Scientific and technical

Associated postmortem dental findings as an aid to personal identification

IA Pretty* and LD Addy Faculty of Medicine, Department of Clinical Dental Sciences, The University of Liverpool, Daulby Street, Liverpool L69 3GN, United Kingdom Science & Justice 2002; 42: 0 0 Received 28 February 2000 accepted 31 January 2001

The use of the unique features of the human dentition to aid in personal identification is well accepted within the forensic field. Indeed, despite advances in DNA and other identification methodologies, comparative dental identifications still play a major role in identifying the victims of violence, disaster or other misfortune. The classic comparative dental identification employs the use of postmortem and antemortem dental records (principally written notes and radiographs) to determine similarities and exclude discrepancies. In many cases the tentative identification of the individual is unknown and therefore antemortem records cannot be located. In such a situation a dental profile of the individual is developed to aid the search for the individuals identity.With such a profile a forensic odontologist can identify and report indicators for age at time of death, race (within the four major ethnic groups) and sex. In addition to these parameters the forensic dentist may be able to give more insight into the individual. This paper outlines, for the non-expert, some of the additional personal information that can be derived from the teeth of the deceased, and which may assist in their ultimate identification.

The Forensic Science Society 2002 Key words Forensic science, odontology, dentistry, anthropology, medical conditions, habits, identification, human

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Introduction The comparison of antemortem and postmortem dental records to determine human identity has long been established. Indeed, it is still a major identification method in criminal investigations, mass disasters (both natural and man-made), grossly decomposed or traumatized bodies, and in other situations where visual identification is neither possible nor desirable [1]. Dental identifications are expeditious, accurate and cost effective. Numerous articles in the literature describe the methods and factors in achieving successful dental identifications in a variety of instances [24]. Despite the well-reviewed nature of comparative identifications, postmortem dental profiles have been somewhat neglected in the forensic literature [13]. Postmortem dental profiles are employed when the tentative identity of an individual is not available and therefore antemortem records cannot be sourced. Such situations are not uncommon when remains are skeletal, grossly decomposed or are found naked in locations unrelated to their place of residence. The purpose of the postmortem profile is to provide information to investigators that will restrict the search to a smaller population of individuals. For example, by profiling the sex of the individual 50% of the possible population can be excluded. Forensic odontologists can usually determine the sex, race (within the four major races), and age (at time of death) from careful study of the teeth, their anatomical arrangement and the skulls osteological features. A review of the basic premise of postmortem profiling, including a worked example is available in the dental literature [1]. In addition to the parameters described above, odontologists may be able to provide information on the individuals habits, occupation, likely place of residence, medical history and socioeconomic status. The following paper illustrates these additional dental findings for the non-dentist, in particular forensic pathologists and anthropologists, illustrating and explaining the various aspects of the dentition that may assist in a postmortem profile. It is important to note that additional dental findings are merely indicators. Few of them offer definitive proof. However, faced with an unidentified individual, any information that may help in the search for their identity is likely to be useful. The following article concentrates on those features visible on the hard dental tissues only, as the condition of bodies usually requiring such profiles negates the use of soft tissues indicators. However, it must be noted that soft tissue conditions and features, such as tattoos, can be of assistance in forensic identifications. Occupation Knowledge of an individuals occupation can assist greatly in the locating of antemortem records narrowing the search and targeting, for example, an artists impression of an individual in appropriate workspaces. The use of occupational health schemes to locate antemortem dental or medical records may also assist in the identification task. The list presented in Table 1 is not exhaustive, but includes many of the more common dental diseases or conditions, which can be attributed to the occupation of the individual.

