June 2015 Dental Identification Age Estimation Bite-Mark and Pattern Injury Analysis JournaCALIFORNIA DENTAL ASSOCIATION

Forensic Odontology Duane Spencer, DDS You are not a market segment.

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DEPARTMENTS 281 The Associate Editor/To Delete or Not to Delete, That Is the Question

283 Letters to the Editor

285 Impressions

333 RM Matters/Report Employee Injuries Immediately

337 Regulatory Compliance/Uses and Disclosures of Patient Health Information: Part II

342 Tech Trends 285

FEATURES 292 Forensic Odontology An introduction to the issue. Duane Spencer, DDS

295 Overview of Forensic Odontology This article provides an overview of the field of forensic odontology and suggests ways to become involved. Roger D. Metcalf, DDS, JD, and Janice Klim-Lemann, DDS

303 Atypical Forensic Dental Identifications Forensic dental identification is accomplished by comparing radiographs of the decedent’s teeth with the dental radiographs obtained from the dentist of the suspected victim. Unfortunately, antemortem dental radiographs are not always available. Anthony R. Cardoza, DDS, and James D. Wood, DDS

309 Bite-Mark and Pattern Injury Analysis: A Brief Status Overview This article discusses some issues that persist in forensic circles and the difficulties surrounding the field of bite-mark analysis that inherently must employ human subjectivity in its execution of duty. Gregory S. Golden, DDS, DABFO

315 Forensic Dental Age Estimation: An Overview This article reviews the principles, methodology and commonly used techniques in forensic age estimation cases. James M. Lewis, DMD, DABFO, and David R. Senn, DDS, DABFO

321 The Forensic Dentist: An Overview of Expert Roles in Animal Bite-Mark Investigations With increasing incidence of human/animal confrontation and the potential for injury or even death, dentists who choose to work in the forensic sciences may be called upon to utilize their skills and training to render opinions in criminal and civil cases. Kenneth Cohrn, DDS, MAGD, DABFO, and Ron Berman, BA, CFE, DABFE

JUNE 2015 279 CDA JOURNAL, VOL 43, Nº6

Volume 43, Number 6 JournaCALIFORNIA DENTAL ASSOCIATION June 2015 CDA Classifieds.

Free postings. published by the Editorial Upcoming Topics Manuscript California Kerry K. Carney, DDS, CDE July/Geriatrics I Submissions EDITOR-IN-CHIEF Priceless results. Dental Association August/Geriatrics II www.editorialmanager. 1201 K St., 14th Floor [email protected] September/Radiology com/jcaldentassoc Sacramento, CA 95814 Ruchi K. Sahota, DDS, CDE 800.232.7645 ASSOCIATE EDITOR Advertising Letters to the Editor cda.org Doug Brown www.editorialmanager. ADVERTISING SALES Brian K. Shue, DDS, CDE com/jcaldentassoc CDA Offi cers ASSOCIATE EDITOR [email protected] Walter G. Weber, DDS 916.554.7312 PRESIDENT Duane Spencer, DDS Subscriptions GUEST EDITOR [email protected] Tiff any Carlson Subscriptions are available ADVERTISING SALES only to active members of Kenneth G. Wallis, DDS Andrea LaMattina Tiff [email protected] the Association. The PUBLICATIONS SPECIALIST PRESIDENT-ELECT 916.554.5304 subscription rate is $18 and [email protected] Permission and is included in membership Blake Ellington dues. Nonmembers can TECH TRENDS EDITOR Clelan G. Ehrler, DDS Reprints view the publication online VICE PRESIDENT Andrea LaMattina at cda.org/journal. [email protected] Courtney Grant PUBLICATIONS SPECIALIST COMMUNICATIONS [email protected] Manage your subscription SPECIALIST Natasha A. Lee, DDS 916.554.5950 online: go to cda.org, log in SECRETARY and update any changes to [email protected] Jack F. Conley, DDS your mailing information. EDITOR EMERITUS Email questions or other Kevin M. Keating, DDS, MS changes to membership@ TREASURER Robert E. Horseman, DDS cda.org. HUMORIST EMERITUS [email protected] CDA classifiedsclassifieds wworkork harder to Stay Connected cda.org/journal bbringring you resuresults.lts. SeSellinglling a practice Craig S. Yarborough, DDS, Production MBA SPEAKER OF THE HOUSE Val B. Mina or a piece ooff equipment? Now you SENIOR GRAPHIC DESIGNER [email protected] can include photos to help buyers Go Digital cda.org/apps James D. Stephens, DDS Randi Taylor SENIOR GRAPHIC DESIGNER Look for this symbol, noting additional video see the potential. IMMEDIATE PAST PRESIDENT content in the e-pub version of the Journal. [email protected] And if you’re hiring, candidates Journal of the California Dental Association (ISSN 1043-2256) is published monthly by the anywhere can apply right from Management California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814, 916.554.5950. Peter A. DuBois the site. Looking for a job? You can Periodicals postage paid at Sacramento, Calif. Postmaster: Send address changes to Journal EXECUTIVE DIRECTOR of the California Dental Association, P.O. Box 13749, Sacramento, CA 95853. post that, too. And the best part— Jennifer George The California Dental Association holds the copyright for all articles and artwork published it’s free to all CDA members. CHIEF MARKETING OFFICER herein. The Journal of the California Dental Association is published under the supervision of CDA’s editorial staff . Neither the editorial staff , the editor, nor the association are responsible for Cathy Mudge any expression of opinion or statement of fact, all of which are published solely on the authority All of these features are designed to VICE PRESIDENT, of the author whose name is indicated. The association reserves the right to illustrate, reduce, COMMUNITY AFFAIRS help you get the results you need, revise or reject any manuscript submitted. Articles are considered for publication on condition that they are contributed solely to the Journal. faster than ever. Check it out for Alicia Malaby COMMUNICATIONS Copyright 2015 by the California Dental Association. All rights reserved. yourself at cda.org/classifieds. DIRECTOR

280 JUNE 2015 AssociateEditor Editor CDA JOURNAL, VOL 43, Nº6

To Delete or Not to Delete, That Is the Question Brian Shue, DDS, CDE

s dentists — the No. 1 best job in 2015 according to the annual rankings by U.S. News On average, one out of eight and World Report (apparently, emails you will receive each day this the No. 2 best job is being AApple CEO Tim Cook) — we have year can be categorized as spam. many pressing duties besides our daily schedules that demand our attention throughout the day: reading emails, deleting emails, reading emails, etc. You surely receive unsolicited helping the sender access riches locked And so far in the 21st century, email commercial emails like these, also known away. The FTC says these scams are still remains the most common form of as spam or junk emails, interspersed with “characterized by convincing sob stories” business communication. In 2014, 196.3 all of your important emails. On average, and “unfailingly polite language” in their billion emails were sent and received every one out of eight emails you will receive attempt to get your personal information day, and digging deeper, each business each day this year can be categorized as and/or bank account number. user will receive on average 88 emails per spam.2 And that is not even counting In addition to service members day and send 38 emails per day in 2015.1 the staggering amounts that technology and those on their last breath, I have Sending 38 emails per day doesn’t seem and anti-all-that-is-bad programs battle also received offers from executives like very many, but over a four-year period to keep away from ever reaching our from African oil fi elds and foreign that would amount to 55,480 emails. inboxes like yesterday’s electronic trash. bank offi cials, including one from the Some emails can be quite interesting. Can spam be banned? Can the “Tamale Branch of the Bank of Ghana.” Here are some that made it to my inbox: image of singing Vikings gathered in an In exchange for my help, I have seen From the sick. “Dear,” one email started, English diner ever be forgotten?3 No. emails offer as low as 20 percent of the “Walk in the path of righteousness and The U.S. Department of Justice defends windfall to as high as 40 percent. One goodness and mercy shall forever follow the existence of spam, stating, “Much graciously offered to let me pick my you all the days of your life.” The sender of it has a legitimate business purpose.” own percentage. If I cooperate, another then tells me she has been on her deathbed But much of it does not, including email email reassures “it is not illegal in any for fi ve years and says, “Now I believe that scams like those mentioned above. way nor will either of us be breaking my time has come to join my ancestors in Here are the most commonly reported any laws.” Another sender asks, “Can heaven. Through divine revelation, I got scams in 2014, according to the Federal you honestly help me from your heart?” your email address from the Internet. I have Trade Commission (FTC): IRS phone Sure, that’s why I wanted to be a dentist, $8,000,000 deposited in a safe location.” calls and/or emails, the Prize Patrol from to help people. “Can I completely trust This conjured up the image of a sender Publisher’s Clearinghouse, technical you?” Of course you can, dentists are barely mustering enough energy to search support warning your computer needs Gallup poll’s third most-ethical profession. for my email address, press the “send” button immediate servicing and/or malware But no one falls for these schemes, and then lapse back into unconsciousness. that needs to be removed and the right? You’d be surprised. Victims have From patriotic men and women who Nigerian scam involving the FBI.4 actually traveled to other countries defend our freedoms. No, not Fox News Notice how prevalent computer to complete these transactions, anchors, I mean soldiers. One U.S. Army technology is involved in these criminal sometimes even shown trunks of fake captain has two military trunk boxes of scams. And consider the Nigerian scam, cash, as they fall deeper into trouble. booty hidden in the U.K. that he took named after the country from where “According to State Department reports, from Iraq. Another soldier in Afghanistan this type of fraud fi rst emerged. It is an people who have responded to these has an undisclosed amount of Benjamins advanced fee scheme from a trustworthy emails have been beaten, subjected hidden in a tunnel and he needs help in “representative” who will give you a to threats and extortion, and in some moving it to a more secure location. cut of millions of dollars in return for cases, murdered,” says the FTC.

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Enter the Internet Crime Complaint Follow these common-sense ■ Use antivirus software and personal Center (IC3), a central processing system recommendations from the Department fi rewalls and keep them up to date. whose mission is to “receive, develop of Justice and the FTC to minimize ■ Confi gure your email client for and refer criminal complaints regarding spam and to reduce your chances of security by changing email viewing the rapidly expanding arena of cyber becoming a victim of an email scam:5 as text only. crime.” The IC3, comprised of the FBI ■ Filter spam. Use the features on ■ Keep your email address as private as and the National White Collar Crime your email applications or mail possible. Center, partners with the proper law services to prevent as much as ■ Have a primary and secondary email enforcement level of authority. “Internet possible. address and use one for people you crime is defi ned as any illegal activity ■ Don’t trust unsolicited email. Don’t know and one for all other purposes. involving one or more components open attachments, don’t click on ■ File an email scam complaint at the of the Internet such as websites, chat links from unsolicited email, don’t IC3 website www.ic3.gov/default.aspx. rooms and/or email,” says IC3. “Internet buy anything and don’t respond. ■ Forward unwanted spam to the FTC crime involves the use of the Internet ■ Approach email attachments and at [email protected]. to communicate false or fraudulent links, even from those you know, So the next time you get an email representations to consumers.” with caution. from a sender, more direct than David Lee Roth backstage after a Van Halen concert, with a message like this: “I have $36.6 million in business to acquaint with you. Contact me,” you know what to do. And remember, it may not be you who falls for these fraudulent emails, but it could very Read this issue well be someone you know. ■ * REFERENCES 1. Radicati S. Email Statistics Report, 2014-2018. www.radicati. on your iPad. com/wp/wp-content/uploads/2014/01/Email-Statistics- Report-2014-2018-Executive-Summary.pdf. April 14, 2014. 2. Ibid. 3.1970 episode of Monty Python’s Flying Circus. 4.Kando-Pineda C. The Grate Pretenders. www.onguardonline. gov/blog/grate-pretenders. March 2, 2015. 5.Department of Justice. Recognizing and Avoiding Email Scams. www.us-cert.gov/sites/default/fi les/publications/ emailscams_0905.pdf. Accessed March 13, 2015.

Brian K. Shue, DDS, is the dental director of a federally qualifi ed health center. He is a certifi ed dental editor, the San Diego County Dental Society editor and is a fellow of the American College of Dentists and the Pierre Fauchard Academy.

*AlsoAl availableil bl ffor iiPhone,Ph AAndroidddroidid oror Kindle Fire. Check it out at cda.org/appsdaa.org/apps

282 JUNE 2015 Letters CDA JOURNAL, VOL 43, Nº6

What Is Aff ordable?

Lambert Stumpel, DDS, writes patient benefi t should ionizing radiation March 2015 Evolution of Guided in his March 2015 Journal article, be used. In addition, most are well aware Surgery Power of Digital Design Cast-Based Implants “A Simple, Safe and Affordable Cast- that health care cost in this country is JournaCALIFORNIA DENTAL ASSOCIATION Based Guided Implant Placement the highest in the world. We should be System,” that in San Francisco where sensitive to the fact that controlling cost he practices, a cone beam CT (CBCT) is in our patient’s interest. The described

fee is $400 and an intraoral scan is $50. guide allows very precise implant Computer-Guided Implant Surgery: Placing the Perfect Implant Dr. Stumpel opines that this CBCT placement, while controlling cost. Ziv Simon, DMD, MSc cost is not fi nancially feasible for a The article was comparing a dentist placing one or two implants. cast-based method to fabricate a The University of the Pacifi c, Arthur fully restrictive surgical guide to the A. Dugoni School of Dentistry fee is computer-aided design/computer-aided $258 for a narrow fi eld Accuitomo manufacturing (CAD/CAM) produced CBCT of three teeth including a board surgical guides. To produce a CAD/ certifi ed radiologist’s report. Its low CAM guide one needs a full arch in the radiation dosage of 20 microsieverts, CBCT data set. A full arch is needed to high-quality resolution and anatomical accurately match the stereolithography accuracy is invaluable for implants (STL) fi le of the teeth. Partial datasets being placed in close proximity to will introduce massive errors between etc. Our patients are not divided vital structures such as the inferior planned and actual implant position. up that way. They are whole and alveolar nerve canal or sinuses. The information from a small complete with body, mind and spirit. Private dental X-ray labs in San fi eld CBCT can easily be used when Neither Hal Huggins, DDS, MS, Francisco charge $200 for a focused fabricating a 3D Click Guide, and or any of the other dentists were fi eld CBCT of one to three teeth. when needed that is what we do. “holistic” dentists. Dr. Huggins had Patient safety is priceless when To fabricate a CAD/CAM guide a protocol that he called “balancing placing implants. Why should not one would need a full arch. body chemistry.” If they have a this choice of superior technology be The cost as described in my article particular technique or protocol, by included with informed consent? We is $450 for the data sets required. defi nition it cannot be holistic. don’t X-ray a patient’s pocketbook. LAMBERT J . STUMPEL, DDS Most of the diseases we treat We should nevertheless provide San Francisco, Calif. are preventable. Preventing dental reasonable choices so the patient disease is more desirable than can decide what is affordable and allowing it to happen and then in the patient’s best interest. The Sum of Its Parts repairing the damage afterward. EDWIN ZINMAN, DDS, JD I was interested in reading the If we want to really help our San Francisco, Calif. editorial on holistic dentistry in the patients become healthier, we have March 2015 issue of the Journal. The to move beyond simply presenting Dr. Stumpel responds term “holistic” simply means that the treatment plans and repairing teeth. I would like to thank Dr. Zinman whole is greater than the sum of its We all know that there are dentists for commenting on my March 2015 parts. A dentist who takes a holistic who have excellent behavioral and Journal article, “A Simple, Safe approach to dentistry sees his or her communication skills that serve their and Affordable Cast-Based Guided patient as a whole person with a patients in an exceptional way. The Implant Placement System.” unique life experience. We are not Pankey Institute is named for one of There is no discussion that when just repairing teeth; we are helping these dentists, L.D. Pankey, DDS. needed, CBCT is wonderful technology our patients become healthier. The editorial mentions a dentist that should be used based on the We compartmentalize our named Weston Price. Dr. Price traveled ALARA principle, acronym for as low as education into departments such as with his wife to primitive areas of the reasonably achievable. Only if there is operative, endodontics, periodontics, world to study the effects of nutrition

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CDA JOURNAL, VOL 43, Nº6

on people’s health. The outcome was changes. People reported that their The Journal welcomes letters a monumental book called Nutrition chronic headaches had cleared up and We reserve the right to edit all and Physical Degeneration. His research others reported that they no longer communications. Letters should discuss an took place before the advent of had leg cramps or seasonal allergies. item published in the Journal within the past antibiotics, when dental infections I do not like to hear our profession two months or matters of general interest could be more life threatening. referred to as the dental “industry.” We to our readership. Letters must be no more A holistic approach is a systems are not a commercial enterprise and we than 500 words and cite no more than fi ve approach — nothing is left out. We look are not in competition with our fellow references. No illustrations will be accepted. at the entire stomatognathic system. dentists or our patients. As professionals, Letters should be submitted at editorialmanager. The three main causes of dental we share our knowledge freely. com/jcaldentassoc. By sending the letter, the disease are caries, periodontal disease and Over the years, we have grown from author certifi es that neither the letter nor one malocclusion. These are all interrelated being tooth pullers to dental repairmen. with substantially similar content under the and we do not treat them separately. By taking a broader view of our writer’s authorship has been published or is In the course of doing comprehensive profession, we can expand our vision to being considered for publication elsewhere, care, some of our patients were reporting becoming true health professionals. and the author acknowledges and agrees that that other health problems had PHILIP HORDINER, DDS the letter and all rights with regard to the letter cleared up as a result of their lifestyle Los Altos, Calif. become the property of CDA.

