Forensic dentistry and dental hygiene: how can the dental hygienist contribute?

ABSTRACT

Introduction: The objective of this literature review was to determine and summarize existing roles for dental hygienists in forensic odontology. Method: The method used was to search and review the limited number of studies published on involvement of dental hygiene in forensic dentistry. The first stage of review was searching PubMed, Ovid, nursing journals, dental hygiene journals, the Internet and university library resources as well as information from one dental hygienist author's direct involvement in forensic dentistry. The second stage of the search used all the papers from the initial search as well as bibliographies and references for additional articles and information. Result: The results of this literature review revealed that dental hygienists are involved in areas such as personal identification by means of the dental records, disaster victim identification, professional negligence and dental standards of care issues and recognition and analysis of the injuries associated with family violence. Conclusion: The literature review also revealed that dental hygiene involvement in forensic dentistry is limited for diploma graduates but there are ways to become more involved with additional education and training.

RESUME

Contexte: Cette revue de la litterature a pour objet de determiner et resumer Jes taches actuelles de I'hygieniste dentaire en odontologie medico-legale. Methode: La revue comporte la recherche et I'examen d'un certain nombre d'etudes publiees sur la participation des hygienistes dentaires en dentisterie medico-legale. Dans un premier temps, des recherches ont ete menees dans PubMed, Ovid, les journaux traitant de soins infirmiers, les journaux d'hygiene dentaire, les ressources bibliographiques universitaires et Internet, et I'information d'une auteure hygieniste dentaire sur sa propre participation en dentisterie medico-legale. Dans un deuxieme temps, on a mis en forme les donnees de la recherche initiale ainsi que les bibliographies et references menant a d'autres articles et renseignements. Resultats: Le tout a revele que les hygienistes dentaires ceuvraient dans des secteurs comme ('identification des personnes par les dossiers dentaires, I'identification des victimes de desastres, I'examen des cas de negligence professionnelle en regard des normes de soins dentaires ainsi que I'identification et I'analyse des blessures associees a la violence familiale. Conclusion: L'examen de la litterature a aussi revele que la participation de I'hygieniste dentaire en dentisterie medico-legale se limite aux detentrices d'un certificat d'etudes specialisees et qu'il y a moyen d'etendre leur participation par un enseignement et une formation additionnels.

Key words: forensic science, dental hygiene, forensic odontology, dental hygienist, domestic violence, mass casualty

INTRODUCTION

Forensic odontology is often considered to be the area of overlap between the dental and legal professions. Occasionally, the forensic odontologist deals with legal issues on behalf of the dental profession. But, most often, the odontologist answers questions posed by the justice system and provides answers to legal authorities and expert opinions in courts of law. Significantly, much of the odontologist's work is on behalf of grieving family members that have lost a loved one and need to have closure to come to terms with their grief. This important role is considered by many to be the area of forensic odontology's highest reward; an area of particular interest to many caring and compassionate dental hygienists.

Modern forensic odontology encompasses five main areas: 1) personal identification by means of dental records, 2) disaster victim identification in mass casualty incidents, 3) human bite mark analysis, 4) recognition and analysis of the injuries associated with family violence, and 5) professional negligence and dental standards of care issues. (1) Following is a summary of these main areas and where the dental hygienist can be involved.

1. Personal identification by means of dental records

All persons possess an identity during their lifetime and the dignity of confirming and maintaining this identity after death is a strong, compelling societal need. Forensic odontology assists society to accomplish this through comparison of antemortem (before death) and postmortem (after death) data to identify the corpse. There are also legal requirements for confirmation of a deceased person's identity, including religious issues, matters surrounding the estate, remarriage of a surviving partner, and insurance or financial affairs. Of particular legal importance is a case in which a person is the victim of violent crime. Identification of the victim's body becomes circumstantial evidence during the police investigation into cause of death, and is later used in the prosecution of the person responsible for the death. (2), (3)

Methods to identify the deceased must be reliable and accurate. The comparison of antemortem to postmortem dental records is a widely accepted and dependable method of forensic identification. Unique traits and characteristics recorded in a person's dentition through anatomical variation or restorative treatment provide data that are used by the forensic odontologist to confirm identity (see Figure 1).