Most occupational diseases result in the loss of dental hard tissues or tooth staining. Occupational tooth substance loss can occur due to three main systems abrasion, erosion and by caries (decay). Individuals working within dusty or particulate environments will frequently exhibit abrasion of their dental hard tissues. This is caused by the grinding of teeth onto hard, roughened particles within the mouth. Such abrasion is most commonly seen on the biting surfaces of the teeth (occlusal and incisal) [5]. Industries such as flour millers, stone grinders and cement workers may, in the absence of proper precautionary measures, exhibit such tooth substance loss [6,7]. Such wear may eventually lead to the exposure of dentine and ultimately the pulp complex. Treatments include the provision of adhesive gold onlays (gold which is placed on the tooth to replace the lost tissue) or resin-bonded tooth coloured restorative materials. While it would be impossible to identify the actual particulate causing the abrasion, e.g., cement, stone or flour, the location of a factory of this type in the area of body discovery may assist the ultimate identification. Erosion is the dissolution of enamel or dentine by acidic conditions. Workers in acidic environments, such as those of battery factories, chemical plants producing acid products or even wine tasters may exhibit dental erosion [815]. Individuals in this group can be distinguished from other erosive causes (see later) by the location of the erosion on the labial or bucall (facial) surfaces of the teeth, indicating an extrinsic source for the acid [16]. Intrinsic acid sources, such as vomiting, will typically produce erosion on the palatal surfaces. Figure 1b illustrates an example of labial erosion on the maxillary central incisors. Dental treatment for such erosion will typically involve restoring the lost tissue with tooth coloured restorations, porcelain crowns or veneers. Dental caries on the facial surfaces of anterior teeth can be an occupational hazard for those individuals working in the confectionery trade or similar professions [17]. The anterior teeth are dusted with sugar that is metabolized by acidogenic bacteria causing dissolution of tooth enamel. Without provision of facemasks and good oral hygiene rampant caries can occur. Such patterns of caries are rare in the adult population and could represent an important occupational indicator. Carious lesions are likely to be restored with resin-bonded tooth coloured restorations. Extrinsic staining of teeth is a feature of a number of different occupations, especially those in the metal working industry. See Table 1 for details of the appearance of the stains. An interesting appearance is that of dental fluorosis which may appear in its mildest form as white spots through to brown discolouration in the severest cases, see Figure 1d. This is a typical feature of the superphosphate fertilizer industry and is particularly acute in individuals who began working in the industry at a young age. Fluorosis has also been detected in cryolite workers and also in those living in close proximity to cryolite factories [18]. Dental fluorosis may be treated by restorative options similar to those for erosion or by gentle acid abrasion to remove the outer layers of enamel. Levels of fluoride can be determined following enamel biopsy and chemical analysis, typically using a fluoride probe [1].

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Table 1

Occupational diseases of teeth. Dental Appearance Generalized abrasion Cause Abrasive dust formation and collection on the occlusal surfaces of the teeth

Occupation Miners Cement and sand workers Grinders Stone cutters Saw mill workers Flour mill workers

Sugar refiners Bakers Candy makers

Caries on the labial and buccal surfaces of the teeth

Sugar dust deposits, and stagnates, on the labial surfaces of the teeth

Metal workers: Copper Nickel Iron Tin

Green staining of dentition Green staining of dentition Fine black lines on teeth Yellow staining of teeth

Inhalation of dust Inhalation of metal fumes leads to deposition of tin sulphide

Chemical workers: Citric acid, tartaric acid, hydrochloric acid, sulphuric acid, etc Superphosphate industry: production of phosphorus and hydrogen peroxide Battery factory worker

Smooth polished eroded surfaces

Decalcification of enamel and dentine, due to exposure to fumes. Main effect to labial surfaces. Mastication and tooth brushing lead to loss of tooth substance Fluorine compounds used in this industry have a direct effect on ameloblasts, especially in younger workers. Cadmium exposure causes the extrinsic staining while the battery acids are responsible for the erosion. Holding nails, takes, needles etc, between their teeth

Fluorosis

Yellow, gold-brown staining of labial surfaces of teeth and erosion of incisors Abrasion single of multiple groves found on incisors

Shoe makers Upholsterers Glass blowers Dress designers Seamstresses Electricians Wine tasters

Erosion, mainly on the labio-cervical surfaces on maxillary incisors and canines

Wine tasting on a daily basis with at least 20 wines tasted per day. Wine pH varies from 3.0 to 3.6 typically

Occupational patterns of tooth wear occur frequently in professions where items may be held between the teeth leaving the hands free. Typical occupations include carpet layers, seamstresses and electricians who often use their teeth to strip electrical wires, see Figure 1a and 1c [19]. Some musicians, often wind instrument players, can also have characteristic wear patterns [20]. The patterns of tooth wear in these individuals are often highly characteristic and, as they serve a function, are rarely treated unless they are painful. Detailed characterization of dental wear patterns can be elucidated using scanning electron microscopy, usually of dental costs.