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284 JUNE 2015 Impressions CDA JOURNAL, VOL 43, Nº6

A Grammar of Ethics

David W. Chambers, EdM, MBA, PhD

Parsing logical sentences and distinguishing one ethical philosopher from another probably compete for last place among the exciting things to do on a Sunday afternoon, right up there with untangling the wires for the stereo system and alphabetizing the canned soups in your pantry. There is a reason — after we have done it, no one can tell the difference. Here is the connection between grammar and ethics. First-person ethics is an academic exercise. Third-person ethics is gossip. Speaking about ethics in the second person almost never happens. Some things we say about ethics never get out of the “I” voice. Some sentences point fi ngers at “they” or “it.” After we have done it, no one can tell the difference. The precious cases begin, “We …” It is very hard to think of an example of ethics that is entirely private. Almost per defi nition, to count as good or bad, what we do has to affect others. So should the solution. There is a danger in mistaking a one-party solution to a two- party problem for a sound, two-party ethical resolution. The real annoyance is third-person ethics. “He should be doing …” “Did you hear how they are overcharging, misrepresenting, underdiagnosing, patient stealing and all the rest? Makes one sick.” There are three parties in these third- The nub: party grumblings: Dr. Righteous, the friend of Dr. Righteous who is listening and “they” (who are generally only spoken 1. Private virtues are only of in their absence). As a rule, “they-ness” is easier to spot ethical when they make the less “they” look like the friend of Dr. Righteous. others’ lives go better. It is easier to tell others how to act when one is standing on a pedestal or wearing some sort of ceremonial garment. 2. Third-person scolds and Avoiding the possibility of having a conversation also helps. Sometimes we clean up third-person ethics by removing ex cathedra judgments the personal dimension. We shift from “they” to “it.” “It would are sham ethics. be best if everyone …” “It is obvious that …” “It stands to reason or everyone sees the wisdom of ...” The “it” arabesque 3. We can only fi x it when also seems to elevate the conversation to universal principles. those involved sit down and Neat and clean, perfectly fair, just do the right thing. It talk about it. only shows up in the very fi ne print that certain individuals are allowed to interpret which “it” is the right one. The defensible position is the second-person perspective. You and me. We may not agree about which philosopher David W. Chambers, EdM, MBA, PhD, is professor of dental education at the University of the Pacifi c, Arthur has the grand insights, but there is a better chance of A. Dugoni School of Dentistry, San Francisco, and editor walking out of the room in agreement than if I insist of the Journal of the American College of Dentists. that you agree with me before you can sit down. ■

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Study Details Mouth,h, Heart ConnectionConnection According to research recentlyently ppublishedublished online bbyy the American Heart BPA Harms Tooth Enamel in Association, scientists at Forsythh and Boston UniversityUniversity have demonstrated that using an oral topical remedyedy to reduce infl inflammation ammation associated with Rats, Mimics MIH periodontitis also results in the prevention of vascular infl ammation and can A tooth enamel abnormality in lower the risk of heart attack. children, molar incisor hypomineralization The researchers of this study demonstrated the ability of an oral treatment (MIH), may result from exposure to the for gum disease to also reduce infl ammation in the artery wall. The active industrial chemical bisphenol A (BPA), ingredient is an infl ammation-resolving molecule, known as Resolvin E1. This authors of a new study recently concluded discovery further underscores the increasing body of evidence showcasing after fi nding similar damage to the dental how problems in the mouth — and how they are treated — can have life- enamel of rats that received BPA. changing infl uences on other key systems in the body, in this case the heart. “Human enamel defects may be used “Our research is helping to underscore the very real link between oral as an early marker of exposure to BPA and health and heart disease,” said Hatice Hasturk, DDS, PhD, lead investigator, similar-acting endocrine disruptors,” said in a news release. “The general public understands the connection between Sylvie Babajko, PhD, in a news release. heart health and overall wellness, and often takes appropriate steps to BPA is an endocrine disruptor, or hormone-altering chemical, that prevent heart disease. More education is needed to elevate oral wellness into has been linked to numerous adverse the same category in light of proven connections to major health conditions.” health effects in humans. It appears This is the fi rst paper to show a rabbit model of accelerated heart in many plastic and resin household disease, demonstrating a range of atherosclerotic plaque stages that more products and food containers, including closely resemble those in humans without genetic modifi cation of the animal, until recently baby bottles, sippy according to the news release. cups and infant formula packages. For more information, see the study published March 19, 2015, online Recent published data show that MIH before print in the journal Arteriosclerosis, Thrombosis and Vascular Biology, affects up to 18 percent of children ages 2015, 35: 1123-1133. 6 to 9 years and although the cause is unclear, appears to have an environmental origin, according to the study authors. In the fi rst part of the study, the researchers gave rats low doses of BPA, takes place from the third trimester these molecules are receptors for sex comparable to exposure in humans. of fetal development to three or four steroid hormones involved in organ The rats received BPA from fetal life years after birth. This cell-based development, endocrine homeostasis to 30 days after birth and, according experiment showed that sex hormones and hormone-sensitive cancers. She also to the researchers, the BPA caused target and infl uence dental epithelial reported that an increase in estrogen enamel defects similar to MIH in cells, according to the news release. activity had a greater effect on the tooth humans, especially in male rats. “Our study shows, for the fi rst enamel in male rats than in female rats In the second part of the study, the time, that BPA affects dental cells, and said this fi nding suggests possible investigators cultured and looked at and subsequently enamel synthesis, sexual differences in enamel quality. rat ameloblast cells, which are present using similar target molecules as These study results were presented in only during the formation of tooth those present in other organs,” said March 2015 at the Endocrine Society’s enamel. In humans, amelogenesis Babajko, who also explained that 97th annual meeting in San Diego.

286 JUNE 2015 CDA JOURNAL, VOL 43, Nº6

New Technique Applies Antibacterial Agent to Plaque Therapeutic agents intended to reduce (farnesol) within the dental plaque and prevent tooth decay plaque, despite the are often removed by saliva and the act presence of saliva. of swallowing before they can take effect. To deliver the But, according to a news release, a team farnesol to the of researchers has developed a way to targeted sites, the keep the drugs from being washed away. team of researchers In a recent study, published in the created a spherical mass of particles polymers and securing the drug with journal ACS Nano, researchers found a — constructing the outer layer out hydrophobic and pH-responsive polymers. new way to deliver an antibacterial agent of positively charged segments of the The positively charged outer layer of the carrier is able to stay in place at the surface of the teeth because the enamel is made up, in part, of hydroxyapatite (HA), Study: E-Cigarettes Not ‘Harmless’ which is negatively charged. Just as oppositely charged magnets are attracted In a major scientifi c review of research on e-cigarettes, scientists at the to each other, the same is true of the University of California, San Francisco discovered that industry claims about nanoparticles and HA. Because teeth are the devices are unsupported by the evidence to date, including claims that coated with saliva, the researchers weren’t e-cigarettes help smokers quit, according to a news story from the university. certain the nanoparticles would adhere. In their analysis, the authors found that e-cigarette use is associated with But, according to the news release, not signifi cantly lower odds of quitting cigarettes and that while the data are only did the particles stay in place, they still limited, e-cigarette emissions “are not merely ‘harmless water vapor,’ as were also able to bind with the polymeric is frequently claimed, and can be a source of indoor air pollution.” matrix and stick to dental plaque. E-cigarettes deliver a nicotine-containing aerosol popularly called Because the nanoparticles could “vapor” to users by heating a solution commonly consisting of glycerin, bind both to saliva-coated teeth and nicotine and fl avoring agents. E-liquids are fl avored, including tobacco, within plaque, the researchers used them to carry the antibacterial agent menthol, coff ee, candy, fruit and alcohol fl avors, the authors wrote. to the targeted sites and found that “E-cigarettes do not burn or smolder the way conventional cigarettes do, so the nanoparticles could release the they do not emit side-stream smoke; however, bystanders are exposed to aerosol drug when exposed to cavity-causing exhaled by the user,” according to the authors, who wrote that a previous study eating habits — precisely when it is found low levels of formaldehyde, acetaldehyde, isoprene, acetic acid, nicotine most needed to quickly stop acid- and other toxins were measured in that aerosol. Toxins in producing bacteria. The researchers the e-cigarette aerosol were at much lower levels compared tested the product in rats that were with the conventional cigarette emissions, they noted. infected with Streptococcus mutans. The authors conclude that “evidence available “When the drug was administered at this time, although limited, points to high levels without the nanoparticle carriers, there of dual use of e-cigarettes with conventional was no effect on the number of cavities cigarettes, no proven cessation benefi ts and rapidly and only a very small reduction in their severity. But when it was delivered increasing youth initiation with e-cigarettes.” by the nanoparticle carriers, both the For more information, see the full study number and severity of the cavities in the American Heart Association’s journal were reduced,” said co-senior author Circulation, 2014; 129: 1972-1986. Hyun Koo, in the news release. For more, see the study published in ACS Nano, 2015, 9 (3), pp. 2390–2404.

JUNE 2015 287 Practice Support

Employment Practices

When it comes to employment practices, there’s one spot where CDA members can get assistance with every nuance of running a practice: CDA Practice Support. Download a customizable employee manual or train your staff with easy-to-use PowerPoint presentations. There are even tips on setting staff rules around piercings and tattoos. What’s more, if you need personalized advice, our employment expert is just a phone call away. CDA Practice Support. It’s where smart dentists get smarter.

800.232.7645 or cda.org/practicesupport

JUNE 2015 IMPRESSIONS

CDA JOURNAL, VOL 43, Nº6

Study Pinpoints Brain Regions Involved in Dental Pain In a recent study, researchers investigated the “task-related” brain activity and functional connectivity patterns following onset of a regional anesthetic nerve block during continuous noxious dental stimulation. For this placebo-controlled, age-matched functional magnetic resonance imaging study, 28 subjects were included (only males, mean age 27) received repetitive electric stimuli to the left mandibular canine, evoking an intensity perception of fi ve on an 11-point numeric intensity rating scale, according to a news release. The experiment was divided into two phases, the fi rst consisting of 30 stimuli for a duration of fi ve minutes followed by a submucosal injection of either Graphene Oxide Eff ective in the anaesthetic articaine 4% (group A) or 0.9% sodium chloride (placebo group) at the left mental foramen. The second phase consisted of electric Killing Dental Pathogens tooth stimulation for 16 minutes, during which subjects indicated pain off set Dental diseases, which are caused by pressing an alarm ball. In the anesthesia group, pain relief was reported by the overgrowth of certain bacteria 4.5 minutes after the injection whereas in the placebo group, no subject in the mouth, are among the most reported pain relief. Between-group analysis of phase two demonstrated “a common health problems in the world. signifi cant activation cluster in the ipsilateral posterior insula (pIns)” in the According to a news release, scientists placebo group. Using the pIns as a seed region, “the PPI analysis yielded a have recently discovered that a material called graphene oxide is effective at signifi cant enhanced coupling to the midbrain (periaqueductal grey/ventral eliminating these bacteria, some of which tegmental area) after analgesia onset in group A only.” have developed antibiotic resistance. The novel paradigm applied in this study Published in the journal ACS demonstrated that dental pain relief was Applied Materials & Interfaces, the accompanied by a signifi cant activity reduction in study explains that dental caries and the posterior insula and an enhanced connectivity periodontal diseases “have a close to the midbrain, according to the news release. relationship with microbes such as The new data was presented March 2015 Streptococcus mutans, Porphyromonas at the 93rd General Session and Exhibition of gingivalis and Fusobacterium nucleatum.” the International Association for Dental Research. The authors point out that dentists often prescribe traditional antibiotics to get rid of bacteria that cause tooth decay or gum disease and that with This research team wanted to see if the leaked out after they were treated the rise in antibiotic resistance, new nanosheets would also stop the specifi c by graphene oxide. Therefore, they approaches are needed to address these bacteria that cause dental diseases. conclude, graphene oxide nanosheets problems, which can lead to tooth loss. In the lab, the researchers tested the would be “an effective antibacterial Previous studies have demonstrated material against three different species material against dental pathogens and that graphene oxide — carbon of bacteria that are linked to tooth the potential applications in dental nanosheets studded with oxygen decay and gum disease. According to the care and therapy are promising.” groups — is a promising material in study, transmission electron microscopy For more information, read biomedical applications. It can inhibit (TEM) images revealed that the cell wall the study published in the journal the growth of some bacterial strains and membrane of the bacteria lost their ACS Applied Materials & Interfaces, with minimal harm to mammalian cells. integrity and the intracellular contents 2015, 7 (9), pp. 5605–5611.

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Survey: Oral Pain Specialists Treat Complex Health Issues In a new study, authors have to chronic and reduce the patient’s discovered that patients with facial quality of life dramatically. pain see an average of 2.2 doctors The authors conducted a survey over 17 months before visiting to better understand the work of facial pain and oral medicine pain specialists and to describe in specialists. According to one author, detail the types of patients these this delay in getting treatment can specialists see in the United States. allow pain to escalate from acute According to their survey, the authors

Xylitol in Tooth Decay Prevention Still Unproven found 46 percent of the specialists New research from The University of Manchester concludes that there is practiced in dental schools, 31 percent limited evidence to show that xylitol is eff ective in preventing dental cavities practiced in hospitals and 18 percent in children and adults, according to a news release from the university. practiced in combined settings. Only Xylitol is a popular sugar substitute and is already known to cause less 5 percent were in private practice. damage to teeth than sugar. It has also been suggested that the addition The average age of the patients of xylitol to products may help to prevent tooth decay by stopping the was 57 and nearly twice as many of growth of decay-producing bacteria. However, according to new evidence the patients were women. The leading published in the Cochrane Library there is little high-quality evidence that cause of referrals to the specialists xylitol is benefi cial in the fi ght against tooth decay. was oral lesions, followed by orofacial The authors gathered together data from 10 studies that analyzed a pain, dry mouth, burning mouth and oral sores or ulcers, according to a total of 5,903 participants. In most cases, the studies used such diff erent news release. The tongue and gums methods that the researchers could not combine the results to create a were predominant sites for pain, but summary eff ect estimate. Based on information from 4,216 schoolchildren less so for teeth and lips, and about who took part in two Costa Rican studies, they found low-quality evidence one-third of the referred patients that levels of tooth decay were 13 percent lower in those who used a reported pain in at least two locations. fl uoride toothpaste containing 10% xylitol for three years, compared to Oral lesions and pain caused by those who used a fl uoride-only toothpaste. For other xylitol-containing oral lichen planus was the main reason products, such as xylitol syrup, lozenges and tablets, there was little or no many sought treatment, followed by evidence of any benefi t. problems with the salivary glands. “The evidence we identifi ed did not allow us to make any robust The pattern of patient referrals conclusions about the eff ects of xylitol, and we were unable to prove any demonstrates the breadth of the benefi t in the natural sweetener for preventing tooth decay,” said lead interprofessional practice with ear, nose and throat surgeons, dermatologists researcher Philip Riley, of the School of Dentistry at The University and oncologists, general practice of Manchester, in the news release. dentists and other health care providers, For more information, read the full review published according to the news release. online in the Cochrane Database of Systematic For more, see the study published Reviews, 2015, issue 3, March 26, 2015. in the journal Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology, 2015; 119 (4): 408.

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Forensic Odontology

Duane E. Spencer, DDS

GUEST EDITOR

Duane E. Spencer, DDS, “They’re dentistry’s detectives, a small Forensic odontology continues to be practices pediatric dentistry group of professionals who lend their skills a relatively small fi eld of dentistry. Most in Walnut Creek, Calif. and training to the often grisly business dentists give the subject little thought, He is a forensic dental consultant to Alameda, of helping identify crash victims, solve unless they receive a call from their Contra Costa, San Mateo rapes and catch killers. Their names and local county coroner/medical examiner and Solano counties and faces may appear in the news, but there’s requesting a patient’s dental records or the California Department little glamour in the job. It’s mainly hard perhaps contemplate obtaining continuing of Justice. work, dedication and attention to detail.” education hours at a forensic dental Confl ict of Interest Disclosure: None reported. presentation. There are currently only his caption was on the cover a few dozen dentists in California who of the September 1989 have experience in the fi eld and only issue of the Journal of the 14 who are American Board of Forensic American Dental Association, Odontology (ABFO) certifi ed. There are titled “Forensic Dentistry.” about 100 ABFO-certifi ed odontologists TIt is seldom that a dental journal in North America. Although the is dedicated entirely to the fi eld of numbers are small, most jurisdictions forensic odontology. Although an have access to qualifi ed forensic dental occasional article on the subject may consultation. Many odontologists appear, the last issue of the Journal continue working in the fi eld after they of the California Dental Association retire from their private dental practices. devoted to forensics was August It is the goal of this issue to not only 2004. That award-winning issue, offer the reader articles on the mainstay with articles submitted in 2003, of odontology and dental identifi cation, was largely related to the terrorist but to cover subjects that might be new tragedies of Sept. 11, 2001. Three and of interest. Five articles comprise authors from that issue, Anthony this issue, each submitted by very “Rick” Cardoza, DDS; Gregory S. experienced authors in the fi eld. All Golden, DDS; and James D. Wood, dental authors are diplomates of the DDS, have contributed to this issue. ABFO and are active in the organization.

