Disaster Victim Management: Role of Forensic Odontology

H James, J Berketa, D Higgins, A Lake, and G Cirillo, The University of Adelaide, Adelaide, SA, Australia
r 2016 Elsevier Ltd. All rights reserved.

Abstract

Forensic odontology is the branch of dentistry that applies dental science to the law. Legal investigation
involving dentistry may include human identification, oro-facial trauma, and dental malpractice. In many
countries identification of the deceased is both a legal requirement to progress estate management and a
social obligation to allow closure for relatives. In single and multiple fatality incidents odontology can assist
authorities assigning identity to deceased persons. This chapter outlines the basis for dental involvement in
identifying the dead and presents key concepts for each stage of the dental identification process.

Glossary physical contact with human remains, dangers from

Case journal A journal of actions and progress
status related to a case.
Disaster victim identification (DVI) Processes to
identify and repatriate victims of a mass fatality
incident.
Disaster victim management (DVM) Management
and protocols to achieve best DVI practice standards.
Forensic odontology The branch of dentistry that
applies dental science to the law.
INTERPOL International policing agency.
Odontologist Specialist dentist trained to apply the
science of dentistry to assist the Courts of Law.
Personal protective equipment (PPE) Equipment
capable of protecting DVI personnel from direct
the environment and/or the incident site, for example,
protective clothing and footwear, eyewear, gloves,
and lead apron for radiation protection.
Phase INTERPOL subdivision of DVI operational
components: scene, postmortem, antemortem,
reconciliation, and debrief.
Response plan A detailed plan outlining
responsibilities, authorities, and mechanisms to
respond to multiple fatality events.
Standard operating procedures (SOP) Standardized
operational practices to maintain appropriate quality
levels.

Introduction
Like all comparative disciplines odontology is grounded
in two principles: firstly, that humans are unique, i.e.,
nature does not repeat itself, and secondly, that macro-
scopic and microscopic variation occurs to allow indi-
vidualization (Tuthill and George, 2002). The degree of
variation may decrease with genetic closeness but even
so-called identical twins can be differentiated dentally
(Figure 1).
The rationale for use of dental comparison techni-
ques to establish identity is based on the recognition that
teeth and dental restorations are resistant to destruction,
illustrated in Figure 2, (Berketa et al., 2010; Patidar
et al., 2010; Merlati, 2004; Rossouw et al., 1999), they
exhibit differences facilitating highly variable patterns
(Martin-de-Las-Heras et al., 2010; Adams, 2003) and
that most people have, during their lives, visited a dentist
and/or had facial photographs taken to provide ante-
mortem data. In many countries it is either legally
mandated, or traditional, for dentists to record details of
their patients’ teeth and the treatment they have per-
formed, and to retain these records for an extended
period of time (see Dental Board of Australia in Relevant
Websites; Dierickx et al., 2006; Figgener, 1994). The
advent of modern digital technology and social media
has also facilitated widespread image availability.
Teeth begin to develop in utero (Nanci, 2003). After
birth, development continues with progressive eruption
of the primary (deciduous) dentition and subsequent
replacement by the secondary (adult) teeth. The mouth
generally contains up to 20 deciduous teeth or 32 sec-
ondary teeth, or a combination of both in the transition
phase and in a small number of adults. Genetic, epi-
genetic, and environmental factors influence the for-
mation of the teeth (Townsend et al., 2012). After
eruption the teeth are also vulnerable to extrinsic effects
such as staining, erosion, abrasion, trauma, and force
loadings; as well as dental disease and the treatment
consequences that may result.
Teeth and the surrounding oral tissues exhibit a large
morphological range of size and shape (Hanihara and

288 Encyclopedia of Forensic and Legal Medicine, Volume 2 doi:10.1016/B978-0-12-800034-2.00238-X

 Disaster Victim Management: Role of Forensic Odontology 289

Figure 1 Dental casts of monozygotic twins showing differences in arch shape, and tooth size, position, and number, between twin A and twin B.
Permission to include this photograph of the twins, who are enrolled in a study of the teeth and faces of twins in the School of Dentistry at the
University of Adelaide, has been obtained from Professor Grant Townsend.