[FIGURE 1 OMITTED]

This type of casework is the most common activity of the forensic odontologist. The dental hygienist can assist in this activity in two ways. First, ensure that both the dental hygienist and all dental treatment team's patients' records are detailed and accurate. Second, assist a practising forensic odontologist to examine and recover data from the dead body.

Dental identification is one approach to human identification. Other approaches include visual identification, which is known to be unreliable due to a high rate of false-positives; comparison of medical records and data, such as serial numbers on prosthetic joints and breast implants; fingerprints if antemortem data are available; and DNA analysis. (2), (4), (5) The contours and extensions of dental fillings, crowns, to name a few, produce unique identifying traits when they are depicted as two-dimensional shadows on radiographs. These are used in forensic comparisons. The decrease in caries rate and the subsequent decline in the use of amalgam restorations over the past few decades has resulted in loss of these important identifiers in some cases.(4), (6-8) These situations create a challenge for the forensic odontologist. (7), (9) Still, radiographs show many other anatomical features, such as root shape, surrounding bone trabeculae, root canal filling materials, retentive pins and posts, pulp size and shape, and periodontal and periapical inflammatory disease that can be of significant value in identification cases. (3), (4), (8-10)

Teeth are the hardest substance in the body and this fact, combined with their location relatively protected behind the soft tissues of the cheeks, lips and jawbones are the reasons why they are so useful in identification. Even in the fire that burns so hot because of aviation fuel after a plane crash, a victim's teeth can remain intact when other body parts are destroyed due to this protection by bone and swelling of the tongue during the intense heat. Dental work such as crowns, fixed bridges and removable dentures can also survive intense physical and chemical forces and aid in identification. To aid in identification the patient's name should always be inserted into the acrylic of dentures and appliances at the time of fabrication. (2-4), (6), (9), (11-13)

The postmortem dental examination is akin to a new patient clinical examination in a dentist's office, including visual examination with mirror and explorer, and recording the data on an odontogram. A full-mouth series of intraoral radiographs (panoramic radiographs are not possible since the body is prone) and a full-mouth series of intraoral colour photographs in addition to orientation photographs of the body, head and face are produced. The angulation and exposure times for postmortem radiographs must duplicate these factors for the living patient to produce comparable antemortem and postmortem views(4) For example, postmortem bitewings are exposed at an angle of 10[degrees] (see Figure 1). Periodontal probing is not required since data based on soft tissues are not reliable in these cases. Dental impressions are usually not required, except for victims of sexual violence and homicide in which the victim might have bitten their assailant during the attack. Such impressions can be used to compare the victim's teeth to any suspects when they are arrested if the bite mark is still visible. (14)

2. Disaster victim identification in mass casualty incidents

Forensic dental response teams provide invaluable assistance in cases of mass disasters in which large numbers of deceased victims must be identified. Similar to personal identification above, but on a larger scale that includes additional complications, disaster victim identification (DVI) involves transcription of antemortem dental records, postmortem examination and recording, and reconciliation of these records to identify each victim to give back their name. This particular area of forensic odontology is the one that is the most valuable for the dental hygienist to be involved.

Natural or man-made disasters leave behind many casualties that include not only the deceased victims but also the next of kin that are left to grieve the loss of a loved one. The actual circumstances of the catastrophe often make victim identifications more difficult.(15) Preparation and training in anticipation of a disaster response is vital as this ensures success in identifying as many victims as possible. (3), (7), (11) In Canada, Public Safety and Emergency Preparedness Canada (PSEPC) is the national operations centre in Ottawa that coordinates the government's response to emergencies at home. The Department of Foreign Affairs and International Trade (DFAIT) deals with disasters that occur outside Canadian borders. Each agency has a working relationship with the emergency management organizations of each province that work with the first and second responders (for example, Canadian Armed Forces personnel) to ensure they have what is needed. (16), (17) Immediately after or sometimes concurrent with an emergency response that assists injured and displaced people, authorities turn their attention to recovery and identification of deceased victims. Identification of the deceased is not a federal jurisdiction; the Chief Coroner or Chief Medical Examiner handles it in each province.