Medical conditions and treatments Knowledge of an individuals health status can be an important clue in the determination of identity and can provide another valuable variable to narrow the search for antemortem records. Medical records can be searched using keywords relating to a particular disorder or treatment and, when combined with other defining characteristics, may enable investigators to provide a tentative identification. Conditions that have a genetic component can be traced using family histories which may, in these rare conditions, provide a useful insight to an individuals identity.

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The multitude of obscure diseases that can present intra-orally can be narrowed when considering those which impact upon the dental hard tissues. It is likely that, in a post-mortem dental profile, it is these tissues that will form the basis of the odontologists examination. Medical conditions with oral hard tissue presentations A range of medical conditions cause dental erosion, and, as described previously, this tends to occur on the palatal surfaces of teeth an intrinsic source of the erosive agent [21]. Any condition that causes a prolonged acidic assault on the teeth will cause erosion. Differentiating between them cannot be done by appearance alone, and factors such as age and sex of the individual must be taken into account. A range of gastrointestinal conditions, such as hiatus hernia [21], gastric ulcers and reflux disease [22,23] can also cause palatal erosion, especially of the maxillary teeth (Figure 2c) [2427]. Another group of individuals who suffer from dental erosion are those with eating disorders which have a component of selfinduced vomiting [28]. Individuals are most frequently adolescent girls, but there is an increase in teenage males [29].

Dental erosion can be found in bulimics [30], anorexics [31], and ruminators [20,32]. Rumination is an eating disorder in which the stomach contents are voluntarily regurgitated and then either re-swallowed or expelled. Chronic alcoholics frequently vomit, and therefore present with similar patterns of dental erosion [33]. Such individuals can normally be distinguished by their poor oral care, which is in contrast to the patients with eating disorders for whom erosion is often the only dental pathology present [3436]. Several medical conditions can cause unique coloration of the dental hard tissues. Neonatal jaundice causes a green or yellowish brown stain of the teeth an intrinsic stain it can be associated with disturbances of enamel development [37,38]. The staining is caused by bile pigments which are deposited in the developing enamel and dentine. The discolouration can be quite profound, and is often treated in childhood by composite restorations or porcelain veneers. Congenital porphyria is a rare condition, which results from an error in porphryin metabolism. This defect leads to a haemolytic anaemia, photosensitivity (and blistering of exposed skin) and red-brown pigmentation of teeth (and bones). The condition is also known as Gunthers Disease.

Table 2

The effect of medical conditions and drugs on the dentition. Appearance Marked erosion of the palatal surfaces of the maxillary incisors and premolars Cause Regurgitation or vomiting of gastric contents. Gastric acid has a pH below 1

Medical Condition Conditions and diseases Hiatus Hernia Gastric ulcer Gastro-oesophageal reflux disease (GORD) Anorexia nervosa Anorexia athletica Bulimia nervosa Rumination Chronic alcohol abuse Neonatal jaundice

As above

Induced vomiting of stomach contents

Green to yellowish-brown discolouration of the teeth Enamel hypoplasia may also occur Affected teeth show a pinkish-brown discoloration that fluoresces red under UV light Hutchinsons incisors and Mulberry molars distinctive shaped teeth

Most frequently associated with rhesus incompatibility

Congenital porphyria

Autosomal recessive inheritance. Circulating porphyrins in the blood are deposited in the dental hard tissues. Transmission of Treponema pallidum from an infected mother

Congenital syphilis

Drugs used in treatments Iron supplements Minocycline Chlorhexidine Tetracycline

Black staining of teeth Brown/black staining

Surface deposition following oral courses Precipitation of dietary chromogens

Yellow/brown bands becoming darker following exposure to light

Systemic administration during the period of tooth development. Deposition occurs in dentine along incremental growth lines