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Roger D. Metcalf, DDS, JD, and to other Southern California counties. of Expert Roles in Animal Bite-Mark Janice Klim-Lemann, DDS, authored Dr. Golden is a co-author of the bite Investigation.” Having worked on “Overview of Forensic Odontology,” marks chapter in the fi fth edition of numerous fatal animal attack cases in which is an introduction, as well an the Manual of Forensic Odontology. California over the years, it seemed excellent overview, of odontology. Dr. He has also taught the bite mark readers might be interested in an article Metcalf is the director of the human component and advanced photography on animal bite marks. Dr. Cohrn has a identifi cation lab and chief forensic seminar at the Symposium of Forensic general dental practice in The Villages, odontologist for the Tarrant County Dentistry at the University of Texas, Fla. He is a consultant to multiple Medical Examiner in Fort Worth, Texas. San Antonio. Due to a recent number medical examiner districts in Florida and He is the recent chair of the ABFO of exonerations of people convicted of is a past president of the International certifi cation and examination committee crimes where bite-mark evidence was Veterinary Forensic Science Association. and president of the American Society involved, there is, rightfully, attention Dr. Cohrn authored the chapter of Forensic Odontology. Dr. Klim- focused by many on the status and “Animal Bitemarks” in the fi fth edition Lemann practices general dentistry future of bite-mark analysis. Dr. Golden of the Manual of Forensic Odontology. in Redlands, Calif. She participated contributes an up-to-date overview of Mr. Berman is a canine behavioral in the identifi cation efforts after bite-mark analysis and discusses the consultant and trainer providing 9/11 and is a consultant with the current recommendations, concerns expert witness services for forensic California Department of Justice. and opinions on this important issue. investigations and litigations of dog bites Drs. Cardoza and Wood combined Forensic dental age estimation and pet-related injuries, specializing their experiences in “Atypical Forensic is a subject that is probably new to in Rottweilers and pit bulls. He has Dental Identifi cations.” As the title most readers. Dental age estimation is participated in more than 700 cases. implies, actual interesting identifi cation important not only in identifi cation It is the hope of this guest editor that cases are presented with photographs. efforts but also in estimating the age readers will gain further information Dr. Cardoza has a general dental practice of an individual who may enter the concerning forensic odontology. This in El Cajon, Calif., and is a forensic criminal justice system without papers. issue can also serve as a reference for consultant for Imperial and San Diego Is he/she a juvenile or an adult? James those in forensic fi elds outside of dentistry counties and the California Department Lewis, DMD, and David Senn, DDS, such as law enforcement and pathology. ■ of Justice. He is a frequent presenter in co-authored “Forensic Dental Age the fi eld of forensics to local, state and Estimation: An Overview.” Dr. Lewis national dental societies/associations. practices general dentistry in Madison, California State Assemblyman (District Ala. He is the forensic dental consultant 2) Dr. Wood is the forensic dental to the Alabama Department of Forensic consultant to fi ve North Bay California Sciences in Huntsville. He also directs counties. As the founding director of the the dental age estimation workshop for California Dental Identifi cation Team the ABFO. Dr. Senn is a past ABFO (CalDIT), he also participated in the president. He is a clinical assistant Disaster Mortuary Operational Response professor at the University of Texas Team (DMORT) identifi cation efforts Health Science Center at San Antonio in 9/11 and post-Hurricane Katrina. and is the director of the Center for Dr. Golden authored “Bite-Mark and Education and Research in Forensics Pattern Analysis.” He practices general (CERF). Drs. Lewis and Senn also dentistry in Rancho Cucamonga, Calif, co-authored the chapter on dental age and is an ABFO past-president and a estimation in the current edition of past chair of the ABFO certifi cation/ the Manual of Forensic Odontology. examination committee. He is the Kenneth Cohrn, DDS, and Ron chief forensic odontologist for San Berman, BA, CFE, wrote “The Bernardino County as well as consultant Forensic Dentist: A Basic Overview

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Overview of Forensic Odontology

Roger D. Metcalf, DDS, JD, and Janice Klim-Lemann, DDS

AUTHORS

Roger D. Metcalf, DDS, Janice Klim-Lemann, t’s 8 a.m. on Monday, and you’re all required basic science information and JD, is a forensic dentist DDS, is a general dentist ready to start on a 10-unit crown and critical clinical skills, the amount of time practicing in Fort Worth, in Fontana, Calif. She has bridge case. But suddenly your offi ce available for introduction to niche areas Texas. He is the full-time been a forensic dentist for forensic odontologist and 10 years and assisted at the manager appears at the operatory door such as forensic dentistry has become director of the human World Trade Center after and wants to speak with you now. Out very limited. Many practitioners may not identifi cation laboratory 9/11, helping to identify Iin the hallway she tells you that there’s be completely aware of the full spectrum for the Tarrant County victims. She is a diplomate a deputy from the sheriff’s offi ce waiting of practice encompassed by modern medical examiner’s district. of the American Board in the reception area. He’s presented a forensic dentistry, also known as forensic He is board certifi ed by the of Forensic Odontology American Board of Forensic (ABFO), a fellow of the subpoena and would like to have Mrs. odontology. Most dentists probably know Odontology (ABFO) and is American Academy Jones’ dental records. Your mind races … that unidentifi ed human remains can the immediate past-chair of of Forensic Sciences you begin to think: “Why does he want be identifi ed via dental records in some the ABFO Certifi cation and (AAFS), a member of her records? Did I do something wrong? way. And, some are also likely aware Examination Committee. He the American Society Do I need to call my attorney? Maybe my that occasionally when a defendant was is currently the president- of Forensic Odontology elect of the American (ASFO), the California malpractice insurance carrier? Do I have convicted of some heinous crime, part Society of Forensic Dental Identifi cation Team to give him the records? Let me think … of the evidence presented at trial by the Odontology. (CalDIT) and the California what treatment did I do for Mrs. Jones?” prosecution was a bite-mark analysis. To Confl ict of Interest Society of Forensic Dentistry Those were exactly the types of be sure, the majority of cases that forensic Disclosure: None reported. (CSFD). questions running through our minds dentists are involved with center on either Confl ict of Interest Disclosure: None reported. the fi rst time dental records for one of the identifi cation of human remains or our patients were requested by a medical a bite-mark analysis, but the broad fi eld examiner’s (ME) offi ce for identifi cation of forensic odontology encompasses purposes.1 If and when this ever far more than just those two areas. happens, once your initial angst So, how much more? And exactly subsides, you will fi nd that the fi eld of what does it cover? Who are these forensic dentistry is very fascinating “forensic odontologists”? Where can one — not as it is portrayed on television learn more about this interesting fi eld? shows — but fascinating nonetheless. How can one become more involved as As our dental schools’ curricula are one of these dentists-turned-detectives? now packed with courses emphasizing We’re glad you asked.

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Identifi cation of Human Remains has given his or her opinion and individual from his or her siblings via Dental Records made a recommendation, the actual (unless, rarely, a known antemortem A serial killer has been on the loose, certifi cation of a decedent’s identity falls sample of the decedent’s own DNA is and the police have tracked him down and to either the coroner/ME or a judge. available for a direct comparison) and surrounded him in a cabin in the mountains. It has been said that teeth are the cannot distinguish between identical A fi re accidentally breaks out at the scene part of a human body most susceptible to twins. Analysis and comparison of and completely burns the cabin to the ground. disease during a person’s life, yet are the mitochondrial DNA profi les is less Human remains are recovered, but are not most durable part after a person’s death. powerful statistically than comparison visually identifi able due to thermal damage. This characteristic makes the dentition of nuclear profi les. Another limitation In addition, the decedent’s fi ngers have been extremely useful for identifi cation is the relatives being compared using burned so badly a fi ngerprint comparison purposes. Severely decomposed or burned mitochondrial DNA must also be for identifi cation is simply not possible. Law individuals are commonplace in most maternally related to the decedent. enforcement and the public are anxious to morgues. It is with these types of cases Both mitochondrial and nuclear DNA know if the deceased person is indeed the that the forensic odontologist can be analyses are relatively expensive to wanted serial killer — and they want to know perform and, due to backlogs in many now. The media quickly reports the decedent government labs, it may take an has been positively identifi ed as the wanted inordinate amount of time to get the suspect, and the identifi cation was made by Forensic odontologists results. Forensic dentists can render very a forensic odontologist using dental records. valuable assistance in these situations. While this is the sort of scenario that is can easily distinguish Forensic odontologists can easily probably the best known to the public, it between siblings distinguish between siblings and even is just one part of the forensic odontology and even between between identical twins. If suitable discipline. Forensic odontology is one of antemortem records can be located, the fi ve methods generally accepted for identical twins. identifi cation of remains using dental forensic identifi cation of unidentifi ed records may be possible and can be remains in most U.S. jurisdictions. In performed quickly, reliably and on addition to identifi cation via dental a cost-effective basis. However, the records, the other four methods are: most helpful in establishing identity, downside is that some information ■ Visual ID either by a relative as visual identifi cation is usually not must be known about the tentative or by use of some acceptable possible, or the decedent’s fi ngers may identifi cation of the decedent in order photo document. be too damaged to obtain satisfactory to interview family or friends to learn ■ Identifi cation by fi ngerprint postmortem fi ngerprints. Complicating the identity of the treating dentist. comparison. the situation further, even if suitable Sometimes that information is readily ■ Identifi cation by anthropological postmortem samples can be obtained, available and sometimes it is not. means (typically comparison known antemortem fi ngerprints for Sometimes the treating dentist can of ante- and postmortem comparison simply may not be available. easily be located, sometimes not. medical radiographs). Nuclear DNA may be too degraded to The forensic odontologist called to ■ Identifi cation by analysis and develop a satisfactory postmortem DNA the morgue will perform many dental comparison of DNA samples. profi le of the deceased or an antemortem examination procedures, such as charting There may be other methods that are DNA profi le of the decedent or the existing restorations, missing teeth and acceptable in some limited circumstances, decedent’s family members may not be taking radiographs and photographs, such as identifi cation by distinctive available for comparison. Additionally, just as if the decedent were a living marks or tattoos on the decedent’s even if the decedent’s nuclear DNA patient in the offi ce. However, unlike body, or identifi cation by comparison profi le can be developed and compared with a living patient, certain conditions, of serial numbers on implanted surgical to a family reference sample, the such as rigor mortis or advanced hardware or cardiac pacemakers. It should typical parentage-type nuclear DNA decomposition, can make the postmortem be noted that once the odontologist analysis cannot distinguish a particular examination rather challenging.

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If the putative decedent’s treating the celebrated “Midnight Ride.” Gen. a computer’s hard drive. In California, dentist can be located, and if appropriate Warren was later killed in the legendry dentists are not required by statute records are obtainable, the odontologist Battle of Bunker Hill (which actually to archive records, but the American will compare the ante- and postmortem took place mostly at Breed’s Hill). His Society of Forensic Odontology (ASFO) records. Depending on convention in a body was mutilated and roughly buried has issued a position paper on records particular jurisdiction, the odontologist by the British in a mass grave. His retention that encourages dentists to may take the lead in locating and family later wanted to exhume his body maintain and archive all dental records, obtaining antemortem records or so he could be reburied properly with particularly radiographs, indefi nitely. the ME/coroner investigators may be appropriate recognition. His remains were One of the seminal, defi ning moments responsible for obtaining these records. eventually recovered by his brothers and in the development of organized forensic The three things an odontologist identifi ed as Dr. Warren by Paul Revere, dentistry in the U.S. was the Big will look for when comparing these who was a dentist as well as silversmith. Thompson Canyon fl ood that occurred written and radiographic records are Revere reportedly had made a dental on July 31, 1976, in Colorado. It has consistencies, explainable inconsistencies prosthesis from a walrus tusk for Warren. been described as one of the worst fl ash and unexplainable inconsistencies. fl oods in U.S. history. One hundred and Consistencies are, of course, conditions forty-four victims lost their lives and that are the same between the ante- and fi ve people were never found. Forensic postmortem records. Inconsistences are dentists participated in identifying the conditions that are not the same between The trained forensic deceased, and this was reportedly the fi rst the antemortem and postmortem records odontologist will occasion a computer program was used to — for example, tooth No. 3 may have compare the antemortem assist in comparing ante- and postmortem an O amalgam noted in the antemortem and postmortem records dental records. In addition to natural chart, but is found to have an MO disasters such as fl oods, forensic dentists composite upon postmortem exam. This is tooth by tooth. will also be mobilized to assist with an inconsistency, but it is explainable by identifi cation of victims in a number of the normal course of dental treatment and other large-scale incidents — including does not rule out a positive ID. However, natural events such as a tsunami or if tooth No. 14 has had a full crown placed In today’s world, the fi nal forensic earthquake or man-made disasters antemortem, but is a virgin tooth on dental opinion usually relies on the such as the intentional and criminal postmortem examination, then this would comparison of postmortem records destruction of a populated skyscraper be an unexplainable inconsistency that to antemortem records. Thus, it is or airliner. In these cases, the dentally would preclude a positive ID, assuming extremely disheartening for the ME/ related disaster victim identifi cation the ante- and postmortem records are coroner investigator or the forensic (DVI) procedures employed are still the accurate and correct. The trained forensic odontologist to obtain information from same dental identifi cation procedures odontologist will compare the antemortem the putative decedent’s family about the used when identifying a single individual and postmortem records tooth by tooth decedent’s dentist, only to locate and call at the morgue, but with the organization and develop an opinion as to whether or that dental offi ce and be told “Oh, I’m and logistics on a larger scale. Duties not the comparison results in a positive ID. so sorry, we saw that patient for several may be shared and delegated among One of the most well-known years, but his fi lms and records were many dentists with a formal organization early cases of dental identifi cation of shredded a couple of years ago.” Please hierarchy implemented. The dentists unidentifi ed remains, and probably the archive and don’t destroy your patients’ may be deployed to a distant, remote fi rst in North America, is that of Gen. old records. While we understand that site where the infrastructure of basic Joseph Warren of Massachusetts. Gen. traditionally archiving hard copies of utilities has been destroyed or is literally Warren was a patriot, physician and charts and fi lms can be a bit cumbersome, nonexistent, rather than reporting to a distinguished military leader during in today’s computerized world, long- morgue near home. Several government the Revolutionary War, and was the term storage of digital fi les and images agencies with overlapping jurisdictions colonial leader who sent Paul Revere on essentially requires only some space on may be involved in a large incident,

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perhaps local, state and federal, and the coroner/ME offi ces, whereas participation Bite Marks incident might be treated as a criminal with NCIC may be mandatory for the A baby is brought to the hospital having investigation. If the incident is very large agencies by statute. The advantages of suffered several serious injuries including scale and involves international victims, NamUS versus NCIC are that NamUS broken ribs and broken limbs. The emergency agencies of other countries may expect is more “user friendly,” and the missing department physicians and nurses are to be involved in the investigation, as persons’ component of NamUS is immediately suspicious about the mother’s well. The time frame for resolution of accessible to the public for data entry explanation of the wounds — she says the the incident may be on the order of and perusal. Dentists may be requested to baby fell off of a couch onto a carpeted fl oor. weeks to months instead of a few hours provide a patient’s records to an agency The police detectives consider her boyfriend a or days. Media scrutiny may be intense. so the information can be uploaded, “person of interest.” Unfortunately, the baby Dentists also may be asked by or may even be asked to prepare the dies. The coroner is duly notifi ed and takes investigators or family members to assist NCIC or NamUS entry for the agency. jurisdiction of the decedent. At autopsy, the with a missing person or unidentifi ed The Health Insurance Portability and forensic pathologist notices injuries consistent person case by releasing a patient’s Accountability Act of 1996 (HIPAA) with a sexual assault. Additionally, there are records to the appropriate authority, several injuries that resemble human bites. such as a police department or coroner’s The coroner calls in a forensic odontologist. offi ce. Information about a missing The forensic odontologist examines the baby person, including a dental profi le, may Bite-mark analyses and takes photos of these patterned injuries. be entered in various databases by law Later, the photos are compared to dental enforcement or another appropriate are extremely models from the boyfriend. The odontologist agency. Coroner and ME offi ces may useful and powerful unequivocally excludes the boyfriend. Other upload information about unidentifi ed in excluding suspects must now be considered. DNA human remains. The entries from both profi les developed from swabs of the bite- the missing and the unidentifi ed persons’ certain suspects. mark injuries and from the sexual assault databases can be compared periodically examination taken at autopsy are later to determine by various criteria if found to be consistent with the profi le of the there are potential matches between baby’s biological uncle. He is arrested and them. One such federal database is the has a specifi c exclusion (CFR 45 charged with sexual assault and murder. National Crime Information Center §164.512 (g)(1)) that allows a “covered This scenario depicts one of (NCIC) operated under the Criminal entity” to release information about one the very important, and very often Justice Information Services Division of its patients to a coroner/ME offi ce overlooked, functions that a competent (CJIS) of the FBI. Access to NCIC is for ID purposes without any consent forensic odontologist can serve in the open only to approved law enforcement required (note that while the dental criminal justice system — protecting agencies, and the information contained records do belong to the dentist, it is a the innocent. Bite-mark analyses is not available to the public. California’s well-established law that such records are extremely useful and powerful state database is administered in must be released to the coroner/ME upon in excluding certain suspects. While Sacramento by the Missing and a properly presented request). For these exclusion of a suspect may not initially Unidentifi ed Persons (MUPS) division database comparisons to work properly, it seem important in the overall scheme at the California Department of Justice is imperative that the dental information of things, it is profoundly important to (DOJ). Another useful database is the be entered correctly. Training in NCIC the accused individual who is excluded, National Missing and Unidentifi ed and NamUS dental coding is available and is just as important to investigators Persons System (NamUS) administered from the respective agencies as the seeking to apprehend the proper by the University of North Texas Health proper coding of antemortem versus suspect. Further, a district attorney’s Science Center in Fort Worth for the postmortem dental records is not always fi rst job is to ensure that justice is National Institute of Justice (NIJ). Entry intuitive or straightforward. A local done. No prosecutor has an interest of information into NamUS is voluntary diplomate of the ABFO will be glad in pursuing an investigation against for law enforcement agencies and to assist with this coding, as well. and prosecuting an innocent person.

