Barriers to human remains identification using forensic odontology in resource-constrained settings

Abstract

An effective strategy for human remains identification with a high success rate and low cost is vital for low to low-middle-income countries. Prompt identification of human remains is essential for the swift recovery of families and communities affected by large-scale disasters. However, the systematic integration of forensic disciplines into standard practice remains to be implemented in many areas. Even countries like the Philippines – where over 20 typhoons occur annually, leaving numerous, even thousands of persons remain missing so many years after the disaster, institutions continue to struggle in adopting standard protocols for human remains identification (HRI). This paper examines the barriers to implementing such protocols and explores the feasibility of maximizing the use of forensic odontology in the identification process in resource-constrained settings. The discussion highlights the situation in the Philippines resulting from these barriers and provides actionable plans for overcoming these challenges. In doing this, we can maximize the use of available technologies such as forensic odontology when local resources are limited, trained professionals are scarce and a sustainable and efficient operational local framework to handle mass fatality incidents (MFI) is not in place.

1. Introduction

Human remains identification (HRI) plays a crucial role in rebuilding a community after a disaster. This process is especially critical in resource-limited areas, where rapid self-sufficiency is essential. A systematic approach focused on the recovery and identification of human remains, followed by the issuance of death certificates for surviving family members, is paramount [1].

The International Criminal Police Organization (INTERPOL) has developed a Disaster Victim Identification (DVI) guide that serves as a global standard for DVI operations. After a mass fatality incident (MFI) involving multiple states, INTERPOL plays a pivotal role in coordinating international efforts. This includes identifying human remains, combating crimes such as human trafficking and looting, providing intelligence and resources to local authorities, facilitating cross-border cooperation among law enforcement agencies for efficient resource and information sharing, and assisting in investigations to identify and prosecute perpetrators, if any [1].

INTERPOL procedures follow four broad phases namely 1: Scene coordination or processing of human remains at the disaster site; 2: Post-mortem (PM) coordination or detailed examination of human remains in mortuary or designated location; 3: Ante-mortem (AM) coordination or collection of data from families; and 4: Reconciliation and coordination of AM and PM data [1].

The routine practice in some places that use families' visual identification of recovered human remains is discouraged because emotional stress increases the likelihood of wrongful identification [2]. Instead, the INTERPOL, the International Organization of Migration (IOM), and the International Committee of the Red Cross (ICRC) recommended the combined use of primary identifiers [[3], [4], [5]].The combination of PM data generated from fingerprint analysis, dental examination, and DNA testing, is compared with AM to identify the human remains. In many instances, disasters affect the entire community months and up to decades after the incident, hence accurate and timely identification of victims’ remains is valuable in the recovery process.

The present study examines the barriers to implementing standardized DVI protocols and explores the feasibility of maximizing the use of forensic odontology in the identification process within resource-constrained settings. To better illustrate some of these challenges, examples from our own efforts in the Philippines, will be highlighted.

2. Barriers to the routine use of forensic odontology in HRI

An effective strategy for human remains identification with high success rates and low costs is essential for low-to low-middle-income countries. Among the three primary identification disciplines—fingerprint analysis, odontology, and DNA profiling—odontology stands out for its flexibility and cost-effectiveness, particularly in the immediate aftermath of a disaster.

Forensic odontology plays a pivotal role in identifying distinctive dental features, with teeth being among the most resilient tissues in human remains [6]. Statistical analyses indicate that odontology was the predominant identification method, or “gold standard,” from the 1970s to the mid-1990s, before DNA technology became more widely adopted [7]. However, in countries like the Philippines, which faces up to 20 natural disasters annually, relying on DNA testing as the primary method for human remains identification is not a cost-effective option.

Therefore, forensic odontology and fingerprint analysis should be employed as the main tools for HRI in disasters for countries whose resources are limited. Preliminary identifications should be done using these two forensic disciplines with DNA testing serving only as an auxiliary method, reserved for cases where recovered remains cannot be identified through other means. The common belief that identification by DNA profiling should be done for all recovered human remains should be discouraged. For example, more than ten years after Typhoon Haiyan hit the Philippines in 2013, DNA testing of over 6000 human remains has not been done. The extremely high cost of processing bone DNA samples recovered from the remains and reference samples from relatives of the missing persons could not be sourced from the government's budget.

