age estimation in prenatal, neonatal and early post natal children Primary tooth germ forms → 7 th week in utero (IU) Enamel formation of deciduous teeth → 1 st year. Permanent first molar → germ formation → 3.5 - 4 months IU. Age estimation in this group - very accurate . It makes use of histological techniques, which enable observation of tooth mineralization up to 12 weeks before it is actually apparent on radiographs. The neonatal line - indicator of birth.

37. Age estimation in children and adolescents Two events – A) tooth emergence or eruption and B) tooth calcification. Deciduous teeth : emergence → genetic control → 6M- 2.5 years. Permanent teeth : under the influence of the intra oral environment, being affected by infection, arch space and premature tooth loss. Methods: 1) Schour and massler 2) Demirjian’s method 3) value of 3 rd molars

38. AGE ESTIMATION IN ADULTS Age estimation in adults is challenging when compared to younger age groups - “are influenced not only by the age of the individual, but also by numerous endogenous and exogenous factors, such as disease, nutrition and physical strain”. Methods : Gustafson’s method Dentin translucency Incremental line of cementum Amino acid racemization Radiographic method of Kvaal

39. Bite marks DEFINITION : Bitemarks have been defined by MacDonald as a ” mark caused by the teeth either alone or in combination with other mouth parts. Classification of Bite Marks: Mac Donald’s Classification : a) Tooth Pressure Marks: Marks produced on tissues as a result of direct application of pressure by teeth . These are generally produced by the incisal or occlusal surfaces of teeth. b) Tongue Pressure Marks: When sufficient amount of tissue is taken into mouth, the tongue presses it against rigid areas. c) Tooth Scrape Marks: These are caused due to scraping of teeth across the bitten material . They are usually caused by anterior teeth and present as scratches or superficial abrasions.

40. Bite mark cases have to be dealt step by step in the following way: Description of bite marks. Collection of evidence from the victim. Collection of evidence from the suspect. Bite marks comparison .  

41. interpretation OF BITE MARK ANALYSIS By Levie Positive identification : characteristic matches between the bite mark pattern and the pattern of the suspect's teeth.   Possible identification : This implies that although the suspect's teeth could have made the bite mark, there are no characteristic matches to be absolutely certain.   Excludes identification : When features on the bitemark indicate that the suspect's teeth could definitely not have caused them, it represents a Negative or exclusion.

42. Cheiloscopy Cheiloscopy is a forensic investigation technique that deals with identification of humans based on lips traces. Lip prints have to be obtained within 24 hours of time of death to prevent erroneous data that would result from post mortem alterations of lip. Pattern depends on whether mouth is opened or closed. Closed mouth position - well defined grooves Open position - ill defined and difficult to interpret

43. Suzuki and Tsuchihashi (1970) Type I - Clear-cut vertical grooves that run across the entire lip Type I' - Similar to Type I, but do not cover the entire lip Type II - Branched grooves Type III - Intersected grooves Type IV - Reticular grooves Type V - Grooves that cannot be morphologically differentiated.

44. AMELOGLYPHICS The study of the enamel rod end patterns is known as Ameloglyphics ( amelo -enamel; glyphics -carvings) The basic structural unit of enamel is the enamel rods (enamel prisms). The uniqueness of these tooth prints may be utilized as a successful identification tool in forensic science.

45. The shape of the enamel prisms approximates to one of the three main patterns Pattern I : Prisms are circular. Pattern II : Prisms are aligned in parallel rows. Pattern III : key hole appearance.

46. Child abuse Child abuse may be defined as any act of commission that endangers or impairs a child's physical or emotional health and development. Such acts include physical, sexual, or emotional abuse, as well as physical neglect, inadequate supervision, and emotional deprivation. Most of the abusers (offenders) are the family members or relatives of the children.

47. Oral facial findings in Physical abuse: Craniofacial, head, face, and neck injuries occur in more than half of the cases of child abuse. A careful and thorough intraoral and perioral examination is necessary in all cases of suspected abuse and neglect. Oral cavity may be a central focus for physical abuse because of its significance in communication and nutrition. The abuse may result in: contusions, burns, or lacerations of the oral cavity; or facial bone and jaw fractures.