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Not every suspicious injury examined and years later DNA analysis showed the and practitioners have improved over the will turn out to be a bite mark and not convicted defendant could not have been years, and the current critical examination every actual human bite mark will be the actual perpetrator. Some of those cases of this area of practice can only result in suitable for analysis and comparison. are indeed inexcusable. However, note continued improvements. We believe Before embarking on a bite-mark analysis that many of these cases were tried before an exciting new era in this forensic or comparison, the analyst should be well today’s modern techniques and standard science area is about to begin with the trained and well prepared. Bite-mark cases operating procedures were in place. Some recent appointment of the Odontology are commonly involved with heinous of the early analysts essentially worked in Subcommittee of the National Institutes crimes, such as the death of a child or a a vacuum, with little formal training and of Standards and Technology (NIST) brutal sexual assault, and the stakes in these very little organizational support. Over Organization of Scientifi c Area Committees cases are often high, literally, life-or-death the years, professional odontology groups (OSAC). We are confi dent the fi eld of consequences in states that have the death have recognized and learned from mistakes bite-mark analysis will survive the critical penalty. The bite-mark analyst will most made in the early days. They have taken examination it is currently undergoing likely be called to testify if the case goes to and are taking corrective and preventive because, even as detractors agree, it offers a trial. It is not hyperbole to say these cases powerful method to exclude the innocent in can be extremely stressful for all involved. many cases. Even if for no other reason than In some bite-mark cases, the just that one alone, the fi eld should not odontologist may be able to opine to be abandoned. The modern discipline of some particular degree of belief that a Consultation and bite-mark analysis and comparison is simply certain suspect may have made the bite collaboration with not practiced the same way it once was, and mark on a victim (note that occasionally competent peers when one is we believe frank and careful evaluation of the roles may be reversed and the crime analyzing a bite-mark case this forensic specialty will ultimately result victim may have bitten the suspect). in many more desirable improvements. Such linkage can be very important in are strongly encouraged. In consideration of the foregoing, it is an investigation, as this could indicate our suggestion that one should not take a in some instances the suspect was with bite-mark case lightly or without carefully the victim perimortem (i.e., around the considering the potential ramifi cations. time of death), a temporal fi nding DNA actions. In fact, it has been members of The consequences of a bite-mark analysis cannot show. Additionally, a bite mark the ABFO who have provided requested gone wrong could be disastrous for all could show the suspect used a great deal expert assistance to the wrongly convicted parties involved — including professional of force to infl ict an injury that caused defendant in many of these cases. The sanctions and even steep monetary the victim pain and suffering. Further, challenges have been noted, taken to penalties, as there should be, for an fi nding a suspect’s DNA on a victim heart and the pertinent issues are being incompetent odontologist found to be liable may not be probative in a family/friend addressed. Standardized written guidelines, for performing a faulty bite-mark analysis. situation (it might not be unusual to fi nd recommended methods and procedures, the suspect’s DNA on the victim in these vetted standards and best practices have Age Estimation situations and vice versa), but presence been adopted and promulgated by the A house fi re has claimed the lives of a of a bite mark is not so easily explained. ABFO, the leading forensic odontology mother and her three sons. All four victims are There have been some high-profi le certifi cation organization. Consultation very badly burned. The mother has had dental bite-mark-cases-gone-bad that were and collaboration with competent peers treatment in the past and her dental records publicized recently, which have made some when one is analyzing a bite-mark case are available. Because she is the only known critics opine it is time for this discipline are strongly encouraged. Appropriate female adult in this incident, her remains are to be discarded. Most of these cases seem fundamental research in the subject is quickly identifi ed by the odontologist. However, to be when the forensic odontologist being proposed and performed. Very after the mother and father divorced several involved testifi ed that the suspect made stringent requirements must be met in years ago, she had not taken the boys, ages a bite mark on the victim, the suspect order to challenge the ABFO certifi cation 6, 10 and 14, to the dentist and no dental was then convicted of a heinous crime, examination. The discipline has evolved records exist for the children. DNA reference

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profi les are obtained from the father and from truth about their age, or with youthful- Organized Forensic Odontology the mother’s remains. Analysis shows the appearing criminal offenders who lie about If after reading this introduction you’ve DNA profi le of each child is consistent with their age because juveniles are treated decided to explore the fi eld of forensic being a biological child of the father and the separately and more leniently in the legal dentistry a bit more, we certainly encourage deceased mother; this routine DNA analysis, system than adults. There are various you to do so. Please read the other articles however, cannot specifi cally individualize the dental development charts and software written by well-regarded practitioners in remains. The best this analysis can tell us programs available for the odontologist this issue. Check out organizations such is that the child is a child of the parents, but to use for estimating the age of a living as the American Society of Forensic not which child he is. In addition, because subject. However, these methods all Odontology at asfo.org or a certifi cation the remains are so badly burned, size of the typically involve analysis of radiographs organization for forensic odontologists such remains is not a reliable indicator of which of the subject’s teeth. Obtaining dental as the ABFO at abfo.org. California has child is which. The forensic odontologist is radiographs that are not for a true the most board-certifi ed odontologists of able, though, to provide a straightforward diagnostic or therapeutic purpose, but all 50 states; locating a nearby odontologist prediction of which child is which based that are strictly for an administrative to answer your questions should be on dental age estimation procedures. fairly straightforward (check the ABFO The two primary areas of forensic website for members and their locations). odontology practice traditionally have California has a rich heritage in forensic been identifi cation of human remains and Remember, forensic odontology beginning with true giants in bite-mark analysis and comparison. Age the fi eld such as the late Reidar Sognnanes, estimation also has been performed by odontology in the real DDS, MS, PhD, and Gerald Vale, DDS. forensic dentists for many years, but has world is not as it is Norman “Skip” Sperber, DDS, is one of recently become an increasingly important portrayed on television. the founders of the ASFO and an early area of odontology. For example, diplomate of the ABFO. He was a fi rst estimation of the age of human remains It is not easy and sanitary. co-editor of the ASFO Forensic Odontology can assist in determining the identity Workbook, the book destined to evolve of an unidentifi ed decedent. There into the highly regarded ASFO Manual have been many methods developed of Forensic Odontology (to order a copy for predicting the age of an individual proceeding such as estimating the age of a of the current edition go to the ASFO based on his or her dentition. Some of person for an immigration investigation, website). Join the ASFO and the American the characteristics evaluated involve is considered by many to be unethical for Academy of Forensic Sciences (AAFS, measurements such as root transparency, the practitioner, and is actually illegal aafs.org). If you are really serious about which requires the sectioning of a tooth, in some jurisdictions, as well (see Texas pursuing forensic odontology, fulfi ll the or measuring and counting certain Administrative Code §289.227(c)(2); qualifi cations and take the examination internal anatomical landmarks within consider whether or not the subject is to become board certifi ed by the ABFO. a tooth. These destructive methods are actually a patient of the odontologist). It is by no means an easy or quick process, appropriate only for deceased subjects. The estimate provided by many of these but is very gratifying. In the future it is However, the recent area of interest has methods may be given as either a point possible board certifi cation may be required been estimating the age of living subjects. estimate with standard error, such as in order to practice in the discipline. You Pedodontists and orthodontists have an “10 years ± three years,” or might be a might look at applying for membership armamentarium of various methods to use point estimate with a probability, such with a DMORT team — the federal for estimating the dental age of patients, as “there is a 65 percent probability Disaster Mortuary Operational Response and some of these have been adapted this person is 16 years old.” This type Teams. These regional teams are deployed for forensic use. For odontologists, the of estimation range may be acceptable in the event of large-scale disasters such as request for an age assessment can arise in civil legal cases, but may not be hurricanes, tornados or fl oods. There are in cases such as refugee children who do accurate enough for use in criminal also state ID teams such as the California not know their own true age, in cases of cases. Age estimation is currently a fairly Dental Identifi cation Team (CalDIT) illegal immigrants who do not tell the active area of odontology research. and the California Society of Forensic

300 JUNE 2015 CDA JOURNAL, VOL 43, Nº6

Dentistry (CSFD) you might explore. deceased victims, especially children, better feeling than being able to help in One way to get a good introduction to is overwhelming for some. The mental some way, be it with law enforcement or by this discipline is to attend a training stresses are great. The crimes we are witness assisting a family in getting closure to some course such as the biennial Southwest to are often horrifi c. Frankly, no one is very awful, tragic event in their lives and Symposium on Forensic Dentistry, held likely to become rich from practicing helping them begin the healing process. ■ in even-numbered years at the University forensic odontology. In fact, a very REFERENCE of Texas Health Science Center at San signifi cant investment of time and money 1. The local medico-legal authority may vary from jurisdiction Antonio Dental School (utforensic.org). for training may be required in order to get to jurisdiction. In some states the Medical Examiner is the Remember, forensic odontology in started in the fi eld, and one might spend investigating authority, while in others the Coroner is the offi cial designated to investigate sudden, violent, or otherwise the real world is not as it is portrayed a lot of time as an unpaid “volunteer.” unexpected deaths. In California, for example, the Coroner’s on television. It is not easy and sanitary. To be blunt, it is not easy to establish Offi ce is administratively a part of the Sheriff ’s Offi ce in many Sometimes it is physically demanding work oneself and practice in the fi eld of forensic counties. See California Government Code §27490-27512. under the most challenging conditions. odontology, and there are only a handful THE CORRESPONDING AUTHOR, Roger D. Metcalf, DDS, JD, can be Sometimes we are deployed to remote of full-time positions available in the U.S. reached at [email protected]. locations with no basic amenities. The You might be wondering, “Why do you condition of the remains is often very do it?” Because, for those of us who choose unpleasant. Dealing with so many to practice forensic odontology, there is no

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JUNE 2015 301 2015 MASTER ESTHETIC DENTISTRY CONTINUUM

September 13, 2015 - June 6, 2016

Loma Linda University Division of Continuing Dental This comprehensive Continuum covers contemporary esthetic Education is proudly presenting the Master Esthetic and restorative dentistry, from a view of the latest materials to Dentistry Continuum (MEDC). The 2015 MEDC offers photographic skills and digital patient presentations, and will 250 hours of lectures, hands-on workshops, online provide an in-depth review of esthetic therapies and treatments sessions, case presentations, and literature reviews. that can be immediately incorporated into the dental practice. The 10-month program (1.5 on-site days per month) provides the It will expose participants to the latest equipment, materials participants with the most up-to-date information, techniques, and techniques, and provide in-depth hands-on experience and experience and knowledge from some of the most sought after training in the latest treatment options and modalities. Each experts in the field of esthetic dentistry. The curriculum is attendee will participate in case presentations on June 6, 2016 designed to prepare the participants to take the International The fundamental objective is to have each participant leave Academy for Dental Facial Esthetics/International Academy of the Continuum with the ability to immediately use the esthetic, Cosmetic and Esthetic Dentistry Fellow Membership Examination. restorative, and operative skills acquired through lectures The program is unique in that it takes a systematic and and workshops. Participants will have the opportunity to build interactive approach to esthetic and cosmetic dentistry, their confidence and knowledge in esthetic dentistry that they through evidence-based case presentations. can incorporate into their dental practice, and provide their patients with comprehensive esthetic dentistry options. COURSE DIRECTORS SPEAKERS AND TOPICS Viviane S. Haber, DDS ON-SITE ONLINE (ALL DAY SUNDAY AND HALF DAY MONDAY) (90 MINUTE EVENING SESSIONS) FACD, FIADFE, FPFA Assistant Professor Nicholas C. Davis, DDS, David Hornbrook, DDS, FAACD, Steve J. Anderson Restorative Dentistry MAGD, FAACD, FIADFE FACE The Art and Science for Case September 13 and 14, 2015 February 21 and 22, 2016 Presentation Loma Linda University Smile Design, Indirect Restorations Porcelain Veneers: Plan, Prep and Mark Estey, DDS School of Dentistry Provisional Removable Partial Dentures and Stephen R. Snow, DDS, FAAED Esthetics October 4 and 5, 2015 March 13 and 14, 2016 Porcelain Veneers: Lab Viviane S. Haber, DDS, FACD, Peter S. Young, DDS Mastering Digital Dental Photography: FIADFE, FPFA Communication and Cementation FAGD, FIADFE Cameras, Computers, and Consultations Color Character George Freedman, DDS, Joseph Kan, DDS, MS Jim McGuire, CDT Assistant Professor April 10 and 11, 2016 FAACD, FACD, FIADFE Shade Selection Restorative Dentistry November 1 and 2, 2015 Decoding Anterior Implant Esthetics: Steven R. Snow, DDS, FAAED Loma Linda University Dental Materials and Techniques: the Ortho-Perio-Restorative Simulation as a Diagnostic Tool New and Improved connection School of Dentistry Marilyn Ward, DDS, FAGD Fay Goldstep, DMD, FACD, FIADFE Corky Willhite, DDS, Teeth Whitening November 1 and 2, 2015 FAGD, FACD, FAACD May 15 and 16, 2016 Gerald Denehy, DDS, MS Credit: 250 hours of CDE credit Diagnostics, Bioactive Materials and Direct Realignment - A Conservative Tuition: $13,950 per person Remineralization Anterior Composites and Transitional Alternative to Orthodontics Bonding: Non-traditional Composite Deposit of $7,000 required to Joyce L. Bassett, DDS, FAGD, Dan E. Fischer, DDS confirm registration; remaining FAACD, FICDE Restorations for Major Occlusal and Adhesive Dentistry amount due by September 1, 2015. Esthetic Changes December 13 and 14, 2015 John Kois, DMD, MSD Aesthetics Built to Last: The Synergy Steve J. Anderson The Kois Dentofacial Analyzer For more information call the June 5, 2016 of Esthetics and Function in All Nelson A. Rego, CDT Office of Continuing Dental Ceramic and Composite Applications The Art and Science for Case Which Ceramic When 909-558-4685 Presentation Education at Ziv Simon, DMD, Richard Trushkowsky, DDS, FAGD, MSc, Dip.ABP Peter S. Young, DDS FICD, FACD, FADM, FPFA January 24 and 25, 2016 FAGD, FIADFE Pathways for Restorative Success Soft Tissue Esthetics and Essential June 5, 2016 - Class II Composite Resins and Periodontal Procedures Being a Dental Leader Cements dental identification

CDA JOURNAL, VOL 43, Nº6

Atypical Forensic Dental Identifi cations

Anthony R. Cardoza, DDS, and James D. Wood, DDS

ABSTRACT Forensic dental identifi cation specialists are typically the last conventional option for postmortem identifi cation. Forensic dental identifi cation is most often accomplished by comparing radiographs of the decedent’s teeth with the dental radiographs obtained from the dentist of the suspected victim. Unfortunately, antemortem dental radiographs are not always available. When presented with this challenge, the authors of this article have been successful in completing identifi cations using means other than dental radiographic comparison.

AUTHORS

Anthony “Rick” James D. Wood, DDS, orensic dental identifi cation of the tooth but also the morphology Cardoza, DDS, is a is a forensic dental specialists are typically the of the roots, pulpal chamber and their forensic dental consultant consultant for fi ve Northern for the County of San Diego California counties and last conventional option for relationship to their surrounding structures Medical Examiner, Imperial the California Department postmortem identifi cation. (i.e., sinus proximity, mandibular canal County Coroner, California of Justice, Missing/ DNA is also utilized, but due proximity, interproximal bony trabecular Department of Justice and Unidentifi ed Persons Unit. Fto the high cost and the extensive patterns, etc.). Following the natural director of the California He is a member of Disaster time required for analysis, it is used dentition, if you add man-made dental Dental Identifi cation Team. Mortuary Operational Confl ict of Interest Response Teams, DMORT. sparingly or when absolutely no restorations, the unique combination for Disclosure: None reported. Dr. Wood is also a member other option exists. Other forms of any given individual is greatly magnifi ed. of the California Assembly, postmortem identifi cation include There are numerous reasons for representing the second visual, personal effects, fi ngerprints, identifying the deceased. A legal district. scars, marks, tattoos, medical certifi cation of death is necessary to Confl ict of Interest Disclosure: None reported. radiographs and, of course, dental. consummate legal matters such as life Forensic dental identifi cation has insurance, business transitions, wills, etc. been successful because of the nature There are family and personal reasons of the human dentition. Enamel is the as well. In criminal investigations, it is hardest substance in the body and the important to establish the identity of only exposed portion of the skeletal the victim in order to proceed with the system (FIGURES 1 and 2). Teeth are very criminal investigation and to identify the resistant to thermal damage and blunt suspect. In a fi re, bodies are often burned force trauma, and the dentition remains beyond visual recognition (FIGURE 3). stable during tissue decomposition. Personal effects are also destroyed or lost The dentition is unique to a specifi c in a fi re. Even if the personal effects are individual. This includes not only the recovered, they may not be considered morphology of the coronal portion reliable due to the typical calamity that

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FIGURE 1. Orientation photo, mummifi ed FIGURE 2. Lateral view, resected jaws in occlusion. FIGURE 3. Level fi ve (cremated) postmortem burned skeletonized human remains. remains.

