Pink Teeth in a Series of Bodies Recovered From a Single Shipwreck

Forensic significance of postmortem pink teeth: A narrative review

OBJECTIVE

To review the phenomenon of postmortem pink teeth, exploring its etiology, correlation with the cause of death, and the potential forensic significance of this medico-legal finding.

METHODS

A comprehensive literature search was conducted using databases such as PubMed, Scopus, and B-on, employing keywords like "Forensic Pathology," "Forensic Dentistry," "Pink Teeth," and "Medico-legal aspects." The search included studies without temporal limits to gather extensive data on the postmortem pink teeth phenomenon.

RESULTS

The postmortem pink teeth phenomenon is characterized by a red-pink discoloration of the dentin, typically sparing the enamel. It is most often observed in moist environments and cases involving water immersion, strangulation, and carbon monoxide poisoning. The study found no consistent relationship between the pink discoloration and specific causes of death, suggesting the phenomenon is more closely related to environmental conditions and the state of decomposition. The pink coloration is more prevalent in anterior, single-rooted teeth and younger individuals.

CONCLUSION

The postmortem pink teeth phenomenon remains a complex and enigmatic finding in forensic science. While it does not conclusively indicate a specific cause of death, understanding its occurrence can aid forensic investigations. Further research is needed to elucidate this phenomenon's mechanisms and validate its forensic relevance.

Study on the Mechanism of the Pink Tooth Phenomenon Using Bovine Teeth: A Pilot Study

The pink teeth phenomenon has occasionally been observed in forensic autopsies. This study aimed to establish an experimental pink tooth model and an objective color tone evaluation method in order to clarify changes in the color tone of teeth and the relationship with hemoglobin monoxide and its decomposition products and with red pigment-producing bacteria, under various external environmental factors. It was confirmed that the color tone evaluation with ΔE and the L*C*h color space was useful. The results of various examinations using this model showed that color development was suppressed under aerobic conditions, faded early under light, became bright red under a low temperature and showed a tendency to be reddish at 3 days under high humidity and in the presence of soft tissue. The biochemical analysis revealed a significant increase in carboxyhemoglobin at 7 days and a tendency toward increasing the total heme pigment and bilirubin levels over time. The bacteriological analysis revealed that red pigment-producing bacteria increased over time but that the color faded after 7 days. These results suggest that putrefaction greatly affects the pink teeth phenomenon, whereas red pigment-producing bacteria have little effect on the occurrence of pink teeth. However, further studies are needed to clarify bacteriological involvement.

Effects on oral tissues of asphyxiation caused by cervical compression: The pink teeth phenomenon in Kato's studies (1941)

The effects on oral tissues of asphyxiation caused by cervical compression were investigated in 203 rabbits by Kiyotoshi Kato, who published four papers in classical Japanese in Kokubyo Gakkai Zasshi (now The Journal of the Stomatological Society, Japan) in 1941. The aim of this review is to summarize and disseminate the enormous amount of experimental data (reprint permission in English has been obtained from the journal). Based on the experimental models of hanging, strangulation with an external force equal to body weight, and strangulation with an external force equal to 1/10th body weight, the macroscopic and histological findings of the oral region immediately after death, including the respiratory condition until death and ocular conjunctival petechiae, were obtained and compared with 4 cases of human strangulation. Strangulation after each of four physical conditions (anesthesia, starvation, alcohol intake, and bleeding) was also investigated. Experiments were performed to investigate the effects of tracheal obstruction, cervical vein ligation, common carotid artery ligation, cervical nerve amputation, or combinations thereof. In the discussion focusing solely on tooth discoloration, it was suggested that the presence of pink teeth at a stage when putrefaction has little or no effect might be a finding indicative of death from asphyxiation caused by cervical compression. This review provides detailed data on the condition of oral tissues after asphyxiation caused by cervical compression and is expected to be used not only for elucidating the mechanism of the pink teeth phenomenon but also for conducting other forensic research.

