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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 12  |  Issue : 1  |  Page : 16-20

A vigilance alert for forensic odontology: Preservation and maintenance of dental records in Central India


1 Department of Oral and Maxillofacial Pathology, Index Institute of Dental Sciences, Malwanchal University, Indore, Madhya Pradesh, India
2 Public Health Dentistry, Index Institute of Dental Sciences, Malwanchal University, Indore, Madhya Pradesh, India
3 Department of Pedodontics, ACPM Dental College, Dhule, Maharashtra, India

Date of Submission02-Jun-2019
Date of Decision28-Aug-2019
Date of Acceptance04-Nov-2019
Date of Web Publication27-Jan-2020

Correspondence Address:
Kundendu Arya Bishen
Department of Oral and Maxillofacial Pathology, Index Institute of Dental Sciences, Malwanchal University, Indore - 452 016, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJDS.IJDS_61_19

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  Abstract 


Introduction: One of the most encouraging facts about forensic odontology is that it is looked upon today as a reliable methodology which is highly accurate when maintained correctly. Dental tissues are the strongest in the human body. They remain unchanged even after the long period of exposure to extreme conditions. In the field of criminal investigation and medicolegal cases, dental practitioners play a pivotal role. The maintenance of dental records is legally important in most of the European and American countries. Unfortunately, the law is not very clear in India and the awareness is very poor. Materials and Methods: A cross-sectional study was conducted in which a questionnaire was designed for the participating dentists to self-assess their awareness regarding forensic odontology and forensic value of the dental records maintained in routine practice. The Chi-square test was used for evaluating the results statistically, and the level of significance was set at 0.05. Results: Our study revealed that the dental practitioners of Madhya Pradesh, India, are not adequately prepared for any kind of forensic and medicolegal need if it arises at all. Conclusion: Our study reveals that there is an alarming call for rectification and improvisation in forensic odontology awareness among the practitioners.

Keywords: Dental records, dental remains, forensic dental records, medicolegal cases


How to cite this article:
Tomar U, Airen B, Sarkar PA, Singh H, Bishen KA. A vigilance alert for forensic odontology: Preservation and maintenance of dental records in Central India. Indian J Dent Sci 2020;12:16-20

How to cite this URL:
Tomar U, Airen B, Sarkar PA, Singh H, Bishen KA. A vigilance alert for forensic odontology: Preservation and maintenance of dental records in Central India. Indian J Dent Sci [serial online] 2020 [cited 2020 Apr 1];12:16-20. Available from: http://www.ijds.in/text.asp?2020/12/1/16/276887




  Introduction Top


Forensic odontology is the application of the art and science of dentistry to resolve matters pertaining to the law. Recently, forensic odontology has evolved as a new ray of hope in assisting forensic medicine, but this vital and integral field of forensic medicine is still in a state of infancy in India.[1] The question always arises as to whether the dental practitioners should know about forensic odontology, the reason being that dental identification provides an accurate source of identification of the victim or the suspect in natural and human-made disasters.[2]

Updated, high-quality dental records are keystones in the dental identification process. Dental professionals are compelled by law and duty to produce and maintain adequate patient records. The successful identification of a victim depends on the availability of accurate and comparable antemortem and postmortem data.[3] However, from a forensic point of view, dentists often do not keep adequate files. Incomplete dental files may obstruct forensic work, delaying identification, and prolonging grief and mourning of relatives.[4]

Dental records may well prove valuable in forensic identification if recorded methodically. Record maintenance is legally mandatory in the American and European countries,[5] but the rules are not clear in India, and there is ignorance regarding the same among dentists in our country with most of the dentists maintaining a poor quality or no dental record at all.[6] In view of this background, this study was conducted to analyze and assess the awareness about forensic odontology among the dental practitioners in Madhya Pradesh, India, and to assess dental record maintenance by them in their clinical practice.


  Materials and Methods Top


Study design

A questionnaire-based cross-sectional survey was conducted among private dental practitioners in Central India to assess the awareness of forensic odontology among them and the mode of dental record maintenance in routine practice. To preclude any potential bias, the disclosure of the name of the responder was made optional.

Study frame

A precise list of private dental practitioners was obtained from Indian Dental Association (IDA) branch of the city, and 8–10 dentists were selected randomly from different parts of the city. A total of 112 dentists were contacted, of which 104 filled the questionnaire giving a response rate of 93%. The study was conducted over a period of 6 months from March 2017 to August 2017.