Figure 2 Excavated remains from Pompeii (organic material replaced

by plaster) showing teeth and skull still intact from the AD 79
eruption of Mount Vesuvius. Figure 3 Periapical radiograph showing tooth anatomy, variation in
tooth restorations, and spatial relationships.

Ishida, 2005). Variation is seen in the spatial arrange-
ment of teeth within the same jaw (Figure 3) and in the
relationship of teeth in one jaw to those in the other.
Loss of tooth structure, except for very limited micro-
scopic re-calcification, is irreversible and can only in-
crease with time. Dental treatment is highly individual,
with restorations (fillings) varying in size, shape, com-
position, and location (Figure 4). An enormous range of
patterns is possible (Keiser-Nielsen, 1980).
A number of different methods exist to assist
human identification. Dental, DNA, and finger-
print comparisons are considered by INTERPOL to be
primary (stand-alone) identifiers, while medical, an-
thropology, and property data are designated as sec-
ondary identifiers, requiring primary corroboration or
strong combination detail (see INTERPOL in Relevant
Website). Dental comparison has been shown to be cost-
effective, efficient, and accurate in numerous disaster
victim identification (DVI) events (De Valck, 2006;
James, 2005; Lain et al., 2003; Brannon and Morlang,
2001; Chapenoire et al., 1998) and can be used alone or
in combination with other primary or secondary
identifiers.
Disaster can present in many forms: naturally such as
a forest fire, earthquake, or tsunami; accidentally such
as a transport accident; or as a result of a deliberate act,
as in the case of a terrorist attack. Disasters are generally
unexpected and surrounded by confusion. This con-
fusion should not be of concern for those entrusted with
managing the identification and repatriation of the de-
ceased, and those specialties invited to assist, such as
odontology, if sound documented and tested protocols
are in place. Forensic odontologists operate within a
modular unit, which should articulate seamlessly into
the central Disaster Victim Management (DVM) Re-
sponse Plan. The role of forensic odontology in DVM is
290 Disaster Victim Management: Role of Forensic Odontology
Figure 4 Palatal view showing diversity of dental and surrounding visible tissue features, including teeth, restorations, spatial tooth arrangement,
arch width and depth, rugae, wear, and decay.
to maximize comparable data to allow identification to
be established, and minimize data error and data cor-
ruption. This requires an ethos of quality management
to allow efficient functioning.
Pre-Disaster Management
Quality management in forensic odontology is the
understanding and implementation of methodologies
that ensures collection, collation, and preservation of the
maximum amount of available dental data and the ap-
propriate interpretation of that data to achieve outcomes
to a standard expected by instructing authorities, im-
pacted parties, and the forensic odontology specialist
community (Lake et al., 2012). This involves two as-
pects, quality assurance, the creation and maintenance
of an appropriate pre-disaster protocol, and quality
control (QC), the enforcement of that protocol through
standard operating procedures (SOP). The phrase “by
failing to prepare, you are preparing to fail,” commonly
attributed to Benjamin Franklin, is an apt summation of
DVM. Much of the success of any DVM operation can
be attributed to preplanning and a sound response plan.
For an odontology team to respond to a request for
its services it is essential that there is a designated co-
ordinator to whom authorities can make their point of
contact. The odontology coordinator needs to be ex-
perienced in DVM, and have an appropriate response
protocol (Figure 5) and trained core team prepared
(Taylor, 2009). The protocol should have the flexibility
to require only fine-tuning once the nature and extent of
the disaster has been determined. Table 1 highlights
issues to consider in development of such a plan. For an
odontology component to be created, maintained, and
integrated into an overall DVM response plan author-
ities need to know the requirements and limitations of
odontology. If a DVM Committee exists, having the
odontology coordinator involved is strongly advisable.