To support this recommendation, we identified four MFIs wherein forensic dental examination was sufficient for identification without the need for more costly DNA testing methods. In the 2004 tsunami in Phuket, Thailand, 54.16 % of the remains were identified solely through dental examination [8]. Similarly, in the DANA air crash in Lagos in 2012, forensic odontology and DNA analysis accounted for 97.4 % of the identification [9]. Finally, in Malaysia, seven out of 34 bodies after the Malaysian aircraft Fokker 50 accident and 16 out of 48 remains resulting from the Highland Towers Condominium disaster were positively identified [10,11].

The identification of human remains using forensic odontology, fingerprint analysis and postmortem examination should be done immediately after a strategy of identification and recovery had been discussed by the agencies identified to lead the process. Notably, the blood samples collected from recovered remains immediately after recovery, placed on solid FTA™ cards, and assigned with the “body and sample code” serve as a valuable biological source if DNA testing is to be done in the future. Each air-dried card should be stored in the folder containing the PM file of the deceased.

Understandably, each DVI is determined by conditions specific to the MFI such as the number of missing persons, condition of human remains and the capacity of the local government to respond. Hence, to fully harness the potential of forensic odontology in disaster response and recovery efforts, it is essential to identify and address the barriers that limit its use, particularly in resource-constrained countries.

2.1. Scarcity of trained professionals

There is a significant shortage of qualified forensic odontologists in many regions. Training opportunities and academic programs need to be reviewed to assess the extent of forensic training that future dentists are receiving from their schools. In a survey conducted in Australia, one of the four responding dental schools reported that they did not have any faculty or staff member trained in forensic odontology [12] which presumably means that this field receives minimal attention in that institution.

The Philippines has a limited number of formally trained forensic odontologists. Most Filipino dental practitioners prefer to specialize in clinical dentistry disciplines such as orthodontics, implant dentistry, and aesthetic dentistry [13,14]. These fields offer abundant training opportunities, higher incomes, and greater prospects for professional development. For those interested in pursuing forensic odontology, practical experience is typically gained within law enforcement agencies. However, such opportunities are scarce and not easily accessible. As a result, many dentists choose to remain in private practice, contributing to a significant shortage of forensic odontologists in the country.

The country has tried to address the shortage of dentists trained in forensic identification by encouraging the inclusion of forensic dentistry in the Philippines' undergraduate dental curriculum [15]. Dentists who may have a different specialization but have undergone forensic training as an undergraduate could be tapped in emergencies, even if they are engaged in private practice. India provided a different approach towards increasing the number of forensic practitioners by proposing a model for a forensic odontology department [16].

In the Philippines, professional organizations such as the Philippine Dental Association and the Forensic Odontology Society of the Philippines, Inc. have included lectures on forensic sciences in their annual conventions, but more collaborations with international organizations that have established forensic odontology programs such as the American Dental Association and the Malaysian Forensic Odontology Society should be explored to help in training local dental practitioners in forensic odontology [17].

2.2. Inconsistent or missing dental records

The loss of dental records makes it challenging to match PM findings with AM records. After the natural disasters in Japan [18], Palu [19], and New Zealand [20], identification via dental examination was impossible because of the destruction of dental clinics and loss of dental records at ground zero [21].

In many areas located in low-income and low-middle-income countries, the problem is not solely caused by the destruction of dental records during a disaster. The unavailability of dental records may also have been caused by the inadequate record management of dental practitioners, the fact that many citizens did not go for regular dental examinations by choice or the inaccessibility of dental clinics for those living in remote areas. The unavailability of antemortem dental records prevents forensic odontologists from adequately identifying human remains. At times, dental profiling can narrow potential identities, such as those found in a mass grave in Croatia [22], the earthquake and tsunami in Palu, Indonesia [19], the Malaysian aircraft Fokker 50 accident [10], the Highland Towers Condominium Disaster [11], and the Nepal Air Crash [23]. Forensic odontologists identified dental treatments and performed dental age estimation, which were insufficient for complete identification but still supplemented the results of other examinations.