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The dental aspects of the condition are likely to be treated in childhood although the staining should be visible on nonaesthetic surfaces [3940]. Syphilis, while easily treated with antibiotics, is enjoying a resurgence in the western world [41,42]. Congenital syphilis presents orally as misshapen molars (Mulberry molars) and incisors (Hutchinsons incisors). The disease is caused by the transmission of the causative organism (T. pallidum) from the mother to foetus. The appearance of the condition is more apparent in the deciduous than permanent dentition (Figure 2d). Medical treatments with oral hard tissue presentations With the exception of iatrogenic medical or dental damage to teeth, the conditions with hard tissue presentations all cause staining of the dentition. Iron supplements can cause a surface deposition resulting in a black or brown staining of the teeth. It should be noted that iron supplements may be taken without prescription and therefore may not be documented in medical notes [43]. Minocycline and the popular mouthwash chlorhexidine cause a brown/black staining on all surfaces of the teeth acting by precipitating dietary chromogens [4446]. Such stains can be difficult to remove and may be associated with poor oral hygiene or periodontal disease. One of the most profound stains is that caused by tetracycline. A long-term antibiotic its use in individuals with developing teeth has been banned in the West it is commonly used to treat acne. Tetracycline is deposited in developing hard tissues and thus causes bands of stain in teeth. Such bands can be used to determine when the tetracycline was administered. Tetracycline staining can be seen in children (Figure 2a) and adults (Figure 2b). The staining is most frequently hidden using bleaching, porcelain crowns or veneers as can be seen on the maxillary teeth of the subject in Figure 2b [4748].

Figure 1 (a) Characteristic notching of the mandibular and maxillary left central incisors associated with electrical wire stripping. The individual has worked as an electrician for many years. (b) Labial erosion characteristic of the type seen among workers in acidic environments. (c) A notch caused by the holding of pins between the teeth; this individual was a seamstress. (d) A severe case of dental fluorosis of the type seen among workers in the superphosphate industries.

Habits A number of lifestyle habits have an effect on the dental tissues. This can be useful in the search for an individual information such that the individual was a pipe smoker can facilitate the antemortem record search and prompt people who may have known them. Common habits, such as tea and coffee drinking, cause extrinsic stains but, due to their high incidence in the

Figure 2 (a) Pediatric tetracycline staining. (b) Severe adult tetracycline note that the upper incisors have been treated by the provision of (poor) porcelain crowns. (c) An example of intrinsic erosion note that the anterior teeth have lost almost all of their clinical crowns. (d) An example of a Hutchinsonian incisor in a case of congenital syphilis.

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Table 3 Habit

The effects of habits and pastimes on the dentition. Appearance Brown/black staining on labial, lingual and palatal surfaces Unusual patterns of tooth wear in addition to staining Unusual patterns of erosion especially on the buccal surfaces Cause Extrinsic staining

Coffee, tea, red wine drinkers

Pipe smoking

Wear

Painting (canvas)

Gouache in paint is acidic, and transferred to mouth as brushes are often placed intra-orally Extrinsic staining

Betel nut use

Staining on buccal surfaces, usually unilateral Tooth erosion

Alcoholism

Two-fold the acidity of the alcoholic drink and acid-reflux as alcohol is a gastric irritant Testing the purity of cocaine by rubbing it into the gums. Cocaine is often mixed with sugar Clenching of teeth plus consumption of carbonated drinks during the trip Oral neglect

Cocaine

Localised and severe dental caries, particularly in the maxillary premolar region Occlusal wear of molar teeth and acid erosion High caries rate and severe periodontal disease Rampant caries

Amphetamines (Ecstasy)

Heroin

Methadone syrup

Methadone is often delivered as a sugary syrup which adheres to teeth tenaciously

Figure 3 (a) Classic example of unilateral betel nut stain, also known as smokeless tobacco. (b) Lingual stain and associated poor oral hygiene in a heavy cigarette smoker. (c) Pattern of anterior wear associated with habitual pipe smoker the wear is unilateral.

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Table 4

Abnormalities of tooth formation and eruption. M:F (male:female) Description Prevalence

Abnormality Supernumerary teeth

Most common in the premaxilla. 75% do not erupt 1.5 3.5% (visible on postmortem radiographs). May be conical, M:F 2:1 tuberculate (multi-cusped), supplemental or odontome-like Missing teeth. Effects, in descending order of frequency, mandibular and maxillary 3rd molars (wisdom teeth), mandibular 2nd molars, maxillary lateral incisors, and 2nd premolars. Severe Hypodontia is associated with Down Syndrome and ectodermal dysplasia Abnormality of tooth size, microdontia mainly affects the maxillary lateral incisors so called peg laterals. Strongly associated with hypodontia Enamel defects caused by high levels of fluoride. >1ppm. Mildest form presents as white flecks or diffuse cloudiness, severest exhibits brown patches with surface enamel pitting 3.5 6.5% M:F 1:4