Selecting and training personnel, defining and sourcing
equipment needs, and creating protocols ad hoc after a
disaster has taken place does not lead to good quality
assurance and operational control (Hinchcliffe, 2011;
Sweet, 2010; Prieto et al., 2007).
Disasters do not follow a specific timeframe and
refresher team training exercises are advisable at regular
intervals (Sweet, 2010). Different DVM events will
encompass a range of legal, cultural, ethnic, religious,
governmental, and community issues (Sahelangi and
Novita, 2012; Hinchcliffe, 2011; Fitrasanti and
Syukriani, 2009; Brannon and Morlang, 2002). It is
important, if possible, that these be addressed in the
pre-event stage with the instructing authority and during
multidisciplinary training.
Simulated exercises will increase the understanding
of roles, improve cross-specialist cooperation, and
improve the odontology team members’ understanding
of the overall chain of command. The opportunity to
provide feedback is advantageous in fine-tuning odon-
tology SOP as well as providing team members with
 Disaster Victim Management: Role of Forensic Odontology
Figure 5 South Australian odontology response plan.
some joint ownership of the overall DVI standards
and results, thus also improving the potential for
active compliance (De Winne, 2006). Simulations in-
volving complex dental scenarios, such as fragmen-
tation, incineration, and comingling of human and
animal remains, may identify deficiencies in existing
SOP (Lain et al., 2011; Pretty et al., 2001). To gain the
most from training exercises they should encompass
all aspects of the SOP, including recording formal chains
of evidence and progress logs, adherence to an internal
chain of command structure and implementation
of occupational, health, safety, and security manage-
ment practices with peer reviews by one or more DVM
trained odontologists. It is recommended this be fol-
lowed by debriefings and reviews of the pre-event
protocol and the operational SOP to see if improvements
are indicated.
291
Event Management
Initial Response
Urgency of action is critical for those involved in man-
aging survivors and stabilizing the scene following an
incident. However, for the other operational DVI phases
time is available to assess the situation and adapt a re-
sponse plan to current circumstances, thus providing for
a sound quality management platform. The temptation
to rush to immediate action, without clearly defined
SOP, should be avoided. Byard and Winskog (2010)
proposed that a measure of an effective management of
a disaster might be the number of cases/specimens that
need to be reexamined to correct failures in procedures.
Pressure by family, media, and politicians to hasten or
prioritize body release must also to be resisted.
292 Disaster Victim Management: Role of Forensic Odontology
Table 1 Preplanning considerations
Communication A formal odontology protocol
Standard operating procedures
Reporting mechanisms
Data management Location, collection, and collation
Standardized text recording
Storage and retrieval
Facilities and Secure site for temporary mortuary
equipment Sites for antemortem data collation and reconciliation
Information technology requirements
Equipment – suppliers, installation, calibration, and licensing
Methodology Nomination of sound, tested, and regionally appropriate methodologies for data recognition and input, age estimation and facial
comparison
Protocols for search and matching
Standardized report definitions
Review mechanisms to ensure current best practice
Training and Sourcing personnel
accreditation Workplace contract template, including wages, insurance, travel, accommodation and expenses, work specification, and
confidentiality agreement
Memorandum of agreement with government agencies for registration/licensing of personnel
Once a clear picture of the nature and scope of the
incident is established from the scene coordinator, dis-
cussions between the DVI commander and odontology
coordinator will define the staff, equipment, and ma-
terials needed to deliver a timely outcome. Data man-
agement and flow patterns, reporting mechanisms,
technology and methodologies, and QC internal audits/
peer reviews can be established (Lake et al., 2012).
Berketa et al. (2012) have compiled a checklist of con-
siderations for odontology involvement in DVI.