Association of Cadaveric Factors with the Degree and Region of Discoloration on Pink Teeth: An Approach to Serial Cases

The pink teeth phenomenon has been observed in cases of hanging and drowning, but the relationship of this phenomenon with cause of death has not been positively affirmed. To date, teeth with a pinkish tone have been simply regarded as pink teeth. However, we speculated that classification and evaluation of the degree and region of discoloration with reference to how color is classified in prosthodontic dentistry may produce novel findings regarding the pink teeth phenomenon. Therefore, we classified the degree and region of discoloration on teeth into three grades and attempted to evaluate the relationship of grade with various cadaveric factors in 68 cases of pink teeth. The degree and region scores of discoloration did not show significant differences in terms of sex, age, cause of death, and place of discovery, but the degree of discoloration in terms of time after death showed a significant increase at 6 months (p < 0.01) and a significant decrease after 7 months (p < 0.05), while the region score also showed a significant decrease after 7 months. Furthermore, in 18 cases of drowning, the degree of discoloration significantly increased with time after death (p < 0.01). Thus, it was clarified that time after death was most strongly related to the pink teeth phenomenon, suggesting cadaveric decomposition may affect the occurrence of pink teeth. Further investigation in cases of early postmortem changes would be required to determine whether pink teeth in putrefactive cadavers have utility in medico–legal assessments.

Sixty-eight cases of postmortem pink teeth observed in dental autopsies of unidentified cadavers

The pink teeth phenomenon was first reported in people who died by hanging or drowning in 1829. In recent years, there have been many reports that the occurrence of postmortem pink teeth is closely related to the condition of surroundings and time after death rather than to the cause of death, as had previously been thought. We observed pink teeth in 68 of 324 unidentified cadavers autopsied during 2015-2021, and we investigated the relationship of pink teeth with age, sex, cadaveric condition, time after death, tooth type, and cause of death. The results showed no significant differences in the occurrence of pink teeth according to sex or place of discovery (indoors, outdoors, or in water). Pink teeth tended to be observed below the age of 60 years. In the 68 cases with pink teeth, 29.1% of all vital teeth were affected, with the anterior teeth being most common. No evidence was found that supported an association between pink teeth and cause of death. These results are largely consistent with recent reports on postmortem pink teeth. As it stands, the pink teeth phenomenon may be nonspecific and must not be misinterpreted in medico-legal investigations. This case series provides further evidence supporting recent reports and contributes to clarifying in greater detail the mechanisms of the coloration and fading of pink teeth.

Autopsy Findings on Decomposing Drowned Body: Identification of Specific Diagnostic Features of External, Internal, and Laboratory Examinations

BACKGROUND: Drowning is one type of asphyxia caused by the entry of fluid into the airway. Death due to drowning is one of the hardest things that are difficult to diagnose in the field of forensic medicine, primarily if the victim found to be in a decomposed state. The state of decomposed examination often does not show typical signs. The diagnosis of drowning can be reached after considering all the results of the forensic examination including external, internal, and laboratory examinations. CASE PRESENTATION: A body has been found in the residential area on the east side of the beach, Tambaksarioso Village, Asemrowo District, on Tuesday, May 18, 2021, at 13.30 West Indonesian Time and reported to the police for investigation. The body was then identified at Dr. Soetomo General Hospital by a forensic expert. External, internal, and laboratory investigations were conducted. On external examination, the corpse was not intact, with signs of decay, saponification, and violation. In an internal examination, sand in the airways and other signs of drowning were identified. In the acid destruction test using the right femur, a positive diatom result was obtained. CONCLUSION: A complete autopsy is vital to determine the cause and mechanism of death, reconstruct the events before death, and identify the victim. It is also essential to determine whether the deceased died by drowning was alive before entering the water. All injuries suffered by the victims should be described.