FIGURE 5. Postmortem radiographs.

FIGURE 4. Antemortem radiographs. surrounds a fi re and fi re suppression efforts. originals, are sent and have been either radiographs are not always available. In A forensic anthropologist will examine poorly duplicated and/or are not labeled California, it is a common misconception the remains of the skeletal system and right and left for orientation. In addition, that the legal requirement for record can then estimate age, race and sex of the antemortem radiographic image retention is seven years when in fact the victim. Positive identifi cation is may be of poor quality due to improper California has no mandatory time interval best performed by examination of the operator technique (cone cuts, overlapping for retention of records. As a result, surviving dentition. In a fi re where the interproximals, elongation/foreshortening, when the death investigator contacts the temperatures may be very high (1,000° etc.) or poor processing (contrast, burned decedent’s dentist of record, the records, C) even the dental remains may be images, etc.). When poor antemortem including the radiographs, are no longer destroyed. Crowns may fracture or radiographs are compared to an ideal available. This forces the investigator explode leaving only the roots. Roots postmortem radiograph, the two may not to pursue other options to successfully may burn leaving only the enamel appear consistent. This could seriously complete the necessary postmortem shell. The bone may also be completely hamper the identifi cation effort. identifi cation. When presented with consumed leaving only scattered roots In forensic dental identifi cation, this challenge, the authors have been with no bony sockets for reference. we stress that good quality, properly successful in completing identifi cations Forensic dental identifi cation is mounted and labeled original antemortem using means other than dental most often accomplished by comparing radiographs be sent for comparison. In radiographic comparison. The following radiographs of the decedent’s teeth addition, copies of the victim’s dental cases illustrate some of these examples. (postmortem) with dental radiographs treatment progress notes should be The fi rst case is an example of a obtained from the dentist of the suspected submitted as well. This allows the postmortem identifi cation utilizing dental victim (antemortem) (FIGURES 4 and 5). forensic dentist to verify dental treatment radiographic comparison to a medical Ideally, the antemortem radiographs should that was performed subsequent to radiograph. The decedent, a 60-year- be the original full-mouth series. Often the date of the radiographs. This may old white male, was seen in the parking this is not the case. Children’s radiographs then explain the existence of a dental lot of a department store pacing around are typically bitewings only unless they restoration that is not present in the his vehicle. Minutes later witnesses have orthodontic records as well. Often antemortem fi lms or a missing tooth. noted his vehicle engulfed in fl ames times duplicate radiographs, not the Unfortunately, antemortem dental with him sitting in the passenger seat.

304 JUNE 2015 CDA JOURNAL, VOL 43, Nº6

FIGURE 7. Antemortem medical FIGURE 8. Postmortem periapical radiographs (tooth No. 30, radiograph with dentition cropped and implant at No. 31). enhanced.

FIGURE 6. Antemortem medical radiograph with mandibular dentition (tooth No. 30, implant at No. 31) visible.

Bystanders attempted to extinguish the fi re and a 911 call was placed. Emergency FIGURE 9. Antemortem pretreatment maxillary FIGURE 10. Postmortem maxillary model. personnel responded and confi rmed the orthodontic model. death without intervention was due to the obvious thermal injuries. A gas can was found in the back seat. The autopsy confi rmed the cause of death as inhalation of products of combustion and the manner of death as suicide. The investigator summoned the forensic odontologist to complete a dental identifi cation. Only medical radiographs of the head and neck were available. These radiographs were a frontal and lateral skull series highlighting a medical implant on the cervical vertebra. The dentition was visible on both radiographs but because of the radiographic orientation, the lateral fi lm FIGURE 11. Palatal rugae comparison of antemortem to postmortem models. showed the lower teeth more clearly and with more detail (FIGURE 6). Tooth No. 30 (lower-right fi rst molar) was restored been restored with a crown. Postmortem of palatal rugae. The decedents were with a porcelain-fused-to-metal crown dental radiographs were taken and the involved in a motor vehicle collision. The and had an endodontic fi ll with two posts positive identifi cation was completed decedents’ SUV was stopped in traffi c and in both the mesial and distal roots. In based on the comparison of these dental rear-ended by an intoxicated driver who addition, tooth No. 31 (lower-right second restorations (FIGURES 7 and 8). was driving home from an impromptu molar) had been replaced with a dental The next case is an example of Christmas party. His full-size pickup implant and healing cap but had not identifi cation through the comparison truck was traveling in excess of 70 mph

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FIGURE 14. Comparison of antemortem to postmortem models.

FIGURE 12. Antemortem models of FIGURE 13. Postmortem models of the the edentulous mouth. edentulous mouth.

FIGURE 15. Photographic stand and computer for photographic superimposition. when it impacted the SUV, causing both the orthodontist in Tijuana for possible We have commented on the vehicles to spin around and then burst postmortem comparison. The driver of the uniqueness of the human dentition and into fl ames. The driver of the truck was SUV had antemortem dental radiographs this extends to the edentulous. In this able to exit his vehicle unscathed but both available from her dentist in San Diego. case, an elderly woman died in a fi re that occupants of the SUV were killed upon The investigator obtained those records consumed her mobile home and burned impact. The bodies were charred to a level and the odontologist completed the her beyond visual recognition. During four postmortem state (burned beyond dental identifi cation that night. autopsy, it was discovered that she was recognition). Identifi cation by dental On the following night, the postmortem edentulous and was not wearing dentures at record comparison would be necessary. The dental identifi cation was completed for the the time of the fi re. In many fi res involving medical examiner’s investigators worked passenger. The investigator had obtained people who wear dentures, the dentures through the weekend procuring the the antemortem pretreatment orthodontic can survive depending upon the intensity necessary antemortem dental records for models (FIGURE 9) and fortunately the and duration of the fi re. California law postmortem comparison. It was assumed postmortem condition of the oral cavity requires dentists to offer the option to that because the passenger in the SUV was unaffected by the fi re and was sound. patients of having a denture labeled with was traveling to Tijuana, Mexico, for The jaws were resected, an alginate an identifying mark such as a name. This an orthodontist appointment, adequate impression of the maxilla was taken and a label, while not suffi cient evidence for a dental records would be readily available. stone model was poured up to be separated positive identifi cation, can contribute to Unfortunately, this was not the case. at a later time. Once the model was a preponderance of evidence that allows On Monday morning, the investigator trimmed and fi nished (FIGURE 10) a the coroner or medical examiner to make discovered that the Mexican orthodontist comparison was made between the a judgment as to identifi cation. In this had not taken pre-orthodontic treatment antemortem and postmortem models. case, there were no dentures. However, radiographs of any type. The only There were numerous consistencies in the the decedent was in the process of having pretreatment records the orthodontist patterns of the rugae and this identifi cation dentures made. Antemortem models possessed were study models. It was decided was clearly to the level of positive of the edentulous mouth were made to obtain the pretreatment models from identifi cation (FIGURE 11). available for comparison (FIGURE 12).

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FIGURE 17. Postmortem anterior dentition FIGURE 18. Postmortem anterior dentition superimposed onto antemortem photograph (100 superimposed onto antemortem photograph (50 FIGURE 16. Resected maxilla in correct photographic percent opacity). percent opacity). orientation.

Impressions were made of the edentulous photo nearby was crucial when taking was very fragile and powdery; it crumbled victim using a polyvinyl-siloxane the postmortem photo of the resected when manipulated (FIGURE 19). Amongst impression material with stock metal jaw. This is because the angulation of the this material were the enamel crowns of denture trays. Stone models were photos must be duplicated in the X, Y and teeth and some associated dental amalgam made for comparison (FIGURE 13). It Z (depth) axes for the superimposition to restorations. Relying on basic dental became readily apparent that the many be correct and accurate. After shooting anatomy it was possible to determine that anatomical features of the postmortem numerous photos, the best picture, which the dentition was from a single individual edentulous mouth compared precisely captured the correct angles in all three (FIGURE 20). Antemortem dental X-rays to the antemortem models allowing for planes, was achieved (FIGURE 16). were available from the possible decedent, a positive identifi cation (FIGURE 14). Next, using Adobe Photoshop digital but were of poor quality and a signifi cant If there are no dental records of imaging software, both the antemortem amount of dental work had been performed any type available, photographic and postmortem images were cropped, after the fi lms were made. Without the superimposition has become another recent resized lifesize 1:1 (actual lifesize) ability to orient the teeth in an arch as option with the advent of analysis using and then the postmortem image was they might appear in the mouth, a large digital photo software. The following case superimposed onto the antemortem number of radiographs from varying is an example of a dental identifi cation image (FIGURE 17). This image was faded angles were made of individual enamel through photographic superimposition away in percent increments to reveal crowns for comparison. While the overall of the maxillary anterior dentition. the underlying antemortem image. The evidence indicated that the identifi cation The body of an adult male who had ideal fade was 50 percent opacity, which could be considered possible, and that been missing for approximately one month allowed both images to appear together the decedent could not be eliminated was found next to his car at the base of and showed multiple consistencies in the from consideration, a single enamel shell a 300-foot ravine. The body was in an dentition (FIGURE 18). These multiple and its associated amalgam restoration advanced state of decomposition and the consistencies allowed for a confi dence became the subject of further scrutiny. pathologist requested the identifi cation be level of positive identifi cation. After more than 20 exposures, an angle completed by dental record comparison. Occasionally, the thermal damage from was duplicated that allowed for a positive Unfortunately, there were no antemortem a fi re has such devastating impact that identifi cation based upon the unique dental records of any type available. The there is little left of the human body that is characteristics of the amalgam restoration investigator discovered that the family had recognizable as human tissue. In the early (FIGURE 21). The person providing the tip just recently posed for family photographs. 90s, a 23-year-old woman disappeared from was a juvenile at the time of the murder. These photos were shot by a professional a rural community in Northern California. His father murdered the young woman photographer and were readily available. More than 20 years later, the local sheriff’s and forced his son to help him dispose of The author obtained the photos and chose department was contacted by someone the body. The tipster feared for his own the photo that best depicted the maxillary claiming to know where a body had safety and waited until his father had died anterior teeth from canine to canine (teeth been taken and burned after a homicide. before leading authorities to the remains. Nos. 6-11). At the medical examiner’s Provided with detailed maps of the area, The uniqueness of dental restorations offi ce, the author then resected the sheriff’s investigators found a small amount can be as critical as the uniqueness of the maxilla and placed it on a photographic of charred material that was recovered for dentition as illustrated by the above case stand alongside a table with a laptop analysis. The body had been burned along and the one that we will now describe. that had the antemortem photograph with rubbish and the fi re had burned for In 2013, a badly decomposed body was (FIGURE 15). Having the antemortem a very long time. The recovered material recovered along the Marin coast, north

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FIGURE 19. Human cremated remains. FIGURE 20. Collection of dental evidence from cremains.

FIGURE 21. Antemortem to postmortem comparison FIGURE 22. Gold “fi lling” (onlay) recovered of amalgam restoration. in decedent’s home. FIGURE 23. Postmortem mandible showing tooth No. 18 with missing restoration. of the Golden Gate Bridge. There have been more than 1,600 confi rmed suicide victims who have jumped from the bridge since it opened in 1937. It is very likely that there are more victims who were not witnessed or otherwise confi rmed as having jumped as well. Personal effects and the circumstances of discovery of this body were such that investigators were able to fi nd a possible missing person that warranted further FIGURE 24. Postmortem mandible showing gold FIGURE 25. Postmortem mandible showing gold investigation. In this case, family and onlay seated in place on tooth No. 18. onlay seated in place on tooth No. 18. friends had no information that could lead to dental records. Interviews with family and friends led to the discovery of itself a defi nitive identifi cation because should be aware that even details that of a gold fi lling that had fallen out there was no antemortem trail of evidence may seem insignifi cant at fi rst could and was saved in a plastic bag in the to confi rm the source. The identifi cation prove to be a critical clue in the identity decedent’s apartment (FIGURE 22). was determined by the coroner on the of an individual. Therefore, it is prudent Examination and comparison to preponderance of evidence in the case to thoroughly document the existing the remains showed that tooth No. 18 and in essence, the onlay was considered conditions of new patients and subsequent (lower-left second molar) had what a personal effect by investigators. dental work. It is critical that the entire appeared to be a lost onlay (FIGURE 23). original documentation be submitted to When compared to the gold fi lling, it was Conclusions authorities when requested. In conclusion, immediately obvious that the restoration While traditional dental it is important to remember that patient fi t the tooth extremely well and because identifi cations made by comparisons of privacy restrictions do not apply when of the nature of the restoration it was antemortem and postmortem radiographic a person is deceased and authorities highly unlikely that it could be associated evidence account for the vast majority request a decedent’s dental records. ■ to another individual (FIGURES 24 and of identifi cations, unique details of the THE CORRESPONDING AUTHOR, Anthony R. Cardoza, DDS, can 25). In this case, the positive association dentition captured in other ways can be reached at [email protected]. of the onlay to the tooth was not in and lead to positive identifi cations. Dentists

308 JUNE 2015 injury analysis

CDA JOURNAL, VOL 43, Nº6

Bite-Mark and Pattern Injury Analysis: A Brief Status Overview

Gregory S. Golden, DDS, DABFO

ABSTRACT Bite marks are one component of forensic investigation requiring subjective interpretation for determining unknown source evidence to a putative suspect. Recent scrutiny has lead to questions about the scientifi c validity of patterned evidence, bite-mark analysis in particular, and its role in judicial proceedings. This article discusses some issues that persist in forensic circles and the diffi culties surrounding the fi eld of bite-mark analysis that inherently must employ human subjectivity in its execution of duty.

AUTHOR

Gregory S. Golden, o say that bite-mark analysis the teeth of defendant Walter Edgar DDS, DABFO, received has taken its rightful place Marx and a three-dimensional bite his dental degree from the Herman Ostrow in the history of forensic on the nose of 75-year-old homicide School of Dentistry of the investigation would be an victim Lovey Benovsky. Marx was University of Southern unwise statement. Little did convicted of voluntary manslaughter California in 1975. He Tthe Texas Court of Criminal Appeals partly as a result of the weight of the became a diplomate of the realize in 1954 (Texas v. Doyle) the bite-mark evidence, thereby setting the American Board of Forensic Odontology (ABFO) in impact a peek into Pandora’s box standard for cases involving bite marks 1982. In 1992, he became would have on the world’s judicial as evidence. In 1989, Theodore “Ted” the chief odontologist for system of fi nding truth for the trier Bundy, a self-proclaimed serial killer, was San Bernardino County and of fact when general dentist William executed. While normally a master at continues to serve several Kemp tied suspect James Doyle’s removing incriminating evidence from Southern California counties as a forensic consultant. teeth to a bite in a piece of cheese his victims, Bundy left a bite mark on He is a co-director of left at the scene of a grocery store the body of Lisa Levy, a Florida State CDA’s Committee on burglary. Twenty-one years later the University sorority coed. Several experts Mass Disasters and the box was fully pried opened on the testifi ed about that bite mark during southern regional director admissibility of bite-mark evidence in his trial, thereby reaffi rming the value for the California Dental Identifi cation Team. People v. Marx (Court of Appeals of of bite pattern injuries on human skin Confl ict of Interest California, Second Appellate District, committed during violent crimes. Disclosure: None reported. Division Five, Dec. 29, 1975), wherein Much has happened since then. three odontologists testifi ed that Bite-mark evidence has been accepted they could see similarities between during trials in every one of the United