The odontology team can then be briefed by the
odontology coordinator: number and condition of
deceased, timeframes for identification, occupational
health, safety and welfare (OHSW) issues, security, set
up of facilities and equipment for each phase, SOP re-
fined, and Chain of Command defined. Accreditation,
employment packages, rosters, transport, and social
activities can be addressed.
As the work can be both stressful and psychologically
exhausting, enforced breaks need to be included in work
rosters to minimize fatigue and potential for errors.
Memory lapses, periodic and unexpected breaks, or lack
of continuity of personnel pose serious problems. A
trained clinical psychology practitioner should be
available who can not only assist staff members but also
identify for management potential quality control issues.
Scene Phase
At the scene of a disaster, deceased bodies and separated
body parts are located, documented, and imaged before
retrieval, together with property which might assist in
the identification of victims. The scene retrieval teams
are usually DVM trained police officers with a local
scene coordinator in charge of each incident site.
Disasters manifest in many forms and the resultant
effect on human remains will be diverse, including severe
trauma, incineration, and decomposition (Figures 6–12).
Even bodies that could potentially be visually identified
need to be managed within DVM protocols. Different
techniques for recovery of the bodies are required for
different disaster scenarios. In the event of severe in-
cineration or trauma, it is wise that experienced odon-
tologists attend with the retrieval teams to identify jaw,
tooth, and dental restorative components that might
have become separated from the body. The forensic
odontologist is also well positioned to advise on re-
covery and transportation methods for the head and
dental structures to avoid damage and loss of infor-
mation between the scene and mortuary (Hill et al.,
2011; Naiman et al., 2007; Taylor et al., 2002).
Scene odontologists need to be briefed about the in-
cident before entering the scene. A briefing should in-
clude information on issues such as possible hazards, for
example, structural integrity, chemical and biological
hazards, and physical threats. Appropriate safety
equipment (helmets, overalls, boots, rubber gloves, etc.)
should be utilized. A safe pathway to the area of interest
needs to be disclosed, to which there should be strict
adherence.
Appropriate SOP should include instructions to all
scene personnel regarding the handling of jaws, teeth,
and any dental appliances. Equally important is the
examination of the surrounding area, below and ad-
jacent to the head for dental material that might have
been dislodged. Experienced odontologists should be
able to identify dental structures such as dental appli-
ances, restorations, implants, and individual tooth parts
that might have been separated from the deceased.
Other items located in the head region, and useful for
 Disaster Victim Management: Role of Forensic Odontology
Figure 6 House damage following wildfire.
Figure 7 Body discovered beneath rubble of house fire.
identification, include cochlear implants, surgical plates
and screws, and jewelry (Berketa, 2013; Berketa et al.,
2013). Interaction between different specialties involved
in evidence collection needs to be clearly defined to
avoid damage or contamination of evidence.
High-resolution imagery of evidence at the scene,
prior to transportation, is vital and may be later relied
upon if material is lost or there is suspicion that cases
have been mixed up between the scene and mortuary.
Images and documentation collected need to be labeled
with the body number and retained with the body when
it is moved to the postmortem examination area. If
293
remains are very fragile it may be advantageous to
radiograph the teeth at the scene utilizing portable im-
aging equipment, as seen in Figure 13.
Scene revisits and data loss can be limited if sound
SOP exist to ensure that the maximum dental evidence
has been located, labeled, documented, and correctly
packaged for transportation (Berketa et al., 2012).
Postmortem Phase
The postmortem phase identifies and records all dental
evidence of the deceased victims in a standardized
294 Disaster Victim Management: Role of Forensic Odontology