Hypodontia

Macrodontia & Microdontia

1.1% (Macro) Overall occurrence 2.5%

Fluorosis

More common in areas of high natural fluoridated water, i.e. Africa, India and the Middle East. Can also be caused by inappropriate fluoride therapies and dentifrice ingestion by children. See also occupational

Hypoplasia

Enamel defects usually caused by premature loss of deciduous teeth can be an indicator of neglect or poor oral care Genetic defect with various presentations, either hypoplastic or hypocalcified Translucent grey teeth shell teeth may be present Family history good predictor genetic basis Uncommon genetic association family history

Amelogenesis imperfecta

Dentinogenesis imperfecta

Figure 4 (a) Amelogenesis imperfecta. (b) Hypoplastic enamel presenting as white spots on the maxillary central incisors. (c) Severe Dentinogenesis imperfecta with shell teeth. (d) Hypodontia in a case of ectodermal dysplasia.

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population, their use as identifying features may be insignificant. However, other habits offer more useful indicators for investigators. Pipe smoking is a good example of this. Habitually, pipe smokers place the pipe stem in the same location, and thus create, over time, a wear pattern in this area. Pipe smoking is also associated with the usual nicotine stains and a range of soft tissue appearances which are beyond the scope of this article. The ability to instruct a forensic artist to include a pipe on, say, the left hand side, may greatly increase the chances of recognition by a friend or relative. An example of this can be seen in Figure 3c. The recognition of smoking stains (Figure 3b) can also be of use in the placement of a cigarette in an artists impression. Betel nut chewing produces an unusual stain and is more normally seen in individuals from India, Pakistan and Bangladesh. The quid is usually placed on one side of the mouth, and this is normally the same on each occasion that the betel is taken. This habit produces a unilateral brown staining of the buccal surfaces of the teeth typically 1 mm above the gingival margin (Figure 3a). It may be possible to use laboratory techniques to analyse stain and determine, more objectively, its source. Harder recreational drug use can also be detected by examination of the teeth. Cocaine is often tested or taken by rubbing into the maxillary premolar area of the gingivae. Frequently cut with sugar, this can cause localized caries in the area with severe gingival recession that is often in the absence of other decay or periodontal disease. Alcoholism, as described previously, causes palatal erosion through two main mechanisms, firstly, the acidity of the alcohol itself and secondly through acid-reflux or vomiting. The use of amphetamines or Ecstasy (3,4 methylenedioxymethamphetamine) among younger persons is increasing due partly to its association with the dance culture in both the US and the UK. Dental effects have been reported for chronic consumption of Ecstasy and relate to the clenching of teeth causing occlusal wear. Individuals who use Ecstasy frequently dehydrate and the current recommendation is that copious liquids are taken during the trip. These are often sugary carbonated drinks and therefore an increased caries risk with

associated abrasion of the teeth can be seen. The symbiotic relationship of an acidic environment with tooth grinding increases the loss of tooth tissue and, therefore, profound wear can be seen in these young individuals. Heroin users often exhibit severe oral neglect, and while this is not a unique finding (alcoholics may exhibit the same pattern) the age of the individuals is often a defining characteristic. Heroin abusers who are in treatment programmes are frequently prescribed methadone that is often delivered in a syrup form high in sugar. With the associated poor oral hygiene of these individuals, a high caries rate can be seen and this may be of confirmatory use in identifications. Abnormalities of tooth formation and eruption There is a range of rare conditions that affect the developing dentition that lead to distinctive hard tissue appearances [49]. These are listed and described in Table 4 and illustrated in Figure 4. The incidence and prevalence levels are low for each condition and therefore they present useful identifying features for investigators. Many of the conditions are associated with severe medical conditions and it is likely that extensive medical and dental records (often in specialist practices) will be available for such individuals. Their unique physical and dental appearances are easily recognizable to witnesses, relatives and family members. As many of these conditions have a genetic basis, a family history may be available [49]. Supernumerary teeth and hypodontia are among the commonest of dental developmental disorders, and a mesiodens (additional tooth in the mid-line) has been used in the identification of an individual with no dental restorations [1]. Severe forms of hypodontia are associated with Down Syndrome and ectodermal dysplasia, both of which have associated physical characteristics [50]. Abnormalities of tooth size, macro and microdontia, are rare although so called peg lateral incisors are common [51,52]. Hypoplasia ranges from small white spots visible on the teeth (Figure 4b) to extensive enamel pitting. Usually associated with early loss (typically by extraction) of the deciduous predecessor its occurrence may be noted by dentists within their records. The genetic conditions of enamel (Figure 4a) (amelogenesis imperfecta) and dentin (Figure 4c) (dentinogenesis imperfecta) malformation exhibit a range of