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States.1 With the acceptance of bite- In light of the historic blunders and Pros and Cons mark evidence as part of the judicial the technological advances in forensic There are currently two factions with process, hundreds of trials have given investigation since those earlier years, strong and equally opposing positions credence to a diagnostic procedure that one might argue that that was then, this regarding bite-mark evidence. Those the scientific community has accepted, is now. Largely that is true. Forensic who support bite-mark evidence are even embraced, until recently. The science has a much better Occam’s razor dedicated to further research and its emerging notoriety and recognition to deal with the solutions of proving guilt continued judicious application, and they of bite-mark evidence brought to or innocence now that DNA profi ling acknowledge its subjective limitations. the field of forensic dentistry and its has come to fruition. Before DNA Most people in this group consist participants was somewhat premature, typing and the evolution of improved of forensic dentists and prosecuting in that the opinions of some of its photographic and analytical techniques attorneys, however, there is at least one more enthusiastic members in their for tool marks, hair, handwriting, etc., defense attorney who is also concerned efforts for “due diligence” overstepped investigators were limited by their own about the dominance of the current their abilities to accurately interpret amount of experience and their ability to innocence movement.2 The forensic what they were examining, much less experts have a unifi ed goal — to improve exercise sound judgment regarding their respective fi elds by conforming to their opinions. As a result of a desire the rules of scientifi c investigation and to “do the right thing” on the part of Forensic science has a to minimize bias from the subjective a few forensic dentists, coupled with much better Occam’s razor elements inherent in the process. The bungled police work, misidentification to deal with the solutions of skeptics who arrogantly oppose bite-mark from mistaken or bought eyewitnesses, evidence, specifi cally the Innocence coerced false confessions, tunnel- proving guilt or innocence Project (IP), target bite-mark analysis vision by investigators, unethical or now that DNA profi ling within an extensive laundry list of incompetent lawyers, uninformed has come to fruition. those other troubling areas of forensic judges and phony science, the most science. They consider all human-based, unspeakable of outcomes occurred. subjective pattern comparisons to be Innocent people were sentenced to unreliable, and bite-mark evidence in prison. Some 30 to 40 years after the interpret accurate pattern recognition. particular is, as one of their loudest criers innocent person had been vindicated As for bite-mark injuries, considering says, “... the poster child of unreliable and the true perpetrator identified, that the majority of them are evaluated forensic science.3” Not surprisingly, the a review of how the damage was from an elastic medium such as human IP dislikes all forensic odontologists undone is varied, including all those skin and are typically delivered under who engage in bite-mark analysis, and reasons listed above for the original dynamic, variable conditions, one especially those who have rigorously convictions plus more. Louise would expect to see certain inherent achieved board-certifi ed status from Robbins, a footprint expert whose distortions in the victim’s injury. This the most respected credentialing self-proclaimed forensic abilities hypothesis has proven itself true. One organization that exists, the American included her apparent talent to match would think that information alone Board of Forensic Odontology (ABOF). a footprint on any surface to the would persuade forensic odontologists to Everyone in both factions recognizes person who made it, appeared in more use extreme caution when attempting to that there have been errors committed, than 20 criminal cases over a 10-year identify the perpetrator of a bite-mark so far in what has amounted to a period. Her claims were vehemently injury, particularly when their opinion small fraction of the total number contested and were ultimately may cause a signifi cant impact on an of the hundreds of cases adjudicated debunked. Other lab analysts individual’s freedom. It is with these throughout the U.S. courts wherein purposely falsified test results and their thoughts in mind that this author will bite-mark evidence has been admitted subsequent testimony to manipulate attempt to describe the current state into testimony. The IP has focused on the trial outcome. Once exposed, of bite-mark evidence and analysis two dozen exoneration cases wherein they immediately lost credibility. and explain where it is headed. it describes bite-mark evidence played

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a part in the conviction of an innocent allowing bite-mark evidence in judicial Many of the wrongly convicted, once person. A closer look into those cases proceedings, why then do they feel exonerated, are urged to civilly sue shows that only 10 of them were it is necessary to ask members of the the expert dentist(s), the agencies and reversed from DNA evidence, and not same targeted organization of experts jurisdictions that put them behind bars. all of them had DNA collected from to assist them in the exonerations of The IP most likely takes its fair share the bites.4 Additionally, in those cited those wrongly convicted defendants? of these generous fi nancial awards. cases where bite-mark evidence was On the surface, it would appear that As unrealistic as this may sound, a present, the reversals came from various those hostile to bite-mark evidence, more unifi ed and constructive approach means other than DNA from the actual such as one IP attorney who refers to might be to have the IP and forensic bite. Interestingly enough, if one were the admission of bite-mark evidence in experts work together toward the to look deeper into those reversals one the case of NY v. Dean as “... a victory goal of improving the mechanism for would fi nd that many of the errors were for the fl at-earth society,”5 and a former interpretation of scientifi c evidence committed by the same handful of but now resigned ABFO diplomate and rather than perpetuate what to date so-called “experts,” most if not all who prolifi c blogger who refers to bite-mark has been a one-sided vitriolic portfolio have ceased analyzing bite-mark cases in of invectives. The source of the hate- recognition of their own limitations. speak emanates from a collection of One must also consider while there media wonks who put the negative are no solid statistics, law enforcement In this author’s 35 years of spin on bite-mark evidence,8,9 often case fi les are fi lled with scores of forensic work, numerous cases misinforming readers with inaccurate instances where bite-mark evidence with crucial bite-mark evidence reporting of the entirety of the factual has lead to children, who would have details of the case, never mentioning otherwise ended up dead, being removed helped bring closure to friends, those cases wherein bite-mark evidence from an abusive environment. In this families and relatives of victims was crucial to an accurate judicial author’s 35 years of forensic work, of abuse, rape and homicide. outcome or saving of a life. The confl ict numerous cases with crucial bite-mark continues to wage on. Most recently, evidence helped bring closure to friends, the Washington Post chimed in with families and relatives of victims of a four-part lambasting of bite-mark abuse, rape and homicide. In similar experts as “skin readers,”6 would never experts and the notorious cases, most cases, countless hours of court time invite board certifi ed experts from the that occurred decades ago.8 Ultimately, and taxpayer dollars have been saved same organization they attack to assist decisions regarding the admission of by defendants’ plea bargaining rather them with their agenda. Yet they have. bite-mark evidence have been, and than going to trial once confronted with To be fair, one lone director of the most likely will be, determined in incriminating bite-mark evidence. IP recently stated, “Just because the each case by the Frye* and Daubert Interestingly enough, when science has been abused doesn’t mean standards and the decision will land enlisted for assistance by the IP, several it doesn’t have value. That’s not to say squarely in the hands of the courts, odontologists certifi ed by the ABFO that odontology is impossible. There because judges are the fi nal gatekeepers (this author included), have willingly are some strong conclusions that can be of admission of this type of evidence. aided it in seeking freedom for the drawn from odontology and bite marks wrongly convicted in an effort to right specifi cally. It’s just like any tool; you The NAS Report those judicial travesties. And we did have to know how to use it properly.”7 In February 2009, the National so pro bono. Knowing this fact one While the IP’s cause is noble, a deeper Academy of Sciences (NAS) issued its might ask, if lawyers who work for look into its motivation for righting report, Strengthening Forensic Science in the IP are so vehemently opposed to the miscarriages of justice is required. the United States: A Path Forward,11 as

*The Frye standard, Frye test, or general acceptance test is a test to determine the admissibility of scientifi c evidence. It provides that expert opinion based on a scientifi c technique is admissible only where the technique is generally accepted as reliable in the relevant scientifi c community. In Daubert v. Merrell Dow Pharmaceuticals, 509 U.S. 579 (1993), the Supreme Court held that the Federal Rules of Evidence superseded Frye as the standard for admissibility of expert evidence in federal courts. (caselaw.lp.fi ndlaw.com/scripts/getcase.pl?court=US&vol=509&invol=579 ) Some states, however, still adhere to the Frye standard.9

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a blanket government mandate for all forensic investigators to conform to the scientifi c community at large, and to adapt to accepted scientifi c principles and associated research. Since its publication, there have been varied interpretations by members of the same forensic community FIGURE 1. A pattern “suggestive of a bite mark” on FIGURE 2. An adult dentition bite mark on the of not only exactly what the NAS report the abdomen of a rape victim. Low evidentiary quality, shoulder of a female victim of a homicide. Dental no analysis required. actually said, but what it meant for them. arches and individual tooth markings are identifi able. High evidentiary quality, analysis should be initiated. Either way, the fall-out was felt in every corner of forensic investigative fi elds and for now it seems to have forensic scientists and anesthetized pigs. Needless to say, must proceed. The NAS said so, but productively working toward those controlled, long-duration biting of a there are conditions to be met fi rst. intended goals. In 2013, the National refrigerated cadaver with a pair of vice- Research on living subjects must Institute on Standards and Technology grip-mounted study casts, (sometimes comply with rules established by certain (NIST) developed several Organization having maxillary and mandibular models organizations such as the Institutional of Scientifi c Area Committees (OSAC) from two people) will produce totally Review Board (IRB), a committee that working in conjunction with the different data results than research assures in advance and by periodic National Department of Justice to conducted on living people. As useful as review that appropriate steps are taken to strengthen forensic science in the U.S. this research has been, bites on cadavers protect the rights and welfare of humans Members of these committees and and anesthetized pigs can be manipulated participating as subjects in these research subcommittees represent leaders in to produce distorted or nondistorted studies. Complicating the process are the fi elds of DNA analysis, chemistry/ patterned injuries. Depending on what other agencies such as the National instrumental analysis, IT/multimedia results the researchers want to end up Institutes of Health (NIH), the Forensic evidence, crime scene/death investigation, with determines how the bites are made. Science Education Programs Accreditation physics/pattern analysis, even forensic One would expect that research on Commission (FEPAC), NIST, NAS and odontology. Information on these teams living subjects would produce even more the National Research Council (NRC), to and their specifi c areas of scientifi c distorted bites. And therein lays just name but a few. Each of these agencies has investigation can be found at nist. one part of the problem. Locating live an active role in authorizing, controlling gov/forensics/osac/index.cfm. volunteers who are willing to participate and validating certain areas of scientifi c in bite-mark research studies can be research and accreditation. This is not to The Research like searching for a kid who wants a say future research in bite-mark analysis Prior to the NAS recommendations, tetanus shot. Indeed, those who have on living humans is on a dead-end street. several research projects in odontology volunteered have made some interesting, Quite the opposite is true. One recent had been conducted to determine nonsupportive vocalizations while being scientifi c presentation15 and future research important issues relating to the accuracy bitten at 90-100 pounds per square inch projects are currently being designed to of bite-mark pattern injuries, such as (PSI) under controlled conditions. And address these ethical issues so that more the uniqueness of human dentition12,13 as expected, the delivered bites contain realistic and scientifi cally valid data can and the amount of distortion in skin varied amounts of distortion, size and be accumulated to answer the questions during the act of biting.14 Results from appearance. What the data from these of the uniqueness of teeth and their those studies have so far proven that live-subject tests have given researchers reliability for accurately transferring an more and better-designed research is valuable insight into exactly how individual’s dental signature to living is needed. Questions regarding the much pressure is required to deliver human skin under controlled conditions. inherent limitations of several of these a sustainable bruise, and even more Most promising is the research on studies were glaringly focused, in that profoundly, the infl icted pain victims collection of salivary DNA from bite the predominance of that research must experience during violent criminal marks.16 DNA evidence always trumps was conducted on human cadavers activity. Nevertheless, scientifi c research subjective interpretation or opinions by

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Injury

No analysis Suggestive of a Analysis No comparison Not a bite mark Bite mark bite mark No comparison

Bite-mark comparison Bite-mark comparison The biter Not excluded

Bite-mark comparison Can identify Arches Bite-mark analysis Bite-mark comparison individual arches and/or individual The probable biter May be done but not likely to Excluded and individual teeth teeth indistinct diff erentiate between biters

Bite-mark comparison Bite-mark comparison Not excluded Inconclusive Similar or non- Bite-mark analysis Distinctive dentition Bite-mark comparison distinctive dentition Excluded

Bite-mark comparison Inconclusive

Bite-mark comparison Not excluded Open population Closed population Bite-mark analysis Bite-mark comparison of biters of biters Excluded Suspected If single suspected biter Bite-mark comparison biters Create dental lineup Inconclusive

FIGURE 3. The ABFO fl ow chart (2013).

experts in any pattern injury analysis, Meeting the Evidentiary Threshold on the abdomen of a rape victim that which is precisely why the current There are several requirements does not meet the threshold of useful standard operating procedure for bite- to be met before a bite mark should evidence or the defi nition of a bite mark investigation is to swab the bite be considered for analysis. The fi rst mark.19 Although it is round and appears for DNA fi rst, before doing anything consideration is that the questioned to have been made by teeth, there else.17 Another promising tool currently bruise is, in fact, identifi able as a bite. are no individualizing characteristics under development by the ABFO is The source can be from an animal revealing tooth size or position evident bite-mark profi ciency testing.18 Testing or human. Because forensic dentists in the bruise. Once a bruise pattern an expert’s ability to be a “skin reader” routinely see pattern injuries that mimic meets the criteria for being an actual may raise a few eyebrows, but if designed bite marks, anything “suggestive of” bite mark, the second level to consider properly, in the long run it should have or “not a bite” requires no analysis or before proceeding with analysis a positive infl uence on the discipline. comparison. FIGURE 1 is a bruise pattern addresses the quality of the bite mark.

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The more individual characteristics should utilize the current version of dentists-who-describe-themselves-as-%E2%80%9Cskin- reading%E2%80%9D-experts. there are visible to the observer (i.e., the fl owchart to its best advantage. 7. Simpson A. Director, California Innocence Project. separate and distinct arches, identifi able And, as a secondary fail-safe measure, 8. www.washingtonpost.com/news/the-watch/ tooth marks, etc.), the more likely the the ABFO now mandates that the wp/2015/02/13/how-the-fl awed-science-of-bite-mark- analysis-has-sent-innocent-people-to-jail. pattern injury will be useful as evidence primary investigator seek additional 9. news.yahoo.com/ap-impact-bites-derided-unreliable- (FIGURE 2). FIGURE 2 represents a methods and conclusion corroboration court-150004412.html. human adult bite on the shoulder by independent analyses from other 10. en.wikipedia.org/wiki/Frye_standard. 11. www.nap.edu/openbook.php?record_id=12589. of a homicide victim. Maxillary and equally qualifi ed or more experienced 12. Miller R, et al. Uniqueness of the Dentition as Impressed mandibular arches can be determined, experts. The review is done blind, in Human Skin: A Cadaver Model. J Forensic Sci 2009: 54 as well as the individual teeth present without the other experts knowing any (3): 909-14. 13. Kieser JA, et al. The uniqueness of the human anterior in both arches. A third consideration details of who the suspected biter(s) dentition: a geometric morphometric analysis. J Forensic Sci is the population of suspected biters. A is or other circumstances of the case. 2007; 52 (3): 671-7. defi ned population is one in which there To summarize, forensic investigators 14. Bush M, et al. Biomechanical Factors in Human Dermal Bitemarks in a Cadaver Model. J Forensic Sci, 2009: 54 are a limited number of suspects, usually tasked with the specifi c fi elds of pattern (1): 167-76. targeted by law enforcement, social analysis realize that in the short 15. Senn D, et al. High-Speed Videography of Simulated services or health care providers. The run there will be limitations on the Human Bites on the Skin of Living Humans. AAFS Scientifi c Session, Odontology Section, 2014. more differences there are between the acceptance of their opinions in court 16. Sweet DJ, et al. An improved method to recover saliva suspect’s alignment and number of teeth, because their evaluations have, by from human skin: The double swab technique. J Forensic Sci the more likely the actual suspected nature, a subjective component. With 42:320-322. 17. ABFO Reference Manual, January 2015. biter can be identifi ed. An undefi ned the exception of automated fi ngerprint 18. Minutes from ABFO Bitemark Committee meeting. population presents a greater problem identifi cation, the development February 2014, in conjunction with Occupational Research in that there is no limit to the number of nonbiased computer analysis of Associates Inc. of suspected biters. These prerequisites latent patterned evidence is relatively 19. ABFO Reference Manual, January 2015. drive the analytical process and are still in its infancy. Whether or not THE AUTHOR, Gregory S. Golden, DDS, can be reached at necessary steps for the investigating scientifi cally based devices and testing [email protected]. odontologist to evaluate prior to the methods are developed that serve to analysis and comparison of putative brace the underpinnings of bite-mark suspected biters before developing analysis will determine its lifespan in conclusions or linkage to them. the future, and whether or not it will FIGURE 3 represents the initial continue to be accepted in courts. For version of the ABFO bite-mark analysis the most part, it would appear that in fl owchart. Since its acceptance, and spite of previous mistakes, the research due to recent validation studies done is heading in the right direction. The by the ABFO, acknowledgment that scientifi c evolution of man’s knowledge a more refi ned and scientifi cally is always a work in progress. ■ verifi able version is necessary. The next version will have signifi cant changes REFERENCES 1. Pretty IA, Sweet DJ. The Judicial View of Bitemarks that should minimize interexaminer Within the United States Criminal Justice System. J Forensic error. In the meanwhile, odontologists Odontostomatol vol. 24, no. 1, June 2006. are encouraged to follow the current 2. Smith A. In Praise of the Guilty Project: A Criminal Defense Lawyer’s Growing Anxiety About Innocence fl owchart from the top down. Doing Projects. Georgetown University Law Center, 2010 so provides critical decision points scholarship.law.georgetown.edu/facpub/876. for directing the investigating 3. www.innocenceproject.org/news-events-exonerations/ bite-mark-evidence-deemed-unreliable. odontologist in a scientifi c and logical 4. www.law.umich.edu/special/exoneration/Pages/about. step-by-step path toward accuracy. aspx. For now, regardless of one’s practical 5. http://wrongfulconvictionsblog.org/2013/09/06/a- victory-for-the-fl at-earth-society. experience, bite-mark analysts 6. bitemarks.org/2011/03/30/the-inane-responses-of-

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Forensic Dental Age Estimation: An Overview

James M. Lewis, DMD, DABFO, and David R. Senn, DDS, DABFO

ABSTRACT Forensic age estimation is a scientifi c process that estimates an individual’s true chronologic age by assessing skeletal and dental development and maturation. Although human growth and maturation is unique to each individual, dental techniques for estimating age are currently considered the best in assessing true chronologic age particularly during the age range when the dentition is undergoing morphologic development. This article reviews the principles, methodology and commonly used techniques in forensic age estimation cases.