and thorough manner. An ‘ideal’ mortuary setup would pathology, fingerprinting, property recovery, DNA
be impossible to define, and will vary according to the sampling, and anthropology sections before being
circumstances of the disaster, but key elements must examined by a dental team. The mortuary manager
include security of the facility, storage capability for and the postmortem coordinators of each section
equipment and victims, availability of infrastructure
(such as power, water, climate control, and tele-
communications), physical size of the facility, and site
accessibility for personnel. It is important to consider
that although the dental examination is one part of
many examinations taking part in the mortuary, being
involved in the set up will ensure that the dental aspect
can be accommodated efficiently and appropriately.
Usually, the dental examination takes the longest
time and is the last examination for a given body.
Within the mortuary, the body may pass through

Figure 8 Wreckage from airline crash. Figure 10 Facial damage.

Figure 9 Fragmented body from aircraft crash.

 Disaster Victim Management: Role of Forensic Odontology
Figure 11 Tsunami mud and debris covering bodies.
Figure 12 Decomposed body.
will determine the process and flow of the body through
each examination phase.
A dental postmortem team should consist of a team
leader and paired examiners, all of whom will have been
briefed in the specifics of the SOP for the particular
295
Figure 13 Nomad™ handheld X-ray unit (Aribex, East Orem, The
USA) and X-pod™ imaging device (MyRay, Imola, Italy).
disaster. The nature of the disaster and the condition of
the remains of the victims will determine methodology
for examination. For instance, if the disaster is a fire or
explosion and the expectation is that many of the vic-
tims are burnt/incinerated (Figure 14), then consider-
ation will be given to photographing, radiographing,
and documenting the jaws and teeth prior to examin-
ation and/or resection. If computerized tomography
technology is available a pre-examination screen is ideal
(James and Taylor, 2011). Similarly, it is important to
know if a biohazard may require the victims to be de-
contaminated prior to examination and if particular
296 Disaster Victim Management: Role of Forensic Odontology
Figure 14 Incinerated remains.
personal protective equipment (PPE) will be required for
the examiners (Leditschke et al., 2011). Particular
caution is required if commingling of remains is a
possibility.
Within the dental examination area in the mortuary,
‘clean’ and ‘dirty’ sections are designated to separate the
handling of the remains and the recording of the data.
Two experienced forensic dentists are required for a
dental examination (Figure 15), which includes a full
and accurate dental charting of all the teeth and res-
torations; photographic documentation of the teeth,
mouth, and face; and complete radiographic survey of
the teeth and jaws of the remains (Lake et al., 2012;
Kvaal, 2006). Findings should be documented and data
cross-checked with radiographic evidence. A review of
scene documentation and sieving debris collected at the
scene from the head region (Figure 16) may also be
required.
Equipment used during the dental examination will
include dental mirrors, probes, tweezers, cheek re-
tractors, and jaw spreaders. Gauze, cotton rolls, tooth-
brushes, alcohol wipes, water, and any other implements
necessary to clean and remove debris from the dentition
should be available to enable proper visualization of the
remains. Overhead ‘operating’ lights are essential and
Figure 15 Postmortem examination by paired odontologists.
personal magnifiers would also be beneficial. Care needs
to be taken with all equipment so that it is appropriately
disinfected or sterilized to reduce the risk of DNA cross-
contamination between cases.
Data should be recorded on standardized forms and
may later be transcribed into a computer software pro-
gram, which can assist in the reconciliation phase. Direct
data entry into computer software can save considerable
time and personnel but it is important that the examiners
are familiar with the type of software and the codes
particular to that program to minimize the risk of
introducing error. To assist in this, if a particular pro-