Poor quality and management of dental records is another major challenge. Good dental record management reflects the quality of patient care and services provided [24]. In 1978, Presidential Decree 1575 was issued to require all Filipino dentists to maintain accurate dental records and to regularly submit copies to the National Bureau of Investigation (NBI) for databasing purposes [25]. However, many dental practitioners do not maintain good dental records and dispose of them without submitting a copy to NBI [26]. In 2016, law enforcement, forensic, and dental practitioners discussed establishing a standardized dental data record system [27]. Unfortunately, during these meetings, significant concerns were raised regarding the necessity for dentists to obtain consent from their patients when submitting dental records to a centralized system, following Philippine Republic Act No. 10173 or the Data Privacy Act of 2012. Many dentists hesitated to pursue this initiative without the appropriate safeguards placed in the system [27,28].

An additional hurdle stems from the prevalent use of paper-based dental charting by most practitioners in the Philippines, which is more likely to result in inaccurate or incomplete dental records. Electronic health records offer advantages like enhanced information security, simplified access to patient history, standardized documentation, integration with diverse databases, and increased flexibility with imaging and laboratory equipment [29]. However, additional costs, risks of data loss, and training requirements for those who will operate the system have delayed the transition to electronic records [29,30]. Practitioner's lack of uniformity with tooth numbering systems (Fig. 1), dental abbreviations, and diagnostic protocols exacerbate this problem. To standardize procedures, the Philippine Dental Association provided a sample paper-based dental chart [31] which can be customized following the “Guidelines in the Practice Management for Dental Practitioners in the Philippines” [26].

Fig. 1.

Tooth numbering systems for A. Permanent and B. Primary dentition [35] used by dental practitioners in the Philippines. I. Universal Numbering System; II. FDI World Dental Federation notation/ISO 3950 notation; III. Palmer notation.

Unfortunately, there is no sanction if dentists fail to follow these guidelines, and the professional dental community appears not to correct its members actively. Licensed dentists, compared to dental students, also exhibit a lower level of awareness and proficiency in maintaining complete, accurate, and detailed dental records [32]. Hence to date, the Philippines does not have a database of AM dental record of its people at the local, provincial or regional levels.

The implication was evident in the 2018 landslide in Itogon, Benguet. The NBI's plan to use dental records for victim identification failed because of the unavailability of dental records [33]. The identification team had no recourse but to conduct DNA testing which was extremely expensive [34].

2.3. Limited integration into disaster response systems

Given their location within the so-called Typhoon Belt and the high frequency of typhoons passing through this region in the western Pacific Ocean, countries in this area should have well-established national disaster management plans. Among the countries most affected by natural disasters annually are Japan, Vietnam, and the Philippines (www.adrc.asia). Moreover, in addition to frequent typhoons, the Philippine archipelago composed of 7641 islands, is situated within the Pacific Ring of Fire, making it particularly vulnerable to earthquakes and volcanic eruptions. The 2020 World Risk Index Report ranked the Philippines ninth out of 181 countries for its risk and vulnerability to various natural hazards [36].

In the Philippines, workflows for human identification remain to be operationalized at all levels across the country before any disaster occurs. Most forensic practitioners and laboratories are in Metro Manila, Cebu, and Davao, located on the major island groups of Luzon, Visayas, and Mindanao, respectively. These laboratories are not adequately funded and lack modern forensic facilities and specialized tools needed for comprehensive dental examinations. As such, the mobilization of resources, finances and personnel to go to geographically isolated areas, should be an integral part of the disaster response masterplan.