AUTHORS

James M. Lewis, DMD, David R. Senn, DDS, lthough the fi rst recorded Age estimation theory can be DABFO, is a forensic dental DABFO, is the director of use of dental age estimation categorized into three basic scientifi c consultant for the state of the Center for Education is attributed to the Romans rationales: formation and growth Alabama, a fellow of the and Research in Forensics American Academy of at the University of Texas for use in assessment of age changes, postformation and maturation Forensic Sciences and the Health Science Center at for military conscription, changes and biochemical changes. age estimation committee San Antonio. He is a fellow Ascientifi c rationale was not applied Regardless of which scientifi c chair of the American Board of the American Academy to dental age estimation until child rationale is employed in the assessment of Forensic Odontology. of Forensic Sciences and labor laws of the early 1800s prompted of age, its scientifi c basis can be explained Confl ict of Interest past president of the Disclosure: None reported. American Board of Forensic a legal interest in assessing the true mathematically by the normal distribution 1,2 Odontology. chronologic age of children. Forensic curve, also known as a bell curve. Confl ict of Interest age estimation has many possible Morphologic development, histologic Disclosure: None reported. applications in modern society. It and anatomic postformation changes, can signifi cantly aid the process of and biochemical changes of the dentition identifying missing and unidentifi ed conform to a process of random variation individuals through estimation whereby these events generally occur of the age at death; differentiate within a given time interval or age range. clustered victims in mass disasters; aid At any given stage of development or immigration service in the processing maturational change, the statistical results of undocumented immigrants; help will cluster about the mean. There will to determine eligibility of social always be individuals described as outliers. benefi ts and questions of age of These outliers will decrease in frequency the license; and assist the legal system further they are removed from the mean, regarding criminal and civil matters and the results will occur symmetrically. involving questions of legal majority. The measure of variability and risk of a

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TABLE 1 Comparison of Two Age Estimation of Children Techniques Demirjian et al. Moorrees et al. Age range (where useful) Approximate age 3–14 years Birth to maturity Weight assigned to each tooth Equal Individual Radiographic Techniques Error rate 80 percent confi dence 95 percent confi dence The Moorrees et al.,7,9 Demirjian et Population studies Multiple Few al.9,10 and Mincer et al.11 radiographic Limitations Fragmented cases Low number of techniques require the staging of the and missing teeth population studies teeth based upon a tooth’s degree of morphological development. When using any of these methods, teeth that TABLE 2 are malformed or have any associated Adult Variable Checklist pathology should not be considered in Variables Kvaal Maples Lamendin Prince/ Bang and Cameriere Cameriere the age assessment process. Moorrees Ubelaker Ramm 2004 2007 et al. and Demirjian et al. techniques Root translucency ✓✓✓ assist in the age estimation of children. (intact) The Moorrees technique describes 14 Root translucency ✓✓stages of tooth development and allows (sectioned) for age assessment utilizing individual teeth, while the Demirjian technique Secondary dentin ✓ requires the staging of all seven teeth on Periodontal ✓✓ the mandibular left side using an eight- recession stage system. TABLE 1 compares and Root length ✓✓ contrasts the differences between the Radiograph ✓* ✓* ✓** Demirjian and Moorrees techniques. In social benefi t cases and cases of legal *Radiographs taken from labio-lingual direction. age of majority, age is most commonly **Radiographs taken from both labio-lingual and mesio-distal directions. assessed using the Mincer et al. technique staging third molar development. For each normal distribution curve is defi ned by Age Estimation Charts stage of development, these studies publish another mathematical expression unique The age estimation charts statistical data on estimated age, standard to each individual curve, its standard were developed through analysis deviation and probability of attaining deviation. This allows the forensic of the remains of various skeletal age 18. Knowing the probability of the investigator to not only provide authorities collections.4,5 These charts consider attainment of age 18 is most benefi cial in with an assessment of the estimated age neither the ancestral origin nor the immigration cases. However, in other cases of an individual, but also to provide a gender of an individual when utilized of legal age of majority, the probability of statistical range of age possibilities.3 in age assessment. When accuracy attaining any other age in question must is paramount, it is crucial to utilize be hand calculated. Key factors in these Formation and Growth radiographic age assessment techniques types of estimation of age cases include: Techniques that utilize tooth that consider genetic factors (ancestry ■ Consideration of all teeth formation and growth changes assist in and gender). Extreme environmental in the dentition.8 the age estimation of infants, children factors may also affect the growth and ■ Consideration of gender and and adolescents. Tooth formation and development of the dentition and environmental factors.6 growth can be subdivided into progressive should be considered. Environmental ■ Use of the best ancestral population- morphological changes describing factors may include nutrition, disease, specifi c study available.12 development of the tooth’s crown, root treatment of disease, habits, addictions ■ Consideration of the effects and apex, and eruption sequence of and place of residence.6 Therefore, of ancestral admixture.13 the dentition. It should be noted that when possible, the statistical data ■ Utilization of multiple eruption pattern techniques are less from the most closely associated technique modalities for accurate compared to methods considering population study to the individual age estimation, including morphological development of teeth.3 in question should be used. anthropologic methodology.3,6

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known as stereoisomers designated as “L” and “D” forms of the molecule. At birth, only the L form of the amino acid molecule exists systemically. Racemization L-Aspartic Acid D-Aspartic Acid is the gradual and spontaneous process of a stereoisomer pure solution converting to a mixture of equal amounts of the FIGURE 1. Racemization of aspartic acid. L and D stereoisomers (FIGURE 1). Racemization begins immediately at birth. Postformation and Maturation restorative therapy, endodontic and Age can be estimated by measuring Changes orthodontic treatment, trauma, decay, the degree of racemization that has Once all osseous and dental growth and pathology, hyperocclusion and lack of occurred in a metabolically inactive development has ceased, postformation an opposing dentition can affect some tissue.23 Tooth dentin is rich in aspartic and maturation changes are all that remain or all of the postformation criteria with acid and assaying the degree of aspartic to assess age. The six classic postformation the exception of root translucency.16 acid racemization within the tooth dentin and maturation changes that occur in Popular adult dental age estimation has resulted in chronologic age assessment teeth are attrition, periodontal disease techniques, including the Bang and with error rates as low as ± 3 years.24,25 sequelae, secondary dentin formation, Ramm,17 Maples (particularly the S and T cementum apposition, root transparency formulas),14 Lamendin, et al.,18 Prince and Radioactive 14C and root resorption. It is well-documented Ubelaker,19 Kvaal et al.20 and Cameriere et Although 14C dating has been an that root resorption is the poorest of al.,21,22 all require destruction or sacrifi ce of archeological tool since 1949, it has these indicators of chronologic age. Most dental tissue with exception of the Kvaal been developed as an age estimation of the early researchers in dental age et al. and the Cameriere et al. techniques. tool relatively recently. When extensive, estimation concluded that the ranking The Kvaal and Cameriere techniques above-ground nuclear testing began in the of the effi cacy of postformation criteria assess the radiographic tooth pulp volume mid-1950s, large amounts of radioactive that correlate age from best to worst from the labiolingual aspect to estimate 14C was released into the Earth’s is root translucency, secondary dentin age. Therefore, these are the only adult age atmosphere until global treaties ceased formation, attrition, gingival recession and estimation techniques ethical for use in the above-ground testing in the mid-1960s. cementum apposition.14 However, there living. TABLE 2 contains the criteria required The 14C mixed homogeneously within is some very recent research in the use of to perform the techniques listed above. the atmosphere and was incorporated cementum annulations as an indicator into the tissues of plants and animals in of age that may prove very useful in age Biochemical Changes amounts equal in concentration to that of assessment.15 Cementum annuli are the The advantages of biochemical the current atmospheric levels. Knowing concentric rings that can be seen within age estimation techniques are that the measured atmospheric levels of 14C dental cementum upon viewing a cross they may be used in any age group during its release and understanding section of the tooth root. These rings and offer a high degree of accuracy. the decay rate of 14C, date of birth can represent the annual and cyclic deposition Disadvantages include time, expense be estimated from biologic tissues that of dental cementum in mammals. and the sacrifi ce of tooth structure. are inert and biologically inactive. Accurate adult dental age estimation Tooth enamel is rich in 14C and necessitates careful tooth and technique Amino Acid Racemization is metabolically inactive. Forensic selection based upon the dental material All living organisms utilize proteins as radiocarbon enamel analysis has resulted available for analysis and any external the basic building block of their biologic in identifying the date of birth of humans factors that may affect postformation composition. Structurally, these proteins to within an error rate of ± 1.6 years.26 criteria. The effect of ancestry and are comprised of amino acid sequences. Age assessment using this technique gender is minimal on the progression All amino acids (except glycine) have is limited by the earliest above-ground of root translucency and secondary two asymmetrical geometric forms that nuclear testing in 1955. The last tooth dentin deposition. However, dental are mirror images of one another and are to complete its crown formation is the

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Children Adolescents (birth to puberty) (puberty to approximately age 20)

Living or deceased Living or deceased

Early adolescence Late adolescence

Developmental Developmental Developmental radiographs radiographs radiographs

Moorrees, Fanning, Hunt Moorrees, Fanning, Hunt Mincer et al. Demirjian et al. Demirjian et al. Anderson et al. Mincer et al.

Adults

Living Deceased

Morphological and/or Morphological and/or Postformation changes radiographs radiographs (extraction or extraction + sectioning)

Kvaal et al. (1995) Kvaal et al. (1995) Maples Johanson (sectioning) Lamendin et al. Prince, Ubelaker Cameriere et al. pulp/ Cameriere et al. pulp/ Bang, Ramm tooth ratio (2004) tooth ratio (2004 or 2007)

Tooth development and eruption charts and atlases Biochemical techniques (before birth to young adulthood) (all age groups)

Ubelaker, 1989; London Aspartic acid racemization Atlas, AlQahtani et al., 14 2010 Radiocarbon ( C) (requires extraction and destruction of at least one tooth)

FIGURE 2. Dental age estimation procedures.

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third molar at approximately age 12. disease, medical treatment, habits and Cementum Increment Analysis. Journal of Forensic Sciences 522:(6)1334-1337, 2007. Therefore, the earliest practical uses of ancestral admixture. The scientifi c 16. Johanson G. Age determinations from human teeth: A this technique is on individuals born forensic community encourages the use critical evaluation with special consideration of changes after in or after 1943. However, a tooth of multiple techniques and repetitive fourteen years of age. Odontol Revy 22:1-126, 1971. 17. Bang G, Ramm E. Determination of age in humans from 14 enamel C level at historic baseline measurements to obtain maximum root dentin transparency. Acta Odontol Scand 56:238-244, atmospheric levels would indicate that reliability.28 It is advisable, when 1970. the individual was born before 1943. accuracy is paramount, that the forensic 18. Lamendin, et al. A simple technique for age estimation in adult corpses: the two criteria dental method. J Forensic Sci In 2013, Alkass et al. detailed odontologist consider the additional 37(5):1373-1379, 1992. research describing new possibilities use of medical and anthropological 19. Prince DA, Ubelaker DH. Application of Lamendin’s adult for age assessment from teeth. When techniques to corroborate his or her ageing technique to a diverse skeletal sample. J Forensic Sci 47(1):107-116, 2002. used in combination, techniques results. Furthermore, strict adherence 20. Kvaal SI, Kolltveit KM, Thomsen IO, Solheim T. Age evaluating AAR, 14C, 13C and 18O to technique processes as described in estimation of adults from dental radiographs. Forensic Sci Int along with DNA analysis of the human the literature must be observed. ■ 74:175-185, 1995. 21. Cameriere R, Ferrante L, Cingolani M. Variations in pulp/ dentition have produced a genetic and tooth area ratio as an indicator of age: A preliminary study. J geographic profi le of individuals. This REFERENCES Forensic Sci 49(2):317-319, 2004. profi le includes information indicating 1. Müller N. Zur Altersbestimmung beim Menschen unter 22. Cameriere R, Ferrante L, Belcastro MG, Bonfi glioli B, besonderer Berücksichtigung der Weisheitszähne. MD Thesis, Rastelli E, Cigolani M. Age estimation by pulp/tooth ratio in sex, estimated year of birth, estimated University of Erlangen-Nürnberg 1990. canines by mesial and vestibular peri-apical X-rays. J Forensic year of death, information regarding 2. Miles AEW. Dentition in the Estimation of Age. J Dent Res Sci 52(5):1151-1155, 2007. the geographic region where the 42: 255-263, 1963. 23. Ritz-Timme S, Collins MJ. Racemization of aspartic acid in 3. Lewis JM, Senn DR. Dental Age Estimation. In: Manual of human proteins. Ageing Res Rev 1:43-59, 2002. 27 individual lived and a DNA profi le. Forensic Odontology, 5th ed. DR Senn, RA Weems, editors. 24. Ohtani S, Yamamoto T. Age estimation using the Boca Raton, Fla.: Taylor & Francis Group. 2013. racemization of amino acid in human dentin. J Forensic Sci Summary 4. Ubelaker DH. Sex, stature and age. In: Human Skeletal 36:792-800, 1991. Remains: Excavation, Analysis, Interpretation, 3rd ed. 25. Ohtani S, Yamamoto T. Age estimation by amino acid Forensic age estimation involves the Washington D.C.: Taraxacum. 1999. racemization in human teeth. J Forensic Sci 55(6):1630-1633, assessment of an individual’s development, 5. AlQahtani SJ, Hector HP, Liversidge HM. Brief 2010. maturation and physical appearance in communication: The London atlas of human tooth development 26. Spalding KL, Buchholz BA, Bergman LE, Druid H, Frisen J. and eruption. Am J Phys Anthropol 142:481-490, 2010. Age written in teeth by nuclear tests. Nature 437: 333, 2005. an effort to assess true chronologic age. 6. Herschaft EE, et al. (eds.). Manual of Forensic Odontology, 27. Alkass K, et al. Analysis of radiocarbon, stable isotopes and This process is by no means an exact 4th ed. American Society of Forensic Odontology. 2006. DNA in teeth to facilitate identifi cation of unknown decedents. science, but it does rely upon sound 7. Moorrees CFA, Fanning EA, Hunt EE Jr. Formation and PLoS One 8(7)1-12, 2013. resorption of three deciduous teeth in children. Am J Phys 28. Willems G. A review of the most commonly used dental scientifi c research. Accuracy depends Anthropol 21:205-213, 1963a. age estimation techniques. J Forensic Odontostomatol 19:9-17, upon the investigator applying the most 8. Moorrees CFA, Fanning EA, Hunt EE Jr. Age variation of 2001. suitable technique(s) based upon case formation stages for ten permanent teeth. J Dent Res 42:1490- 1502, 1963b. THE CORRESPONDING AUTHOR, James M. Lewis, DMD, DABFO, circumstances. FIGURE 2 is a fl owchart 9. Demirjian AH, Goldstein H, Tanner JM. 1973. A new system can be reached at [email protected]. that summarizes the selection process of dental age assessment. Hum Biol 45:211-227, 1973. that many forensic odontologists utilize 10. Demirjian A, Goldstein H. New systems for dental maturity based on seven and four teeth. Ann Hum Biol 3:411-421, in evaluating individual case criteria for 1976. technique selection in age estimation 11. Mincer HH, Harris EF, Berryman HE. The ABFO study cases. Moral, ethical, cultural and of third molar development and its use as an estimator of chronological age. J Forensic Sci 38(2):379-390, 1993. religious requirements may complicate, 12. Lewis JM, Senn DR. Dental age estimation utilizing third and thereby hinder, an investigator’s molar development: A review of principles, methods and ability to render accurate results. population studies used in the United States. Forensic Sci Int 201:79-83, 2010. Accuracy is also dependent upon the use 13. Lewis JM, Brumit PC. Dental age estimation and of the most current, valid, relevant and determination of the probability an individual has reached the reliable population-specifi c data. When legal age of majority. Paper presented at the annual American Academy of Forensic Sciences Meeting, February 21-25, known, gender and ancestral background Chicago, 2011. should be considered. Mitigating factors 14. Maples WR. An improved technique using dental histology that may affect the forensic dental for estimation of adult age. J Forensic Sci 23(4):764-770, 1978. assessment of age include nutrition, 15. Wedel VL. Determination of Season at Death Using Dental

JUNE 2015 319 There are certain things in life that don’t reveal their true importance until they’re gone. A smile is one of them. Restore it and you return a world of possibility. That optimistic smile and the hope it holds is why CDA unites and passionately supports your profession. Because the world is a better place when people are smiling, and that’s thanks to you.

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CDA JOURNAL, VOL 43, Nº6

The Forensic Dentist: An Overview of Expert Roles in Animal Bite-Mark Investigations

Kenneth Cohrn, DDS, MAGD, DABFO, and Ron Berman, BA, CFE, DABFE

ABSTRACT With increasing incidence of human/animal confrontation and the potential for injury or even death, dentists who choose to work in the forensic sciences may be called upon to utilize their skills and training to render opinions in criminal and civil cases. The authors will show how working in a cooperative environment and combining their skills with those of other experts can achieve the best result.

