Comparative dental analysis: should dentists release dental records?

Forensic odontology

Forensic odontology (FO) is a dental specialism that has been used for hundreds of years, and dates back to 66AD.¹ It involves a liaison between dental specialists and the judiciary system through the proper handling of dental evidence. This discipline is widely accepted among global law authorities and can be used as a form of supportive evidence within courts.^1,2 FO has also been used in a number of high-profile cases, underlining the importance and significance of the vocation. For instance, forensic odontological techniques were employed to aid the identifications of Adolf Hitler and his wife, and were used to identify individuals lost in the Grenfell Tower fire.^3–5 The founding father of FO, Oscar Amoëdo, established the profession as a consequence of tragic events that occurred in Paris in 1897. Unbeknown to him, this catastrophic accident paved the way for the future of forensic odontology.⁶

Dental identification as the main role

This field is composed of four main roles: age estimation, bite-mark analysis, disaster victim identification and dental identifications of the deceased.¹ Dental identifications (dental ID) are the mainstay of work that a forensic dentist will undertake, particularly within the UK.^7–9 This main role has great importance when an unidentified individual has been located. It is most commonly employed when post mortem changes have overwhelmed the body, rendering visual identification by loved ones too emotionally challenging.^7,8 Whether it be due to sustaining traumatic injuries or simply the natural decomposition process that follows death, forensic dentists will always attempt to help. Typically, bodies identified by odontological means are presented to the mortuary in varying conditions: decomposed, burned, mummified, subject to the effects of water, skeletonized, mutilated and even dismembered.⁷ In all the aforementioned situations, some form of dental identification can be attempted, subject to the oral cavity/jaws being present.

Primary identifiers

At the time of writing, the UK has no national fingerprint and DNA database for all its citizens and, therefore, dental ID can be crucial.⁸ Teeth are recognized as one of the three key primary identification methods,^10,11 all of which are equally important.¹² The other two methods involve DNA analysis and fingerprint analysis, and all three techniques are validated scientific modes of identification approved by INTERPOL.^10,11 The choice of technique depends on the condition of the body and is at the coroner's/fiscal's discretion. DNA analysis is much more expensive than dental ID and for this reason, the work of FOs is often requested before DNA determination.¹³ Additionally, although friction ridge analysis might be favoured, in many cases this physiological biometric analysis is not compatible with the body.²

Importance of identifications

Not only does this work assist the police, but it plays a vital role in helping families and friends of the deceased person.⁹ Therefore, the work of the expert must be meticulous to avoid unacceptable mistakes.⁹ Every human being has a basic right to dignity, and an identity before and after death: principles that must be applied to the remains of a person.

This indispensable endeavour is also required for legal, social and ethical reasons.^8,12 Murder investigations cannot proceed until a confirmatory identification has been made for the victim. Additionally, until the deceased person's identity has been proved, different jurisdictions and religions may deny a partner's remarriage, and certain civil proceedings, such as inheritance or life insurance cannot be awarded.^8,12 Families also deserve the right to practise their cultural death rituals, ultimately supporting the grieving process.⁹ When this process becomes drawn out and delayed, it can amplify the grief of the deceased person's loved ones.⁸

Comparative dental analysis process

Comparative dental analysis methodology relies on both qualitative and quantitative comparisons.¹² Analysis is undertaken to determine whether the postmortem findings match the provided antemortem data of an individual with enough certainty that a positive ID can be made.^2,10 The retrieved antemortem information will be the last known dental status of the individual, and enough details must match the postmortem findings in order to declare they are from the same individual.^2,8 Teeth can provide a plethora of unique information, particularly those that have been subjected to dental interventions. These restored teeth provide the expert with a repository of identifying features, which must all have been correctly recorded. The postmortem dental examination must be completed with the utmost skill, employing a systematic approach whereby all the structures are thoroughly examined one by one. The postmortem record must be a comprehensive composite chart of all the findings within the mouth. Every detail, regardless of its significance, should be captured, because the expert may not know what the antemortem data, if available, may contain.⁸ Owing to preventive treatment, individuals are now presenting with a significantly reduced number of restorations. For this reason, oral features are more important during the identification process. Some examples include:⁸

However, many more dental and non-dental features must be taken into account. This method relies on the theoretical understanding that no two individuals possess the same dental make up.¹² There are no guidelines stipulating the minimum number of consistencies that must occur to give a positive match, because each case is different.¹⁴ However, any discrepancies found must be accounted for and explained. If they are not, then the deceased's ID cannot be established with certainty.^7,8,12 The British Association of Forensic Odontology (BAFO) have however, provided guidance regarding the conclusions that can be reached during an ID as follows:¹⁵

Based on the above, it can be seen why accurate antemortem data is so important. Its absence and/or bad quality data can severely impact how successful the comparative dental analysis might be. Forensic dentists are reliant on the putative individual having the dentist correctly record and release their findings.^1,7–9 The ID lies solely at the expert's discretion; however, they must be able to defend their conclusion if questioned.