The forensic dental response team should formulate itself in a way that allows for adequate training and accumulation of the needed resources and equipment. Dental hygienists can select areas of the response team that interest them and dedicate themselves to training in that specific area. For example, if a dental hygienist is not interested in working with the recovered bodies at autopsy, then the person can volunteer in the section that deals with antemortem records. In fact, dealing appropriately with antemortem records is the single most challenging area in any DVI response since it involves accurately and precisely preparing the records for potential comparisons.

i. Antemortem Records Team

Standardization of the DVI forms and terminology is required to ensure accuracy in the comparisons. Antemortem records vary widely in their completeness and the amount of included detail so the team faces a daunting task to summarize all of the incoming data. (11), (18) It is the fastidious attention to detail that is common in dental hygienists' character that sets them apart from other responders. Focusing on the need for precise transcription of data into the computer database, dental hygienists excel at producing the best opportunities to match missing persons' records with those recovered on site from the found bodies.

Several sophisticated computer applications are now available for use in collating and comparing large amounts of dental data. These applications are effective at sorting large numbers of antemortem records to reduce the number of potential matching postmortem records to only a few. This allows the forensic odontologist to complete the manual comparison of the actual charts and radiographs to determine if a match exists. (5), (6), (12), (17), (19)

Examples of current DVI computer applications include the following:

a) The US-based WinID3 (Windows Identification) program, which allows both the Universal/National System used in the USA and Federation Dentaire Internationale (FDI) tooth numbering.

b) DAVID-Web (Disaster And Victim IDentification) from Australia that accepts data entered from either PC or Macintosh computers from distant locations over the Internet.

c) The INTERPOL-sponsored program called DVI System International from PlassData in Denmark. The latter was being beta-tested during INTERPOL's tsunami response in Thailand. It has now developed into one of the world's best DVI databases since it can also handle data from DNA, most medical records and physical descriptors, such as scars, birthmarks and tattoos.

As part of the dental response team, the dental hygienist can assist police, coroners, and medical examiners to find suitable antemortem records and other dental evidence, such as dental casts, fixed and removable dentures, orthodontic appliances, or photographs showing the victim's teeth. (11), (18)

ii. Postmortem Records Team

Dental hygienists can assist the forensic odontologist at autopsy in all aspects of the postmortem dental examination, including charting of dental traits and treatments, exposing and collating radiographs, and photographing oral tissues during documentation. A double-check approach is used during examination to ensure accuracy. Typically, three team members are involved: two dentists and a dental hygienist. One dentist examines the teeth and calls out the findings so that the dental hygienist can record the data in the postmortem chart. The second dentist observes each of the others work checking to be sure the examination and charting are completed correctly. The members then repeat the examination after reorganizing their roles. (11), (18), (20) In some cases, it is necessary to surgically resect the victim's jaws to aid in production of proper records and radiographs. The dental hygienist can assist with this procedure during surgery and examination, and subsequently by ensuring proper labelling and storage of the disarticulated jaws. (18) Along with other members of the response team, the dental hygienist also assumes the responsibility for monitoring other team members for emotional and psychological fatigue during morgue operations. (18)

iii. Reconciliation Team

The data acquired by the antemortem and postmortem records teams must be entered into the computer databases and then searched for best possible matches. The dental hygienist can assist with these procedures by ensuring that the data are correctly entered, collating the potential matches, and then collecting the actual records from secure storage to arrange for forensic comparison by the identification odontologist and coroner.

Finally, the dental hygienist can ensure that the team is prepared for the next forensic response by helping restock and maintain the equipment and response kit, and acquiring the necessary equipment, supplies, instruments and materials. (18) Follow-up evaluation for future preparedness is important, so assisting the team leaders with this difficult task is an essential role for the hygienist. This process is not unlike the dental hygiene model of care that includes: assessment, planning, implementation and evaluation. As it is in dental hygiene care, this model is also necessary for successful mass disaster management.