Figure 5 Figure 5 Examples of dental work (a) Russian. (b) Chinese.

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presentations, although almost always require specialist dental care [53]. Many of these individuals will wear full or partial prostheses and may do so from an early age. Place of residence The determination of likely place of residence can be based on the dental techniques, the quality of work and dental materials that have been used to restore the deceaseds dentition. An assumption is made that the individual had their dental work performed in their country of residence. It is unlikely that a particular country can be identified, however geographical areas can be identified. Dental techniques and the materials available to perform them vary widely, and are usually influenced by the affluence of the country. Dental training is also highly variable, and in many countries there is little or no formal dental training. Two examples are described here. The first example is from Russia. Russian dentistry can often be categorized by the use of non-precious metals faced with acrylic rather than porcelain crowns, the use of non-precious metals in the anterior portion of the dental arch and work of a generally lower quality than is seen in the West. It must be noted that these are generalizations and with the increased wealth in Russia, an accompanying increase in health care quality can be anticipated. The illustrations serve as examples of typical Russian restorative work. Should such treatments be observed it is highly unlikely that such work will have been performed in the West, and is more likely to have originated in the former Soviet region. Figure 5a illustrates a typical example. The second example comes from China. In this example the dental work was an indicator that the individual was from, or had spent time, in Asia (Figure 5b). The dental work utilizes only two natural teeth (canines) to provide support for extensive bridgework. The bridgework is acrylic with wooden components and an underlying metal framework. In the West, more likely treatments would have been a removable denture, over-denture or implant supported prostheses. These two examples serve to illustrate that dental work can be a possible indicator of place of residence. Unusual restorative techniques may alert the investigator to the possibility that the individual may originate from, or have spent time, in a foreign country. It is important to remember that good and poor quality dental work can be provided in any country. However, unusual or gross departures from the norm should always be considered as potentially significant. Sex determination Several authors have examined the ability to determine gender using odontometric analyses. A famous study by Rao et al uses the mandibular canine index to determine sex, although another study has issued a caution in using this technique [54,55]. Another study, using dental casts of children, showed that the teeth, and in particular the canines, were larger in males than females, and suggested this method for determining gender in children whose secondary sexual characteristics had not developed [56]. Many researchers believe that measurements of tooth size or assessment of morphology are insufficiently

accurate for forensic identification, particularly in light of more objective methods [57]. Two examples of such methods are provided. The first is a microscopic technique in which the pulp tissue is examined for Barr bodies (present only in females). This technique has been shown to be of value in burnt and mummified remains and is highly accurate [58]. The second method is based upon PCR analysis of DNA, sourced from the dental pulp, and the subsequent analysis of the amelogenin gene for sex determination [1]. While not unique to DNA obtained from dental pulp, the teeth often remain the only source for DNA following incineration or other postmortem events [1]. Summary This article has described, for non-dental experts, some of the additional postmortem findings which can be determined from the study of individuals teeth. It is implicit that none of these items can lead to a positive identification but, when combined with other dental and circumstantial evidence, they can assist in the focusing of a search for antemortem records or provide useful information for forensic artists. The features presented here are by no means exhaustive but cover the most common and/or useful items to note when performing a dental examination in an unidentified individual. As with all forensic postmortem examinations, copious photographs and written notes should be made of any unusual feature so that specialist advice can be sought. Acknowledgements The authors would like to thank DerWeb (www.derweb.ac.uk) for permission to use Figures 1, 2b, 2c, 3, 4, 5a, Dr Mike Martin (The University of Liverpool) for Figures 2a and 2d, and Dr Malcolm Turnbull for Figure 5b. References
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