Postmortem Otorrhagia in Positional Asphyxia

Otorrhagia is generally associated with basilar skull fractures or diving accidents. In routine forensic medical practice, an accurate knowledge of the etiology of otorrhagia may have a key role to distinguish between traumatic and atraumatic causes and accidental, homicidal, or suicidal manners. The authors present the case of an unusual cause of atraumatic otorrhagia occurred in an elderly farmer found dead in a barn. He remained entrapped in a narrow tunnel created by some hay bales. The autopsy findings revealed only an intense polyvisceral congestion and subpleural petechiae, with no signs of traumatic injuries and no fractures of skull base or temporal pyramid. The cause of death was determined to be positional asphyxia, and the manner of death was deemed accidental. In fact, the head-down position resulted in diaphragm compression causing respiratory failure in combination with the stasis of the upper venous circle districts. Mechanical and gravitational forces related to upside-down position and increased vascular pressure also caused postmortem otorrhagia. In this case, the death scene investigation and circumstantial information allowed for reconstruction of the unique dynamics of the death. At the death scene, the position of the corpse must be accurately investigated because it can explain some cadaveric findings such as the ear bleeding or other markers of increased cephalic venous pressure like pink teeth, facial and conjunctival petechiae, or Tardieu spots. Therefore, forensic pathologists should consider that ear bleeding in dead bodies is not always the evidence of severe head blunt trauma or diving accidents, but it might be a postmortem phenomenon mostly related to body position.

Case-specific characteristics of pink teeth in dental autopsies - A systematic review

The cadaveric alterations that derive from the decomposition of the human body are often investigated and examined in medical autopsies together with any other evidence of thanatological interest. This study aimed to systematically review case-specific characteristics of dental autopsies that reported the pink tooth phenomenon (PTP). The review was performed in October/2018 and followed PRISMA and Cochrane guidelines. Seven databases were searched as primary study sources (PubMed, Scopus, LILACS, SciELO, Web of Science, Science Direct and Embase) and three (OATD, Open Grey and Open Thesis) were searched for "grey literature". Only descriptive studies were collected, namely case reports and case series. The risk of bias among the studies was assessed with The Joanna Briggs Institute Critical Appraisal tool. From each case, the sex and age of the victims were registered, together with the place of body recovery, time of death, cadaveric status, cause of death, and number and position of pink teeth. Additionally, a supplemental quantitative analysis was conducted within a sampled subgroup. Poisson regression with robust variance was used to analyze relative risks of presenting pink teeth according to age and tooth position. Eleven studies out of 1004 were eligible. In total 71 cases of cadavers with pink teeth were reported. Two (2.81%) victims had unknown sex, while 17 (23.95%) were females and 52 (73.24%) were males. The victims were aged between 4 and 85 years (mean age 31.13 ± 13.32). Dental autopsies registered 331 pink teeth (163 anterior, 87 premolars and 81 molars). The age did not influence on presenting an additional pink tooth, regardless of tooth position (p > 0.05). Forensic dentists must be aware of pink teeth in dental autopsies. This is an unspecific phenomenon and must not be misinterpreted in medico-legal investigations.

New insights into odontological exploration of drowning using rat model - A pilot study

Dental forensics for the resolution of unnatural death remains an underdeveloped field. Accordingly, an experimental study was conducted with six to seven months old Wistar rats that were drowned in order to identify key postmortem features and pattern of dental decomposition. The visual, structural and elemental changes were assessed periodically. Based on mode of death, they were designated as SB (euthanized and soil buried), FWD (fresh water drowned) and SWD (sea water drowned). Postmortem features as well as the structural and elemental patterns of decomposition of teeth were analyzed with Field Emission Scanning Electron Microscopy (FE-SEM) and Energy Dispersive Spectroscopy (EDAX) periodically for two months. The periodic observation of elemental changes in the teeth of SB, FWD and SWD rats allowed us to derive an equation using linear regression analysis to relate the degree of dental decomposition with the time since death. The difference in pattern of surface deterioration was also observed. The present findings could provide a better knowledge in resolving unnatural deaths and supporting evidence for legal prosecution.

Forensic thanatology and the pink tooth phenomenon: From the lack of relation with the cause of death to a potential evidence of cadaveric decomposition in dental autopsies - Case series

Forensic thanatology comprises the investigation of every phenomenon related to death performed through cadaveric exams. The pink tooth phenomenon (PTP) emerges as a thanatological finding registered during medical or dental autopsy. The PTP consists of a reddish or pink coloration caused in the teeth by the penetration of pulpal hemoglobin in the dentinal tubules. Initially, the PTP was associated with specific violent deaths, such as drowning, hanging and poisoning. However, scientific reports have pointed towards the occurrence of PTP as an expression of cadaveric decomposition regardless of the cause of death. The present study aims to report eight dental autopsies of victims of violent death that presented the PTP. The autopsies were conducted by forensic pathologists and dentists between 2013 and 2018. Seven victims were males and one was female. The age ranged above 6years old. Cranio-encephalic trauma, firearm shooting and asphyxia figured as the causes of death. All the victims were in advanced decomposition. The PTP was detected in deciduous and permanent, anterior and posterior and maxillary and mandibular teeth. Forensic experts, especially dentists, must be aware of the PTP for more detailed registration of postmortem findings and more accurate cadaveric exams.