Human remains decompose rapidly in the Philippines due to high temperatures which can reach 51 °C because of the El Niño effect and humidity levels ranging from 71 % to 85 % [37,38]. These environmental conditions are ideal for microbial replication, leading to significantly faster decomposition compared to colder climates [[39], [40], [41]]. For instance, two weeks after Typhoon Haiyan in 2013, while the country was still trying to address the large-scale displacement of communities and reunite families in Samar and Leyte provinces that were most affected, 100 % of the recovered remains had already decomposed [42]. Given the resistance of human teeth to rapid decomposition, the importance of forensic odontology to HRI becomes particularly striking in such scenarios, where other examinations may yield limited information.

2.4. Cultural and ethical considerations

In some cultures, invasive procedures or prolonged examination of human remains may conflict with traditional or religious practices. Ethical concerns regarding the storage and use of dental data also present challenges. These issues must be addressed through consultations with the community, balancing respect for cultural autonomy with the need for time to conduct the forensic examinations essential for proper identification.

For example, during the 2018, super typhoon Mangkhut-induced landslide in Itogon, Benguet, in Northern Philippines, 35 fatalities and 68 missing individuals were reported. Before the start of operations, some families resisted forensic examinations, citing cultural norms prevalent in their region [34]. Similarly, the 2017 Marawi Crisis in Mindanao underscored the importance of respecting Muslim beliefs, which require immediate burial near the site of death without embalming [43,44]. Conflicts arose during these events due to the perceived transgressions of customary body purification practices, compromise of physical integrity, and unwarranted burial delays [45]. These concerns were ultimately addressed through dialogue between experts and local authorities.

To prevent such conflicts in the future, formalizing the process through written guidelines and protocols is essential. These measures can mitigate misunderstandings and facilitate the identification process. The involvement of religious and cultural community leaders in planning local DVI strategies is essential [46]. Open dialogue allows for a thorough discussions, including the estimated time involved for forensic processes, while incorporating legal interpretations of cultural laws to ensure equitable and respectful treatment of all human remains [46,47]. This proactive approach, combined with the adoption of efficient identification methods such as forensic odontology, enables families to conduct final rites for their loved ones promptly and respectfully.

2.5. Legal and policy gaps

Many countries lack clear legal frameworks and policies to govern the use of forensic sciences in human remains identification. In addition, the absence of standard operating procedures can lead to inconsistent practices.

In the Philippines, disaster response is governed by Republic Act No.10121 known as the Philippine Disaster Risk Reduction and Management Act of 2010. This law established the framework for disaster preparedness, response, mitigation and recovery in the country. However, this law does not include specific provisions on human remains identification and management, as an integral part of the recovery process. Consequently, the law does not explicitly allocate a budget to support HRI efforts during disasters.

Nonetheless, dental examination results have already been used to identify human remains in forensic case investigations being conducted in the Philippines. For instance, in 2007, a dental examination was pivotal in the identification of Ruby Rose Barrameda's remains [48]. Barrameda had been missing for two years before her alleged remains were recovered. However, the dental examination results in her case revealed inconsistencies with the sworn confession of the accused, the antemortem dental records of the missing person, and the dental report provided by the Philippine National Police Crime Laboratory [[49], [50], [51], [52]].

The Barrameda case underscores a critical challenge in using forensic odontology for human identification in the Philippines. Dental examinations conducted by different practitioners without standardized protocols are prone to producing varying results, leading to confusion. The lack of specific guidelines fosters an ad hoc approach to interpreting dental evidence, which contribute to conflicting and inconsistent outcomes.

Unlike other international forensic odontology organizations, such as the American Board of Forensic Odontology [53], the International Organization for Forensic Odonto-Stomatology [54], and the Australian Society of Forensic Odontology Inc. [55], the Forensic Odontology Society of the Philippines, Inc. has yet to provide specific guidelines on applying forensic odontology for human identification in the country. Developing and validating standard operating procedures (SOP) for victim identification is essential to ensure quality control, assurance, and proper organizational operation during any investigation [56,57].

The absence of national forensic odontology guidelines can partly be attributed to the lack of voluntary consensus among local professional dental organizations, e.g., the Philippine Dental Association, the Philippine Association of Dental Colleges, and the Philippine Regulatory Commission. Currently, the legal and procedural aspects of forensic odontology in the Philippines are governed by general regulations for standard dental practice. However, this broad adoption of legal and procedural frameworks may overlook the unique requirements of forensic odontology and warrants a thorough review.