Dental hygienists form a very important part of DVI teams. It is possible for them to participate fully in any of the three dental team sections mentioned. They can also assume an administrative role in helping manage the support personnel and volunteers such as with timetabling work and maintaining records of daily accomplishments. (11), (18) Other examples of participation by dental hygienists in previous DVI responses include updating and maintaining a master list of identifications, (11) working with antemortem records employing charting and record-keeping skills along with their knowledge of anatomy, and tooth nomenclature (e.g. FDI in Canada, Universal/National System in the USA) to transcribe and translate records into the DVI computer database, and their knowledge of radiography and radiology to interpret submitted records. (18)

Advanced training in Canada is not readily available, unfortunately. But such training can be accomplished by requesting and attending forensic DVI continuing education courses offered at dental schools. (18) In British Columbia, annual DVI training is offered by the British Columbia Forensic Odontology Response Team. (21)

3. Human bite mark analysis

Bite mark evidence recovery and analysis is the most complex and demanding role that the forensic dentist plays in the criminal justice system. Complex issues when bite marks are found on human skin, such as in cases of sexual homicide, sex assault and rape and in domestic violence cases of abuse, require a high level of training and expertise. Unfortunately, there are no areas of this aspect of the discipline that the dental hygienist can be involved in, primarily because of the urgency of the cases that require an almost immediate deployment of the odontologist. Also, there is a legal requirement that warrants, court orders, and legal consent for the seizure of evidence from suspects only include specific personnel possessing specialized training and skills. (14), (22)

Typically, police personnel, usually forensic identification officers, collect bite mark evidence from the bitten victims of crime. This includes recording the injuries using high resolution forensic photographs, making casts of the bite site and swabbing the skin's surface for salivary DNA. Interestingly, bite marks, sucking and/or kissing can leave saliva behind as the suspect's mouth comes in contact with the victim's skin. This saliva can be a source of DNA evidence, which can be analyzed in conjunction with the physical comparison of the shapes and sizes of the teeth to the marks found on the victim's skin.

The photographs of the bite mark that are recovered by the police are submitted to specialty-trained forensic odontologists for examination and interpretation (see Figure 2). The forensic significance (quality) of the injuries depicted in the evidence is determined if there are sufficient details visible from the teeth marks to allow comparison to any suspect's teeth (see Figure 3). In sex crimes, bite marks on women are characteristically seen on the nipples, breasts, thighs, neck and legs. (23) For male victims, bite marks are seen more on the arms, shoulders, back and hands. Bite marks to the hands, arms and shoulders on male suspects may be caused by the teeth of a victim who has bitten in self-defence. (2), (24) If the marks from teeth record a large amount of detail and the evidence is well documented, there is a strong likelihood that the odontologist's conclusions will play a role in the identification of the perpetrators of these crimes.

[FIGURE 2 OMITTED]

[FIGURE 3 OMITTED]

When police arrest a suspect, a warrant to seize dental evidence from them can be obtained to conduct a dental examination, take impressions of the teeth, and obtain an interocclusal record and photographs of the teeth. Subsequently, a time intensive process of forensic physical comparison of the suspect's teeth to the bite mark is completed.

4. Recognition and analysis of the injuries associated with family violence

Domestic violence happens in every walk of life. It is not restricted by a certain social class, ethnicity, education level or religious affiliation.(25), (26) Violence towards children, spouses (especially women) and the elderly is a serious health issue and is escalating in our society with a far reaching impact on our social and welfare systems. (25-30)

Forensic odontology is important to domestic violence issues for two reasons. First, patterned injuries, such as bite marks, are associated with physical and sexual abuse. Teeth are used as weapons of violence and bite marks can be indicative of sexual assault or physical abuse. (23,24) Second, forensic odontologists assist dental professionals in practice to appreciate the importance of recognizing and reporting to authorities the signs and symptoms of abuse that are discovered in their patients. As practising clinicians, dental hygienists can play a pivotal role in the latter since dentists and dental hygienists can be the first to see and recognize the signs of abuse. As much as 50 per cent of the signs of physical abuse injuries occur on the head, neck and face. (23), (24) Family violence issues are usually categorized as follows:

i. Child Abuse

Every person in the dental office should be aware of signs of possible maltreatment of their patients, such as children being inappropriately dressed for the weather, signs of malnourishment, bruises in various stages of healing, burns, slap marks, lacerated lips, broken teeth, scars, oral signs of sexually transmitted diseases and how the child reacts to others. It is also important to be familiar with and be able to recognize a bite mark pattern (Figure 3). Bite marks in child abuse cases can be found anywhere on the child's body, often on the cheeks.(2), (24) Female children are often bitten on any location on the body and male children are more often bitten on the genitalia. (24)