gram is to be used, there must be predetermined termi-
nology and glossary available.
Either one of the dental examiners, or a dedicated
photographer, should be responsible for image man-
agement. Where possible, images should be in digital
format. Utilization of digital radiographs reduces the
chance of poorly exposed images and incorrectly labeled
or orientated images, eliminates chemical issues in pro-
cessing and fixing of films, and reduces the time for
examining the remains and evaluating the images.
Portable handheld dental X-ray machines can be most
useful (James and Taylor, 2011). Larger dental X-ray
machines may be used but can be cumbersome when
limited space is available. With either device, correct
radiation hygiene and infection control standards will
need to be documented and adhered to by the operators
of the device. Specific licensing to use irradiating
equipment is likely to be required, depending on the
disaster and its jurisdiction.
The forensic dentists examining the deceased should
be aware and sensitive to any national, cultural, or
 Disaster Victim Management: Role of Forensic Odontology
(a)
(b)
(c)
Figure 16 (a) Debris from head region following incineration, (b)
sieving for teeth and restorations, and (c) recovered data.
ethical issues, which may impact on their handling of the
remains. Dissection of the remains should only occur if
necessary for access and under predetermined protocols.
The removal of dental structures from the body should
297
be for documentation and imaging only, and must be
immediately return to the body.
Examination may also involve an age estimation of
the deceased using standardized charts (Blenkin and
Taylor, 2012; AlQahtani et al., 2010; Schour and
Massler, 1941). A pictorial comparison will give a quick
estimate, while more complex calculations can be
undertaken, if required, during reconciliation. QC
examiners should review the documentation to ensure
there are no omissions or clerical errors. It may some-
times be necessary to revisit a postmortem dental
examination for the purpose of matching putative
antemortem radiographs or photographic angulations,
or perhaps to harvest a DNA sample by tooth ex-
traction. All other data should have been recorded in the
original examination and failure to do so can be seen as
a failure of that examination team.
Each team member has a responsibility to maintain
occupational health and safety standards and a safe
work environment for all concerned. Maintenance of
equipment may be required during a longer opera-
tion and this should be scheduled appropriately through
the mortuary manager and the postmortem dental
team leader. Equipment failure, breakdown, or unsafe
work practices require immediate notification and
rectification.
Antemortem Phase
Odontology’s role in the antemortem phase involves the
identification and collection of the maximum amount of
dental and surrounding tissue data for each individual
on the disaster’s missing persons register and the com-
pilation of that material to enable a comparison with
any postmortem data. Dental information can be in
many different formats and available from many dif-
ferent locations, including written records and
charts (Figure 17), radiographs (Figure 18), photo-
graphic images, correspondence, appliances (Figure 19),
casts (Figure 20), dental remains, or financial data.
While primarily sourced from dental practitioners,
family, friends, work colleagues, employers, and health
funds may also hold key data. Table 2 indicates the
sources and types of dental data that may be located,
and Table 3 documents correct handling procedures.
In many countries privacy laws and other legal limi-
tations apply if an odontologist wishes to carry out their
own collection of dental information. Odontologists are
generally not trained in interviewing and counseling,
however, it requires odontologists to identify what
questions need to be asked and what dental data needs
to be collected. Practicing dentists create and use their
dental records for treatment and general patient care.
They are not normally exposed to disaster victim dental
identification and without clear instructions may not be
aware that some data they hold may have critical sig-
nificance. Likewise, guessing by the odontologist as to
298 Disaster Victim Management: Role of Forensic Odontology