2.6. Public awareness and education

The limited awareness among dental practitioners and the public about the importance of maintaining dental records significantly reduces the availability of antemortem data. Additionally, public bias favoring DNA testing and fingerprint analysis for human identification-largely influenced by media portrayals – tends to overshadow the importance of forensic odontology.

While DNA testing is widely regarded as a reliable identification method, it is hampered by the high cost of reagents; time-consuming processes for collecting and processing bone samples, and the need for highly skilled technical personnel to perform the analysis. Due to minimal infrastructure and limited budgets for forensic resources, the Philippine government has not fully supported DNA testing for large-scale human identification efforts.

Similarly, fingerprint analysis, often considered the fastest method of identification [58], has its limitations. Its reliability is compromised in cases involving decomposed or submerged human remains [59]. The Automated Fingerprint Identification System (AFIS) also faces significant challenges in the Philippines. These include limited infrastructure, incomplete national fingerprint databases, and the absence of secure, accessible digital platforms for relevant agencies to use collaboratively [47,60].

3. Future directions

The responsibility to identify human remains, whether resulting from individual fatalities or mass casualties due to natural or human-made incidents, must be recognized by all governments [61]. DNA analysis may be recognized by some as the gold standard for forensic human identification [7]. However, in resource-constrained countries like the Philippines, it is essential to acknowledge the significant role that forensic odontology can play in implementing a prompt, cost-effective, and accurate human identification strategy. Comparative dental analysis is one of the quickest, most cost-effective, and least invasive means of human identification [62].

It is crucial to actively pursue the establishment of standardized protocols and guidelines governing forensic dental examinations. Creating comprehensive frameworks that are tailored to the legal and ethical context of the Philippines can greatly enhance the integration of odontology into national policies for human remains identification. The Forensic Odontology Society of the Philippines, the Philippine Dental Association, and relevant government agencies must create platforms for communication to discuss areas of collaboration.

The Philippine Dental Association should address deficiencies in maintaining accurate dental records through training at different professional stages. A comprehensive solution goes beyond mere awareness-it requires rigorous enforcement of the law. This policy should mandate dentists, dental hygienists, and dental technologists to strictly adhere to the timely submission of patient dental records to the NBI, which will act as the institutional custodian of those records. Establishing a national database for dental records is essential for gathering antemortem dental information. It is also imperative to maximize the use of imaging technologies such as cone-beam computed tomography (CBCT), three-dimensional (3D) scanning, and digital record management. Additionally, integrating dental examinations into primary healthcare delivery makes individuals more likely to undergo regular dental check-ups, thereby broadening the coverage of the national dental database once it is established.

To foster growth and competency in the field, incentivizing dentists to pursue forensic odontology training through scholarships and career advancement opportunities will attract more professionals. The Forensic Odontology Society of the Philippines must prioritize proactive collaboration with its international counterparts to strengthen connections and encourage knowledge sharing. By doing so, Filipino forensic odontologists can stay adept with global best practices and research standards. This will help build a robust professional community in the Philippines, and across the Asia-Pacific region capable of providing dental experts to assist in disaster response efforts both at the local and international levels. Cost-effective DVI strategies that include dental examination as a key component must be implemented to ensure timely and accurate human identification, thereby accelerating the recovery process for communities affected by disasters.

CRediT authorship contribution statement

Ernest Joie T. Guzman: Writing – review & editing, Writing – original draft, Conceptualization. Maria Corazon A. De Ungria: Writing – review & editing, Supervision, Conceptualization, Writing – original draft.

Declaration of AI-assisted technologies in the writing process

During the preparation of this work the author(s) used [ChatGPT] to [help improve the writing style]. After using this tool/service, the author(s) reviewed and edited the content as needed and take(s) full responsibility for the content of the publication.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. The authors alone are responsible for the content and writing of the paper.