Dental records

Antemortem data is essential for the odontologist to successfully identify the individual. FOs are reliant on GDPs and hospital dentists maintaining and updating accurate composite records. This is not only in the best interests of the patient, but also important medicolegally for the dentist. Legislation is in place within the UK to reinforce the recommended requirements for note keeping, outlining exactly what they should incorporate.¹⁶ Of the nine GDC standards, Principle 4.1 refers to the compulsory nature of recording complete contemporaneous notes each time a patient undergoes treatment.¹⁷ Unfortunately, not all countries have this legislation in place, and even those that do, can lack the organization to audit these requirements. Dental indemnifiers, such as dental protection/dental defence unions, advocate keeping good records, which must be clear, concise and legible.^18,19 Despite these regulations and ideals, many dentists still fail to comply and produce adequate records, not only within the UK, but worldwide.^7,10

Releasing dental records

Most dental records will usually be located within the dental practice. The records encompass a variety of different dental documents. The most commonly recorded item is the patient's dental chart (odontogram), which can be most helpful during comparative dental analysis. Nevertheless, inaccuracies within the charts are common and can make the comparison stages difficult.^7,9 Therefore, radiographs, when available, are always used in conjunction, as they provide a wealth of identifiable information during both the post- and antemortem assessments with regards to restorative interventions and dental/anatomical morphology.^2,7,9

Additional types of records can also provide supplemental ID data, such as dental casts, clinical photographs, bleaching trays, bite-guards, sports gum shields, dentures and orthodontic appliances. Recent research is currently investigating the use of selfies as a form of antemortem data when all other modes are unavailable. These will be of greater importance for younger individuals being identified, who often have not had therapeutic dental interventions.²⁰ These adjuncts have proved useful during the comparison phases; however, they may not always be located within the dental practice.¹⁰ Therefore, care must be taken by the authorities to ensure an awareness exists surrounding the locations of other potential identifiable dental evidence.

Breaching confidentiality

Current guidance from the Dental Defence Union (DDU), Medical and Dental Defence Union of Scotland (MDDUS) and Dental Protection outline when it is acceptable to breach confidentiality. Disclosure must be based upon the prevailing circumstances. Certain situations that present, such as the requirement for dental records for identification purposes, allow dentists to breach their confidentiality obligations, because it will be in the patient's best interest.²¹ The police or legal authorities should present practices with a written declaration outlining why the records are required and for whom. On receipt, the dentist can release the required patient documents. Evidence or copies must be taken of exactly what records have been disclosed, who they were collected by and their rank/identification number. Delays in disclosure can lead to delays in identification, which ultimately will impact on the emotional and psychological state of the loved ones of the deceased. For this reason, a dental identification record checklist has been created by the authors. This checklist facilitates the process and enables dental professionals to gather as much information as possible within practices. It outlines exactly what records can and should ideally be collected: dental charts, radiographs, clinical photographs, dental casts, dentures, bleaching trays, orthodontic appliances, sports gum shields, bruxism devices and selfies. This checklist can be used by both the police and dentists should they ever find themselves involved with cases where comparative dental analysis is required (Figure 1). This free, downloadable PDF is available to access in 15 different languages from dentalidrecordchecklist.com.

Summary

Teeth are recognized and established primary identifiers with international acceptance. Forensic odontology is a valuable identification tool and commonly employed within the UK. Antemortem records must be as accurate as possible because the comparative dental analysis relies upon the presence of both post- and antemortem data, without the latter an identification cannot be established. For this reason, GDPs and hospital dentists must record and keep accurate dental records.

A number of different types of dental record can be used by an FO; therefore, to prevent delays during the identification process, a record checklist was created to help police officers, family liaison officers and dentists with regard to exactly what is required. This checklist is free to download and available in multiple languages for international use.

The answer to the question ‘Comparative dental analysis: should dentists release dental records?’ is ‘Yes’. Breaching the confidentiality agreement serves to favour the deceased, not only allowing the family of the deceased a piece to the emotional puzzle in which they are involved, but also more importantly, maintains the individual's right to be identified even after death.