Figure 17 Antemortem dental records.

what was meant by a particular practitioner’s abbrevi- coordinator and team members have the authority to
ations or poor writing could lead to quality control communicate with other health practitioners on a pro-
problems. Therefore, it is essential that the odontology fessional basis. The odontology team needs to provide

(a)
(c)
Figure 18 Dental radiographs: (a) periapical, (b) bitewings, and (c) panoramic.
clear instructions on the material required and possible
sources available for collection of dental data.
When interpreting antemortem data a standardized
charting system is essential. This is most easily accom-
plished by a coding system, where each code has a
nonambiguous definition and describes a feature that
cannot be interpreted using a different code. All staff
involved in analyzing and compiling dental data need to
have a wide knowledge of dental treatment and be
pretrained in the use of the particular code system. They
also need to have an understanding of the manner in
which the complied data will be searched and analyzed.
Internationally within the dental profession well-recog-
nized code systems exist for tooth identification and
surface notation. With the development of computer
search engines individual codes for other dental char-
acteristics such as environmental changes and treatments
performed have been developed. A protocol for re-
taining original records for later analysis, which is au-
thenticated, free of corruption and data loss, and avoids
comingling with another missing person’s data through
poor chain-of-evidence procedures is also required.
Disaster Victim Management: Role of Forensic Odontology 299
(b)
Reconciliation Phase
The reconciliation phase involves the comparison of
antemortem and postmortem dental data to formu-
late an opinion of identity for presentation to the
Reconciliation Board. Reconciliation teams may in-
volve individuals searching the available data (data
miners) to identify key features or combinations of
features suggestive of a match, and individuals verify-
ing potential matches and preparing reports for the
Reconciliation Board.
Data searching for potential matches may be done
manually or utilizing computer software (Al-Amad
et al., 2007; Andersen Torpet, 2005). Police can also
help in determining possible matches by way of cir-
cumstantial evidence that may have been associated with
the remains. Computer systems developed for DVI col-
lation and searching should preferably have the cap-
ability for data storage and searches across many
specialist data areas apart from dental and include re-
porting and data mining capabilities. Standardized
dental treatment and environmental effects coding
300 Disaster Victim Management: Role of Forensic Odontology
(a)
(c)
Figure 19 Dental appliances used as a direct fit, anatomical comparison, or source of DNA: (a) full upper denture, (b) partial acrylic denture, (c)
nightguard, and (d) partial chrome denture.
systems that can be adapted for regional requirements is
a prerequisite to efficient and accurate searching, which
is why SOP for data entry are determined prior to
antemortem or postmortem data collection being initi-
ated. A dynamic probability-searching algorithm that
provides suggested matches on a score based on the rest
of the database data for that feature is desirable. Use of
computer systems requires a sound understanding of the
code definitions and the search features available.
Once possible matches have been located using code
matching, it is necessary for skilled odontologists to
compare features that cannot be codified but can pro-
vide the needed individualistic matching characteristics.
As for fingerprints and DNA, dental features can be
converted into digital data. For example, presence or
absence of a particular tooth, type of restorative material
used, and surfaces involved in a particular restoration.
Further to this, odontologists can also compare small
(b)
(d)
variations in a restoration’s outline, variations in tooth
anatomy, external and internal, and the individual spa-
tial relationships between teeth and other specific fea-
tures in the surrounding structures (Wood and Kogan,
2010). Many features can be highly individualistic in
their own right, especially given the handcrafting of
restorations and root canal treatments (Bush and Bush,
2011).
Potential matches are explored (Figure 21) and a
weighting is given to the likelihood of identity being
positively established. Any discrepancies noted between
antemortem and postmortem datasets are assessed. The
odontologist’s role is to objectively determine whether
or not discrepancies are accurate or a result of either
erroneous record keeping by the treating dental pro-
fessional or erroneous data entry by the antemortem or
postmortem team odontologists; and how these differ-
ences may be reconciled. Careful consideration of the
 Disaster Victim Management: Role of Forensic Odontology 301

original records and images, and consensus, is impera-
tive prior to a final conclusion being drawn.
Careful QC review of each case, taking into account
all other data from non-dental sources, is important to
Figure 20 Dental cast used for comparison of tooth anatomy and
arch morphology.
avoid false exclusions, increase the probability factor, or
assist other specialties in improving the level of certainty.
All methods of identification involve probability factors,
as it is impossible to state that no one else in the world
has the same DNA profile, fingerprints, or dental status.
The level of probability will vary depending on the
available evidence.
Insufficient useful antemortem and/or postmortem
dental data available at the comparison stage limits
the value of odontology (Petju et al., 2007), how-
ever, partial dental data comparison can also add
weight to other information such as limited finger-
print and DNA evidence or circumstantial evidence to
aid in identification. Examination of the teeth and jaws
can also provide an estimate of age, sex, and race
(Harris et al., 2001; Gustafson, 1966), which can help
build a profile for a body when insufficient definitive
information is available (Figure 22). The comparison of
tooth size, shape, and arrangement as well as facial
features to antemortem photographic images can
also add weight to an identification when dental data
alone is insufficient to positively identify an individual
(Figure 23).
Reconciliation SOP must include standardization of
methodology as well as report content. Identification
categories (confidence levels) should be nominated and
clearly defined (Higgins and James, 2006). Table 4