Bodies in sequestered and non-sequestered aquatic environments: a comparative taphonomic study using decompositional scoring system

The study of decomposition by using accumulated degree days (ADDs) has been suggested not only in terrestrial decay but also for water-related deaths. Previous studies have demonstrated that the accumulation of thermal energy as a function of the post-mortem submersion interval (PMSI) can be derived from a descriptive decompositional scoring system (DSS). In order to verify how useful can the total aquatic decomposition score (TADS) for ADD prediction be, a comparative taphonomic study has been performed between two series of bodies: 16 corpses found floating in shallower waters with a presumptive PMSI from 3 to 118 days and exposed to water temperatures (Tw) between 10.5 and 20.3 °C approximately equating from a minimum of 46 to 1.392 ADD; 52 bodies, all victims of a single shipwreck, found in sequestered environments and subjected to constant Tw of 4 °C for 210 days approximately equating to 840 ADD. The two series of bodies have revealed different stages of decay and a large DSS variability. In most of bodies, freshly formed adipocere was able to delay the appearance of later decompositional stages explaining why most of the bodies were in relatively good condition. Although promising, the accuracy of the TADS model can be affected by adipocere and animal activity. The TADS model suffers of the same limitations for ADD calculations as they can give a false perception of accuracy due to the complexity of integrating all changing factors affecting human decay in sequestered and non-sequestered marine environments (currents, animal activity, water temperatures, depth of submersion).

Pink tooth phenomenon: an enigma?

BACKGROUND

The appearance of pink teeth is a common phenomenon which has been observed after death in certain circumstances on post-mortem examination. Extra fibrinolytic activity of pulp facilitates rapid breakdown of red blood cells and diffusion of hemoglobin and its derivatives to flow into dentine.

METHODS AND RESULTS

We reviewed various studies on pink tooth phenomenon which have stated the various factors that lead to pink tooth formation. Most of the authors have stressed that post-mortem pink teeth must not be considered as a reliable odontological parameter for determining cause of death.

CONCLUSION

No correlation has been found between the occurrence of pink teeth and the cause of death but condition of the surroundings certainly plays an important role in the development of this phenomenon. This paper reviews the factors and conditions responsible for formation of pink teeth.

Migrant deaths and the Kater Radez I wreck: from recovery of the relict to marine taphonomic findings and identification of the victims

On March 1997, during a naval blockade imposed by Italy to prevent illegal immigration, the motorboat Kater Radez I full of Albanian refugees clashed with an Italian warship with 120 people approximately on board. The boat sank quickly after the collision just in the middle of the Otranto Canal (Mediterranean Sea). Only 34 individuals survived the accident; 58 died, mostly women and children, and dozens were missing. After 7 months spent at depth of 800 m approximately underwater to constant temperature of 4 °C, the motorboat was rescued, and totally, 52 bodies were recovered from the holds. The management of the mass disaster is summarized focusing on the procedures applied in the recovery of the boat and victims, and the identification process. The purpose of the article is to present the unique taphonomic model of decomposition dealing with marine sequestered environments. The postmortem changes have been revised according with a skeletonization scoring system. Surprisingly, most of the victims were in good condition with soft tissues still present except at the head/neck region and the hands resulting in the body parts mostly pre-skeletonized. Closed compartments as well as heavy clothing in multiple layers protected the bodies from animal activity of marine scavengers. Presumptive positive identification was obtained in 49 out of 52 bodies based on the correspondence between ante- and postmortem data. An additional purpose of the article is also to focus on the practice of coercive actions disproportionate to the risk of unauthorized entry criticized by several international organizations for migration and recently condemned by the European Court in Strasbourg.