If physical or sexual abuse of a child is suspected, the child and the caregiver should be questioned separately with open ended questions. An office staff member should be present as a witness to see if the injury accounts are the same and reasonable for the type of injury present. (26)

Documentation of injuries and evidence collection are the same for both a child and an adult. These include photographs of bites, bruises and lacerations. Photographs should be taken with an intra-oral camera to record orientation and close-up details. The photographs should be taken with and without a reference scale, such as a ruler that is present in the image so it is possible to take subsequent measurements. (14), (22), (23)

With respect to child abuse and neglect, dental professionals, including dental hygienists, are mandated by law to report their suspicions. The police, local social welfare agencies for children, calling a children's help line (Zenith 1234 or 1-800-668-6868) or logging on to www.kidshelp phone.ca are appropriate ways to report any suspicions. There is no uniform law for the dental professional to report spousal or elderly abuse but reporting these incidents to similar agencies may help stop the cycle of abuse. (23), (25), (26), (31)

ii. Spousal Abuse

The interview and examination of a potential victim of spousal abuse should be held in private if possible. For a woman patient, a female staff member should be present. All statements regarding the abuse should be recorded in the patient's own words. Complete an accurate written description of all injury patterns and, if possible, written informed consent for taking notes and photographs should be documented in the chart.

Unfortunately, in spousal abuse cases it can take up to three years on average for the woman to leave the dangerous situation after she has confided that she is being abused. Statistically, this is likely the time when the violence will escalate to murder or the woman will commit suicide. (29) Still, in spite of such an alarming statistic, some dental professionals are hesitant to report these injuries. This can be for a variety of reasons, such as fear of consequences for both the patient and the dental professional, economic reprisal, a lack of confidence in one's education and awareness to recognize abuse, the assumption that it is not their problem, or fear of making the situation worse.

Reporting abuse in good faith and without malice gives the dental professional legal immunity from criminal liability, but if there is still doubt, a second opinion from the patient's physician should be obtained. (26), (29) It is interesting that members of the dental professional can be held legally responsible by the victim if it can be determined that there was just cause to report the abuse and it was not acted upon. (28)

iii. Elder Abuse 

For the elderly, knowledge of the aging process and associated health problems are important because not all bruising or skin lesions are from abuse; some can be from medications, systemic or skin conditions or of a fungal, bacterial or viral nature. (25)

Education is important for dental professionals to help recognize the signs of abuse and give them the confidence to make reports of their suspicions. (29) The dental health professional is five times more likely to report domestic abuse situations if they have had training in this area from undergraduate or postgraduate programs. Unfortunately, even with training, under reporting is still an issue. (28), (30)

5. Professional negligence and dental standards of care

Importance of accurate records to forensic odontology

With respect to ensuring that the best possible identification conclusions can result from any comparisons of dental records that are undertaken, it is important to have access to the most accurately and precisely recorded dental data available. Dental offices that maintain a high standard of patient record keeping, and collect detailed dental data are the best sources of antemortem dental data.

The degree of individuality and uniqueness of the human dentition is vast and because of this teeth are important sources of information for forensic identification purposes. (3), (5), (6), (32) The combinations of changes that can occur to teeth over an individual's lifetime, including childhood accidents, habits, wear, provide excellent opportunities for forensic odontologists. Even differences in the sequence of eruption and variations in dental patterns can provide large amounts of comparison data. But these data are only useful if they are accurately recorded in the patient's file. It is not possible to recover forensic information about unrestored or restored crowns, missing or extracted or replaced teeth, or any other useful data unless there is a record of these traits. Plus, importantly, these records must be made available and released to authorities at the time of need.