48. DOCUMENTING AND REPORTING CHILD ABUSE When one suspects child abuse , it is important to document the findings thoroughly . This record of the evidence is crucial for whatever legal proceeding may follow. Documentation may involve written notes, photographs, and radiographs. Videotapes or audiotapes may be helpful. The report can be made to the local police agency or welfare department or to a local agency for other supportive information.

49. Current trends in forensic odontology Facial reconstruction Computerized facial reconstruction method uses a laser video camera interfaced with a computer or with CT scanning. The face can be drawn with the help of computer soft ware (for e.g., Vitrea 2.3 version volumetric visualization software). Denture identification methods Labeling the denture is one of the easiest and reliable methods of identification . Methods of denture labeling falls under two categories: the surface marking method and the inclusion method.

50. Comparison microscopes Examination of teeth under microscope can confirm sex by the presence or absence of Y-chromatin . The observer has to rely on memory when comparing two objects, to avoid these problems, the forensic technology has developed a prototype Virtual Comparison Microscope (VCM). The comparison microscope is a device which helps in analyzing the specimens simultaneously . Tongue prints Use of tongue prints for forensic identification is at budding stage now . For this technique to be successful, the antemortem photograph or impression of the tongue should be available. The tongue prints present in the human tongue recently becomes a new member of the biometrics family.

51. Digitization in forensic odontology Digital forensics could be defined as “ application of computer science and investigative procedures for a legal purpose involving the analysis of digital evidence .” Digital Dental Records Digital Forensic Radiography Digital Photography

52. Computer-Assisted Overlays in Bite Mark Analysis In coming decades, these computer-based methods, especially newly introduced Dental Print 3D software will ease the bite mark analysis in more sophisticated manner reducing the chances of manipulation and errors. Virtopsy/Virtual Autopsy Virtopsy is accomplished by placement of markers on the surface of the body by the help of Virtibot , and then, surface scan of the corpse is done . After the surface scan, the body is subjected to CT, MRI, and magnetic resonance spectroscopy (MRS) scans and data is finally fed to the computer where displayed images could be manipulated, rotated at various angles. MRS is a recent technique in virtopsy that determines the relative concentration of various metabolites in the tissues, thus useful in estimating the time of death .

53. Forensic Thanatology Forensic thanatology is investigation of every phenomenon related to death and is performed mainly by cadaveric examinations. Pink tooth phenomenon (PTH ) is an uncommon autopsy finding that comprises of pinkish or reddish discoloration of tooth due to the penetration of hemoglobin into the dentinal tubules that is saturated with carbon dioxide. In accidental cases that result in cranioencephalic trauma, asphyxia , etc., victims are usually in advanced stages of decomposition, and PTH is detected in most of the teeth. Forensic BioRobots It is well documented that deoxyribonucleic acid (DNA) is a reliable source for human identification , and use in criminal investigations has rapidly grown in recent years. Forensic robots have helped laboratories for automation of DNA sampling process that involves extraction, quantification and dilution.

54. Future of forensic odontology in india Currently, the field of FO is at a very crucial stage in India . The number of experts in this promising new discipline of forensic science/ dentistry is on the rise . Every new specialty has to face a tough struggle for its very existence and carve out its own niche. The future of FO in India is nothing but bright . The only question is when this future will become present ?

55. Dentist as an Expert Witness : Expert witness is an advisor to the court and may give opinions, draw inferences or interpret facts about which the judge has special knowledge. A dentist may be required to testify in malpractice cases, other criminal and civil cases. In principle he should act only as an advisor to the court and not an advocate of either side . All the court exhibits should be simple and straight forward which can be understood by the judges. Always simple and clear language should be used.

56. CONCLUSION The roles of any forensic scientist are to collect, preserve and interpret trace evidence , then to relay the results to the judicial authority in a form of a report . Forensic Odontology is the forensic science that is concerned with dental evidence. Dental records that are used to provide patients with optimal dental service could also be very beneficial to legal authorities during an identification process. Therefore, all forms of dental treatments should be recorded and kept properly .

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