Materials

(1) Consent was obtained from all the dentists. (2) A 26-item structured questionnaire [Table 1] was designed for practicing dental practitioners who in their practice might be encountering cases of forensic interest. The questionnaire contained two parts: the first part was used to assess the awareness of forensic odontology among practitioners and the second part was used to assess the mode of dental record maintenance in their routine practice, prepared as per ADA guidelines,[5] Martín García et al.,[7] Astekar et al.,[6] and Dierickx et al.[4] To validate the questionnaire, a pilot study was undertaken on 10% of the study population (12 dentists).
Table 1: A 26-point structured questionnaire (in two parts)

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Methodology

It was decided to administer the questionnaire and collect the data from all the dentists who could be contacted in three attempts/visits/calls. The questionnaire was handed/e-mailed to them after explaining them the purpose of the study. Data were collected in a personalized manner on telephonic conversation and through E-mail by means of a questionnaire. The nature and purpose of the survey were explained, and consent was obtained.

Data analysis

The data from the pilot study were used to assess the reliability of questionnaire using test–retest. The results of survey questionnaire were transferred to the Excel sheet; a master table was prepared and the data were analyzed question wise, and their percentage value was calculated and graphs were prepared [Graph 1].




  Results Top


The questionnaire-based survey was conducted, and the responses opined by 104 dental practitioners were tabulated. The results were analyzed statistically on percentile basis for each observation. The knowledge or awareness part of the questionnaire revealed that 100% of the practitioners had the basic theoretical knowledge of forensic odontology. In reference to dental records, we found that 91% of the practitioners were aware of medicolegal importance of dental record file. However, on the practical ground, only 72% were maintaining dental records. Strikingly, very few (43%) were maintaining complete records for a duration of average 3–5 years. Only 24% of the practitioners were maintaining their records in computer programs.

There was a 100% maintenance of few records such as patient's details, medical history, and clinical findings. Very few were maintaining the treatment log, and only 58% were updating their patient's dental file periodically. Dental anomalies are an integral part of individual's identity; our study revealed that only 40% of the practitioners were recording dental anomalies in their record. Only 36% were aware of the importance of denture markings in prosthesis.

Child abuse cases have signs and symptoms present over the face-and-neck region. Hence, dental practitioner is the first health personnel who witness these cases. In our study, only 13% of the practitioners have suspected child abuse in their patients. While 63% agreed, these cases need to be reported to authorities, but they did not report. Ninety present devised that anthropological examination is helpful in individual identification.

Surprisingly, 85% of the practitioners were not having adequate knowledge of forensic odontology, and only 6% have undergone formal training courses of forensic odontology. Our study revealed that the dental practitioners of Madhya Pradesh, India, are only partially prepared forensic and medicolegal need if it arises.


  Discussion Top


The practice of forensic odontology has gained importance in a number of developed countries worldwide. However, in developing countries such as India, it is yet to gain full momentum. Greater knowledge and awareness of forensic odontology among the dental practitioners would be required in the growing field of medicine.[2] This study was conducted among the dental practitioners to assess their awareness about forensic odontology. The results showed that the knowledge of forensic odontology among the dental practitioners is not adequate and that there is a dearth of qualified forensic odontologists in Madhya Pradesh, India.

Dental remains are usually the last to get destroyed among the body parts after death. They may be useful for personal identification in cases of mass disasters and decomposed unidentified bodies. Dental records may help in the identification of suspects in criminal investigations and in medicolegal cases.[7]

In mass disasters such as earthquakes, fire, storms and floods, transportation, or industrial accidents where trauma is likely to make visual identification impossible, forensic odontology plays an important role. The teeth are the hardest and most resistant tissues in the body and can withstand total decomposition and even severe fire. In such situations, dental comparison is an excellent method for making positive identification.

The most accurate and reliable method of identifying remains is the comparison of antemortem and postmortem radiographs. Few observations such as tooth and root morphology, shapes of restoration or bases under the restoration, buried root tips, and sinus and jawbone patterns can be identified only by examination of radiographs. In some cases, a single tooth may be all that remains, and on comparison of radiographs, a positive identification can be made; therefore, it is essential that all routine radiographs exposed during the course of a dental practice should be adequately fixed and washed so that they remain viewable years later.

One of the most important aspects of a person's dental record is its potential value in the forensic dental identification of the remains. It is no wonder that the use of dental records is a widely known method for the identification of human remains. Obviously, the better the quality of the antemortem dental records, the easier and faster the identification of the remains will be.[8] The quality of the dental records available for comparison to the postmortem remains of an individual varies from the extremes of nonexistent to inadequate to archival quality. The forensic dentist must be able to select identifying features by decoding the deceased's antemortem dental records.

The dental record serves a purpose of future reference for the practitioners when needed and is not always maintained for a forensic purpose. It is also maintained as consumer court evidence and for dental insurances.[9] There has been an increasing awareness among the public regarding legal issues involving health care, which warrants any dental practitioner to have a thorough knowledge of dental record issues.[9] Whether the records maintained by practitioners are complete and useful for forensic odontology would be a valid question to consider.