An accurate, legible account of work completed for every patient at every visit is the best form of comparison data. In some circumstances, there are no antemortem radio graphs available but detailed chart notes, tooth diagrams, study casts, photographs, etc. are still invaluable. (6), (12), (17), (32) Significantly, there is a need in forensic cases to always use original records to be sure that the right-left markers on radiographs (dots, dimples) and colour notations in the diagnostic or treatment record are not lost through duplication. (5), (9), (10), (33-35) The importance of the dental hygienist (or dentist) that treated a missing person supplying original data in such a legal context cannot be overstated. Conclusions reached by the forensic odontologist about who the victim is depends on the quality of evidence that is made available. (2), (5), (10), (12), (33)

Unfortunately, even if the original records are supplied, a lack of accurate recordkeeping by dental personnel has been documented as a problem in many cases, especially the lack of notes about existing restorations and unique features of the teeth.(7), (10), (20) A rotated tooth, peg-shaped lateral or chipped central incisor, or the size of diastemata can be very crucial. It is important to print legibly in pen, keep notations and laboratory slips, put the patient's name on all documents and store them neatly in the file. If charting is incorrect, outdated or otherwise incomplete, it can complicate the identification process. (6) Expose, develop and mount radiographs correctly and, if possible, keep them up to date. It is very important to insist that dental laboratories insert patients' names or social insurance numbers in any removable prosthetic appliances fabricated for them.(3), (7), (10)

EDUCATIONAL AND EXPERIENTIAL PREPARATION

A diploma in dental hygiene prepares dental hygienists to be involved in some ways. However, with additional education and experience, dental hygienists who are interested can likely become more involved with a forensic team and offer greater contributions in areas such as evidence gathering and documentation, personal identification by means of the teeth and mass disaster responses. Being involved and having a willingness to contribute to forensic dentistry helps our communities, humankind and gives recognition to our profession.

Examples of sources of information, training and important resources for the dental hygienist follow:

i. Provincial DVI team training sessions

In many areas of Canada today, dental professionals are organizing themselves to prepare to respond to natural or human-made disasters. Opportunities exist for dental hygienists to become members of these important response teams. The dental hygienist can work with other aspects of the team if he or she does not want to work in the postmortem situation with victims' bodies. For example, the dental hygienist can sort through antemortem dental records, enter data into the computer databases, organize other volunteers and assist with the large amount of administrative duties. The organizational skills of dental hygienists are seen as a distinct advantage in these team situations. It is suggested that those interested in volunteering should contact the provincial dental association to obtain contact information for dental disaster response teams in their location. For western Canada, information is available at www.bcfort.org.

ii. Continuing education courses

Many dental hygiene study clubs and regional societies sponsor continuing education courses that are presented by forensic odontologists. These courses provide a good introduction to the scope and depth of the discipline. Information is available from the speakers about how to get involved in those regions of the country. Provincial and national conventions also often feature invited presentations on forensic odontology and DVI responses.

iii. Forensic casework

There are only a handful of forensic odontologists in Canada that work regularly on routine casework, which is an indication of the small number of actual cases that occur on an ongoing basis. But opportunities might exist for motivated dental hygienists to contact these odontologists to inquire about the possibilities of training and working on cases. Provincial dental associations can usually provide the information about forensic practitioners in various regions of the country.

iv. American Society of Forensic Odontology

This US-based organization has grown in recent years to include over 1100 members from 26 different countries, including dentists, dental hygienists, anthropologists, physicians and others interested in forensic dentistry. Annual continuing education meetings are held in various locations throughout the continental United States and a newsletter is published three times annually for a nominal membership cost. Importantly, The Manual of Forensic Odontology--4th edition, offers a comprehensive introduction to all aspects of forensic odontology (www.newasfo.com/book_store.htm).

v. Advanced dental hygiene education

The dental hygiene diploma prepares an individual to participate in forensic odontology in limited ways, but for more extensive participation it is necessary to take additional courses and gain experience. Additional courses include studies in forensic odontology, forensic anthropology, mass disaster preparation and law. Courses on ethics, dentistry and law, social and health psychology, computer databases, macro photography and human abuse could be helpful. (36)