Table 2 Antemortem dental data

Written records Dental charts and treatment records, laboratory instructions, codified accounts, treatment plans, medical history forms,
and dental and medical specialist referrals and responses. Dental practitioners should be asked to include a clear
interpretation of notes and abbreviations on a separate sheet if possible
Dental appliances Sport mouthguards, night-splints, full and partial dentures, and orthodontic plates and appliances
Images Radiographs (panoramic, periapicals, bitewings, lateral jaw, head computerized tomography scan, and any other
involving the head). Photographs (current, showing face, teeth and edges clearly, good resolution, and undistorted)
Casts Orthodontic treatment models and casts used in constructing dental prosthetic appliances (detailing when was it
constructed and for what purpose)
Guide to further sources of General and specialist dentists, clinical denture technicians, hygienists, dental therapists, public hospital clinics,
dental data company clinics, family, friends, neighbors, business associates and employers, and government and private health
funds. These might not only be able to provide contacts (dentist, treatment type, and how recent) but also images,
documents, and dental appliances

Table 3 Handling of antemortem dental data

Avoid direct contact with appliances as they may be used as a DNA source. There are also occupational health and safety issues
Image information should include the date they were taken, by whom and how reliable the interviewer consider the photographic evidence to be (i.e.,
how well did the provider know the person and is it a good likeness at the time of disappearance)
Seal each case separately in a bag
Attach an identity label and a chain-of-evidence note (items collected, source, location, contact details, date, and collection recipient) to avoid loss,
confusion, or contamination with other data
Provide a receipt for bag contents and keep a copy with the bag
Protect the bag from damage as some items might easily chip (e.g., plaster casts) and some might degrade if left exposed to light and temperature
excesses
On handing the bag to the authorized file manager, record the transfer, and the contents' details in the case journal. Keep the source details note and the
bag with its contents sealed to retain segregation from other dental source data and to assist auditing
302 Disaster Victim Management: Role of Forensic Odontology
Figure 21 Postmortem (pink) and antemortem (yellow) charts for reconciliation pattern matching, using DVI System International template.
Permission to use this image has been granted by Plass Data Software A/S.
Figure 22 Periapical radiograph showing dental development used to
assess age.
shows identification categories from different agen-
cies. A template for presentation of evidence is also
recommended.
Debrief
The aim of the debrief phase is to assess both the suc-
cesses and deficiencies of the incident and needs to be
conducted at both management and personal levels
(Bassed and Leditschke, 2011). As each staff member
ends a tour of duty they should provide feedback to
the odontology coordinator. In many countries a psy-
chological review of personnel is mandatory (James,
2005). The debrief process should be a collation of
data collected during the incident and presented to the
DVI commander. Timelines of identification, case flow
management, security, reporting practices, staff per-
formances, and OHSW issues should be noted, and
recommendations formulated (Berketa et al., 2012).
Post-Event
Post-event management can be summarized as the four
Rs:
• Recommendations from the debrief phase need to be
reviewed and actioned;
• The response plan needs to be rewritten with em-
phasis on any changes to methodologies and SOP;
• Restock of equipment and consumables; and
• Recruitment and training of new personnel to assist
in the next event.
This post-event merges with the next pre-event, but
it is not a closed circle. The aim is to increase know-
ledge and refine techniques to be ahead of the previous
incident. There will never be a perfect disaster response
but minimizing the chaos by quality management is
the key.
 Disaster Victim Management: Role of Forensic Odontology 303

Figure 23 Postmortem and antemortem images used for comparison of facial features and tooth morphology.

Table 4 Standardized reporting criteria Bassed, R., Leditschke, J., 2011. Forensic medical lessons learned from the
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Relevant Websites
www.ABFO.org
American Board of Forensic Odontology.
www.Aribex.com/
Aribex, Inc.
www.dentalboard.gov.au/
Dental Board of Australia.
www.iofos.eu
International Organisation for Forensic Odonto-Stomatology.
www.interpol.int
INTERPOL.
http://www.my-ray.com
Myray.
www.plass.dk/dok/dvi/DVIBrochure.pdf
Plass Data Software.
http://www.atlas.dentistry.qmul.ac.uk/
Queen Mary, University of London. Atlas of Tooth Development and Eruption.
www.winid.com
WinID3 Dental Identification System.