Our study revealed that the majority of the dental practitioners were aware of the significance of maintaining dental records. Strikingly, only very few practitioners maintain complete records and very few 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.[10]

Although the present study does not reveal the exact requirement of the dental records in any forensic or legal cases, there are few studies which have shown the need of these records for the same. A study was conducted on two groups of dentists who were asked to self-assess the forensic dental value of the dental records maintained in their own practices. The three most frequently recorded identifying dental features, other than caries and restorations, were the presence of diastemas, displaced or rotated teeth, and dental anomalies. Surveyed dentists imbedded identifying information into the removable prosthetic devices fabricated for their patients an average of only 64% of the time. Only 56% of the two groups combined felt that their dental chartings and written records would be extremely useful in dental identifications. It is concluded that the quality of antemortem dental records available for comparison to postmortem remains varies from inadequate to extremely useful.[11]

Delattre and Stimson in their study assessed all forensic odontology cases referred to the department of forensic medicine in Goteborg between 1983 and 1992 with regard to the instructions for dental records from the National Board of Health and Welfare. The results of the analysis showed that information on dental characteristics, normal anatomical findings, and restorative treatment was complete in 43 (68%) of the cases, incomplete in 17 (27%), and missing in 3 (5%). Registration of previous therapy was missing in about 75 (94%) of the records. It was possible to identify patient radiographs in only 16 of the 40 records where radiographs were available. In spite of this, the inaccuracies in the records did not seem to hamper the identification procedures in this study which could be explained by the character of the cases and the availability of medical and circumstantial information.[12]

In a study conducted on practitioners in Chennai, India, revealed that 21% of the dental practitioners did not maintain dental records in their clinic/workplace, with only 12% of the practitioners maintaining complete records.[2] Ninety-three percent of the dental practitioners were not maintaining dental records for more than 7 years. The significance of antemortem records in identifying deceased suspects was not known to 17% of the dental practitioners. Forty percent of the dental practitioners were not aware of child abuse and the actions to be taken. Dental age estimation was not known to 41% of the dental practitioners. Thirty-eight percent of the practitioners were unaware of the accurate method of individual identification. About 18% of the dental practitioners did not know the significance of bite-mark patterns of the teeth. Ninety-three percent of the practitioners lacked formal training in collecting, evaluating, and presenting dental evidence. Thirty percent of the dental practitioners did not know that they can testify as an expert witness in the court of law. Forty percent of the dental practitioners were unaware of identifying the age and gender of an individual in mass disaster.[2]

Forensic dentists who are associated with identification of the deceased and crime investigations are usually required to provide testimony in the court of law in the capacity of an “expert witness.”[13] In our study, nearly half of the respondents were not aware that they could testify as an expert witness in court to present forensic evidence.

A forensic anthropologist may be called in when human remains are found during archeological excavation or when badly decomposed, burned, or skeletonized remains are found by law enforcement or members of the public.[14] Most of the dental practitioners in our study were not aware of the methods to identify the age and gender of the deceased individuals.

Child abuse is presenting a serious social problem with global dimensions, increasing at an alarming rate in all socioeconomic strata and all ethnic or racial communities.[15] Child abuse and neglect is any interaction or lack of interaction between a caregiver and a child resulting in nonaccidental harm to the child's physical and developmental state. Reasons commonly cited for a dentist's failure to report child abuse are lack of education about the signs and symptoms of abuse and neglect, ignorance of the reporting procedure, and concern about making a false accusation and disrupting the dentist's relationship with the family.[16] When asked about suspicion of child abuse in their patients, it revealed that <25% of the practitioners have suspected child abuse in their patients.

The results of our study suggest that the dentists in Madhya Pradesh, India, either do not have records or have the ones which are inadequate. There is a general lack of practice of forensic odontology in regard to its awareness and dental record maintenance. This disparity of knowledge can be resolved by introducing postgraduate/diploma courses/certificate course/short-term course in forensic odontology. Workshops and conferences should be conducted every year for dental practitioners, and fully equipped laboratories for forensic odontology should come into play. An undergraduate program must be improved by including preclinical lectures on forensic odontology and clinical training.

A proper guideline document on examination and record-keeping in dental practice should be prepared.[17] To achieve the positive changes in maintaining the standard of keeping records, proper education is to be given among undergraduates[18] and postgraduates and also raise awareness in practicing dentists.[19] A dentist's responsibilities are production, retention, and release of clear and accurate patient records.[20]

Due to the small sample size, our study cannot reflect the status of the entire country. Hence, further studies nationwide with larger sample size and standardized questionnaire with more elaborative aspects are required to determine the standard that exists.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Ireland RS, Harris RV, Pealing R. Clinical record keeping by general dental practitioners piloting the denplan 'excel' accreditation programme. Br Dent J 2001;191:260-3.  Back to cited text no. 17
    
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