A challenge facing most Canadian dental hygienists is how to obtain academic credit for their diploma-level dental hygiene education towards a bachelor's degree and not be faced with starting over at the beginning to earn credits for a degree. The University of British Columbia offers an opportunity through its degree completion options in the Dental Hygiene Degree Program. In addition to the program's required courses, there are opportunities for students to choose elective courses. In making these choices, dental hygienists can choose science based electives (such as molecular biology and biochemistry) that would help prepare them for roles in forensic odontology. The University of Alberta offers dental hygienists degree completion opportunities as well and Dalhousie University will commence offering degree completion in September 2008. Therefore, once a dental hygienist possesses a bachelor's degree, it becomes possible to study at the master's and doctoral levels where an educational and research focus in forensic odontology or forensic science can be selected. Another alternative includes selecting a master's degree in Interdisciplinary Studies that combines various forensic topics in areas such as law, dentistry, pathology and anthropology, for example, all under the guidance of qualified supervisors.

vi. Other ways to be involved: volunteering

A dental hygienist can volunteer with the Canadian Red Cross or domestic and child abuse agencies. To start volunteering, find local dentists involved in forensic dentistry visit applicable web sites (Table 1), or contact other dental hygienists working in the field.

[TABLE 1 OMITTED]

CONCLUSION

Forensic dentistry involves the assistance of family members and, in some cases, the justice system, to answer crucial questions that arise during times of loss. It is significant and noble work, and dental hygienists can become involved to a degree that suits each person's level of desire. In summary, dental hygienists can be involved in forensic dentistry in the following areas:

Personal identification, record keeping and dental standards of care

* Keeping and maintaining the highest possible standard for dental record accuracy for each patient in the practice.

* Helping to determine the most important patient records to be released from the practice.

* Assisting the forensic odontologist to examine and recover data from a dead body.

Disaster victim identification

* Volunteering with a provincial disaster response team as a member of the antemortem, postmortem or reconciliation teams.

Recognition and analysis of injuries associated with family violence

* Studying and informing oneself of the signs and symptoms of abuse and neglect.

* Recognizing, documenting and reporting any suspicions that develop when treating patients.

* Maintaining a vigilant search for the signs and symptoms of domestic violence in professional and personal aspects of our daily routines and reporting suspicions.

The results of this literature review reveal that there are many ways and areas for dental hygienists to become involved, even through one's own clinical practice. But there are limitations to the specific roles because of the legal context of forensic casework. Still, the motivated dental hygienist can use their dental hygiene diploma as a foundation and build on it with more courses, training and experience in order to become more valuable and more involved with a forensic team. Find your area of specialty, what interests you the most, and search out ways to pursue that topic. If forensic odontology is what you are passionate about, then see it as a combination of preparation meeting opportunity. Research the possibilities, seek out opportunities, and prepare yourself with appropriate courses at all educational levels.

As human beings, we all have a right to dignity, worth and a unique identity in life and death no matter how one has lived that life be it for good or bad or how and why death comes. Maintaining this identity after death is a strong, compelling societal need. All those who volunteer in forensic casework share the common goal of giving that dignity, worth, and unique identity back to deceased victims. In the end, they bring the victims home to their families.

ACKNOWLEDGEMENT

The authors gratefully acknowledge the help of members of the forensic pathology team at Vancouver General Hospital Morgue for allowing an incredible view into their world, and the editorial assistance of Mrs. Ingrid Ellis in preparing this manuscript.

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* Private Practice, Victoria, BC, Canada; [double dagger] BOLD Forensic Laboratory, Faculty of Dentistry; [section]] Dental Hygiene Degree Program, Faculty of Dentistry, University of British Columbia, Vancouver, BC, Canada.

Submitted 13 Dec. 2007; Last revised 10 May 2008; Accepted 14 May 2008

This is a peer-reviewed article.

Correspondence to: DA Ferguson, 468 Moody Crescent, Victoria, BC V9A 7E5; [e-mail]

Donna A. Ferguson *, DIPDH, BDSC(DH), RDH; David J. Sweet[double dagger], DMD, PHD, DABFO; Bonnie J. Craig[section], DIPDH, MED, RADH