AUTHORS

Kenneth Cohrn, DDS, Ron Berman, BA, CFE, n the U.S., there are 237.4 million Consider the following case examples. MAGD, DABFO, is DABFE, is a canine pets, notably, but not limited to, birds, A man was attacked, killed and partially in private practice in behavioral consultant and cats, dogs, horses, reptiles and other consumed by a mountain lion while The Villages, Fla. He trainer who provides expert 1 is a courtesy associate witness services and training small animals, and there are more mountain biking at Whiting Ranch professor at the College of for attorneys and insurance than 241 million adults age 18 years Wilderness Park in southern Orange Medicine Department of professionals regarding the Iand older.2 Doing the math, the potential County, Calif., in 2004.4 On two Pathology, Immunology and forensic investigation and number of human/animal interactions, occasions in Florida, a chance encounter Laboratory Science and a litigation of dog bites and both favorable and not, is considerable. between an alligator and a swimmer lead consultant to the C.A. Pound pet-related injuries. Mr. Human Identifi cation Lab at Berman has participated in Aside from the expected agricultural, to death. In both swimmer cases, the the University of Florida. Dr. approximately 725 cases companion and other legitimate investigating odontologist used bite- Cohrn serves as the chief and forensic investigations interactions, there are many untoward mark analysis to identify the alligators forensic odontologist to and testifi ed in civil, criminal consequences including provoked and responsible for the attacks.5 Criminal multiple medical examiner and federal courts on 80 unprovoked animal attacks, animal complicity involving animals is more districts in Florida, is past- occasions. president of International Confl ict of Interest fi ghting schemes, exploitation, assault prevalent. In 2014, Alex Jackson was Veterinary Forensic Science Disclosure: None reported. and abuse. One can hardly listen to convicted of second-degree murder in Association and serves the news or read a newspaper without California when his four pit bulls attacked on state, federal and a reference to a criminal or accidental and killed a woman who was out for a international disaster teams. negative encounter involving animals morning stroll. The dogs infl icted more Confl ict of Interest Disclosure: None reported. and humans. As far back as 1974, it than 200 puncture wounds. Jackson was suggested that dog bites may be an was sentenced to 15 years to life.6 In unrecognized public health epidemic.3 Okeechobee, Fla., a 4-year-old boy was Currently, because of the encroachment viciously attacked by the family dogs of population growth on natural habitats, outside his trailer while his mother was many species are threatened (FIGURE 1). high on drugs inside. She claimed to have

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FIGURE 2. There are an estimated 20,000 rat bites in the U.S. annually. FIGURE 3. Small bite from a cat.

fundamental understanding of bite marks, ■ Market or replacement value. basic comparative anatomy, investigative ■ Sentimental value including pain, procedures and the law is benefi cial in both suffering and emotional stress. criminal and civil investigations. A proper ■ Damages as punishment treatise of this entire topic would be a for wrongdoing. sizable textbook in its own right. Hence, The law in this area is still evolving, the intent of the authors is to provide an but the trend is toward special abbreviated understanding of bite-mark monetary value placed on pets. FIGURE 1. Alligator in civilization analysis and investigation with a selection Herman Bernitz, BChD, MSc, from of relevant examples. We will concentrate the University of Pretoria, opined, “By on canine cases because they account for owning a dog, man welcomes into his not heard the boy’s screams yet a neighbor the majority of the cases, injuries and costs. home a beast that preserves much of its a half-mile away heard him.7 The mother primordial self, and is capable of infl icting committed suicide. Dog Bites and Related Costs a fatal bite wound.”13 We love and fear Concomitant with the rising There are approximately 83.3 million our animal friends. The controversial occurrence of human/animal interactions owned dogs in the U.S., according to debate over dangerous breeds typifi ed is the increase in civil and criminal the 2013-2014 American Pet Products by the pit bull breed is indicative of that litigation, insurance claims, striking Association (APPA) survey.10 Although dichotomy. Consider a recent court case monetary settlements and public health the social and psychological benefi ts of involving a dog bite on a 4-year-old boy concerns. All 50 states now have felony dog ownership are well-known, dogs are at a public playground by an unsecured animal cruelty provisions including making new and increasing inroads into dog that had bitten a 2-year-old girl on domestic violence protective orders, the fabric of our culture. An article in the a previous occasion. The attorneys were animal fi ghting as racketeering offenses New York Post reported that, according amazed to fi nd that half the prospective and stiffer penalties for abuse offenders. to data from the Centers for Disease jury members hated the breed but There is a rising national consensus that Control and Prevention, more young the other half loved them. Pit bulls, egregious behavior involving animals U.S. women are choosing dog ownership once the breed closely associated with should be punishable with severe over motherhood.11 We are a society of gangs and protection, are now family monetary and criminal consequences. pampered pets. APPA statistics show that pets. Feared for their aggressiveness The number of animal bites in the U.S. spending on pets, dogs being a very large and strength, they are also loved and is impressive. There are 4.7 million dog part, has consistently increased every year adored for those same qualities. bites, 400,000 cat bites, 45,000 snake bites, from $17 billion in 1994 to more than In 2012, dog bites and related injuries 250,000 human bites and tens of thousands $53 billion in 2013.12 Concomitantly, cost the insurance industry almost half a of other small animal bites reported the perceived value of a pet has evolved billion dollars and made up approximately annually.8 Animal attacks on humans from mere property ownership to the one-third of all homeowners’ liability include those by dogs, bears, large cats, status of family member. People expect claims. That fi gure, according to the sharks, alligators, snakes and rodents. It is to be compensated for the loss of their Insurance Information Institute, is up estimated that there are 20,000 rat bites animals. Factors to be considered are: about $50 million since 2003. State alone in the U.S. annually9 (FIGURE 2). A ■ The cost of treatment. Farm, one of the largest home insurers,

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paid out $109 million on nearly 3,800 dogs roaming the streets. Dog bites and history. Plaintiffs may embellish their dog-bite claims in 2013. California led related cases happen everywhere dogs account in order to increase the potential in the number of dog-bite claims with and people commingle. The dog owner recovery in settlement or at trial. It 1,919, and claims paid, $64.7 million.14 may not be the only one responsible for is the responsibility of the experts to Rising costs are due to increasing costs of damages. California dog-bite statutes extract the truth, render an opinion medical care in general and larger claims should be referred to for specifi c details based on their independent review of settlements. The majority of bites involve about who is responsible and how the evidence and hopefully educate the young children followed by the elderly, damages apply to more than just a bite. jury, enabling them to reach a just and both high-risk groups. According to the ■ The owner of any dog is liable for the fair verdict. In cases where a settlement American Society of Plastic Surgeons, damages suffered by any person who between both parties is reached prior to there were about 26,935 reconstructive is bitten by the dog while in a public trial, it is often the expert’s testimony procedures to repair dog bites in 2013 at place or lawfully in a private place, that helps both sides to more clearly see an average restorative cost of $27,862.15 including the property of the owner the real strengths and weaknesses of their Most home insurance policies provide of the dog, regardless of the former case. When the experts offer confl icting between $100,000 and $300,000 in opinions, it is the job of the jury to liability. If the policy covers the insured’s decide which expert is more credible. dog (modifi ed by breed restrictions) and the victim sues and wins a settlement in In 2012, dog bites and Mammalian Dentitions excess of the policy limit, the dog owner related injuries cost the Carnivore teeth have adapted or responsible party is personally liable. As insurance industry almost half specifi cally to primary survival roles of a result, dog owners can fi nd themselves hunting, catching and killing prey as losing their assets especially if punitive a billion dollars and made up well a specialized functions including damages are assessed for egregious behavior. approximately one-third of all grooming, social interaction, offensive Punitive damages, when allowed by the homeowners’ liability claims. and defensive behavior and feeding judge and supported by a jury verdict, functions of crushing, shearing and can add many hundreds of thousands grinding.18 The obvious example of this of dollars to the settlement. In addition evolutionary adaptation are the canine to civil consequences, all 50 states have viciousness of the dog or the owner’s teeth, which are the most prominent felony animal cruelty provisions. knowledge of such viciousness. teeth and have the longest roots. As California Civil Code section 3342. one might expect, the canines make Types of Dog Bites and Dog-Related ■ Any person owning, controlling or deep, invasive wounds and are typically Cases having care or custody of any animal recorded in the bite mark. Although Dog-bite cases come in many sizes shall be liable for any injury caused highly variable in size, the nonoccluding and shapes, from a superfi cial laceration by such animal, and for any damage canine teeth are effectively adapted for or “nip” to a severely mauled victim caused to any public property or incising, grasping, catching, holding and exhibiting major tissue loss with to any private property. Beverly tearing. Cat and dog dentitions differ punctures, contusions and lacerations Hills Municipal Code:5-2-111. in that “unlike the dog who grasps the over the entire body. In today’s litigious ■ Special rules apply to children, hide of an animal, then begins ripping by society, culpability from damages caused such as provocation.17 utilizing his own weight and strength, the by an animal encompasses a wide net There may be sizable fi nancial gain/ feline employs a much different method. of pockets. More than half of the states loss by either the plaintiff or defendant Cat canine teeth are better adapted for have statutes that make the owner or in a civil case tempting both parties vertical punctures, not horizontal ripping. responsible party liable if their dogs cause to distort or simply delete relevant The canine teeth of felines are more injury.16 Scenarios range from a formally information regarding their case. Dog structurally at risk so a cat will secure itself passive family dog to a criminal’s highly owners often fail to accurately remember with its claws and puncture the neck at aggressive Rottweiler and from a highly previous incidents of aggression or simply the base of the skull or suffocate the prey trained police dog to a pack of feral choose to deny the dog’s aggressive by restricting the windpipe” (FIGURE 3).

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class characteristics of the contacting surfaces of the human dentition. Dogs FIGURE 4A. Human. and humans, as mammals, share this general description (FIGURES 4A–D). FIGURE 4B. Bear. The starting point in a bite-mark evaluation is to establish if the patterned injury is, in fact, a bite mark. Class characteristics allow us to distinguish between species, animate and inanimate objects, adult versus child dentitions and upper versus lower arches. Examples of class characteristics are, as previously mentioned, the six incisors in the canine dentition versus four incisors in humans FIGURE 4C. Dog. and as with all carnivores and many omnivores, predominate canine teeth.

FIGURES 4. Species dentition comparison. FIGURE 4D. Mountain lion. Individualization or source attribution linking the suspect to the bite mark is determined by individual characteristics, Cats are highly specialized carnivores breeds.20 The canine teeth become a good which are defi ned as a variation of a feature, with less robust and more pointed reference point in a bite-mark evaluation trait or pattern from the normal expected posterior teeth for piercing soft tissue.19 although the wound may be large and fi nding. Individual variation consists of both torn. Class differentiation between human arch and teeth variation. Arch variation Canine Dentition and canine dentition is demonstrated allows for distinguishing arch size and shape, Over the last 12,000 to 15,000 by the number of incisors, with humans which is evident in human versus animal years of dog domestication, from the having four and dogs six per arch. This dentitions. Teeth variation can consist of wolf subspecies Canis Lupis to today’s characteristic is benefi cial in distinguishing rotated and missing teeth, malposition, varied domesticated dog species, between human bites and dog bites. eruption variation, anterior-distal migration, functional changes in the dentition Supernumerary teeth are common in broken teeth, damaged teeth, restorations, have occurred. For example, dietary dog dentitions so it is important to wear patterns and other variations. needs determine premolar function and count the teeth for the evaluation. The premise of bite-mark further differentiation in molar anatomy identifi cation is based on the presumed and size. Omnivores, such as humans, Human and Animal Bite-Mark uniqueness of the dentition and the have teeth that are more conducive to Comparison accurate transferability of teeth marks crushing and do not possess carnassial The defi nition of a bite mark, to a substrate, particularly skin. Skin teeth. Dogs have larger molars for crushing according to The Manual of the American has viscoelastic properties that can in contrast to human teeth. Many Board of Forensic Odontology,21 can be result in distortion, making bite-mark individual teeth fail to meet the opposing applied generally to both animal and identifi cation potentially problematic. dentition or else they overlap and protrude human scenarios. A prototypical bite Inanimate objects such as Styrofoam, between opposing adjacent teeth. mark is described as a circular- or oval- vegetables, hard candy and cheese are The dental formula for dogs is incisors, patterned injury consisting of two opposing better recorders of teeth marks than the 3/3; canines, 1/1; premolars, 4/4 and symmetrical U-shaped arches separated skin. Other factors resulting in potential molars, 2/3 for a total of 42 teeth. Breed at their bases by an open space. Along inaccuracies include, among others, variation shows considerable intercanine the periphery of the arches is a series of decomposition, positional variation, distance (ICD) variation ranging from 2.5 individual contusions, abrasions and/ photographic error, time interval, cm to 4.5 cm (mandible) and from 2.9 cm or lacerations refl ecting the size, shape, bruising, healing, incomplete bite marks to 6.5 cm (maxilla) for North American arrangement and distribution of the and the effects of age and medications.

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Data Collection in Animal Bite-Mark if needed and take impressions Cases if appropriate. Pour models and Evidence collection, examination import information into Photoshop. and interpretation of veterinary bite- Animal DNA databases have been mark cases offer unique challenges. As established so DNA from feathers, with any evidence collection, proper epithelial cells, hair, muscle and saliva consent in the form of a court order or can be collected procedurally similar summons must be obtained, bearing in to human protocols. By employing mind that the procedure varies with genetic-based techniques, proper different jurisdictions and authorities. identifi cation of specifi c individuals, FIGURE 5. Vinylpolysiloxane impression. There may be multiple animals familial relationships and illegally and many bite marks making evidence obtained animals can be determined.27 The adult human ICD typically ranges collection and analysis more diffi cult. Animal skin is less vascular and from 2.5 cm to more than 4 cm compared Another issue with larger animal bites bruising is less pronounced compared to child ICD of < 3.5 cm. Deciduous teeth is the destructive nature of the bites. to humans. The veterinarian may need have a smaller mesial-distal width and may Ripping, tearing and tissue avulsion to expose the underlying soft tissue to have spaces between the teeth. In theory, all can render the patterned injury uncover the patterned injuries. The the teeth in the arch could mark in a bite uninterpretable. Eye-witness accounts powerful canine teeth may leave marks mark, but that does not happen. Rarely does of the incident may be benefi cial in bone through the soft tissue, which the bite mark extend past the fi rst premolars. to determine the dynamics of the can be recorded with vinylpolysiloxane Bite marks occur in a number of variations, attack particularly in determining the dental impression material (VPS). including double, overlapped, single arch, positions of the victim and animal Because of the divergent canine teeth, marks through clothing, tearing and during the incident. Collect evidence the use of impression material is avulsion. Critical individual characteristics from the crime scene, the victim suggested rather than alginate to avoid of the dentition are determined by teeth and the suspect animals if available. tearing of the impression material. that are rotated, missing, malpositioned, General principles to consider in Likewise, the use of polyurethane dentally altered, worn, fractured, etc. investigation of dog-bite cases include: plastic for the dental models is preferred The size and shape of the dog skull ■ The scene. Photograph the scene. for preventing the divergent canines is related to the variation in the size and Determine the owner/caretaker from fracturing off the model versus position of the teeth, breed and weight. and who was in charge of the stone or plaster models. If possible, two Note that medium-sized dogs can have a animals at the time of the incident. impressions and two models should similar-sized ICD compared to humans. Get eyewitness statements. be made for each arch (FIGURE 5). In There are racial variations with human Document all activities including addition to DNA, the stomach contents skulls and dentition but they are far more all people present at the scene. and feces should be checked for evidence. subtle compared to dog variations. ■ The dog(s). Determine which Animal bite-mark/teeth comparisons Bite-mark wounds can occur anywhere animal(s) were involved. Secure can be done in the same manner as but often they are on the neck, head and DNA samples if appropriate and human bite-mark comparisons. Overlays groin. Particularly vulnerable are the arms rabies tests if needed. Arrange are fabricated from the dental models for used in a defensive posture. Claw marks can to have the dogs sedated for comparison. Direct comparison of the mimic teeth marks. However, these marks photographs and dental impressions. models onto the photograph of the bite will be parallel, evenly spaced, superfi cial Fabricate dental models of the mark or the actual bite mark can also be and without canine punctures. Bite-mark dentition in either stone or casting done. The protocol for patterned injury sequela often includes infection with acrylic. Import all the data into recording and comparison is outlined in rates ranging from 2-20 percent in dogs, Photoshop for evaluation. the current American Society of Forensic 15-50 percent in cats and 9-50 percent in ■ The victim. Photograph the Odontology (ASFO) Manual of Forensic human bites.22 Exsanguination is the most wounds. Get a statement of the Odontology23 and the American Board of common cause of death in severe dog bites. incident. Collect DNA samples Forensic Odontology Reference Manual.

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an inhibited manner, and then releases on Typical Issues in Dog-Bite Cases its own is generally demonstrating Whether a dog had demonstrated defensive response to a stimulus the dog dangerous and/or vicious propensities prior regards as a threat. This scenario is often to an incident will usually be an important found in cases where the victim has factor in most dog-bite cases. Dog owners provoked the dog in some fashion. The often, in an attempt to protect both their dog is trying to increase the distance fi nancial and personal interests, do not between itself and the source of the threat. give accurate information about their dogs’ FIGURE 6. Multiple lacerations, contusions and In some situations, when a dog has already past behavior. Owners can consciously or avulsions caused by a pack of dogs. demonstrated fear aggression in the past, it unconsciously deny their dogs’ aggressive may be that the dog’s fear makes it overly nature the same way a parent of a bully reactive and a normal greeting from a may choose to blame other kids or friendly stranger may be perceived as a teachers for the child’s bullying behavior. Legal Anatomy of a Dog-Bite Case direct threat. Conversely, a dog that runs Just as often, plaintiffs can overly Litigation in a dog-bite case typically up and attacks a person on or near its embellish the particulars of their incident. starts with a summons to the dog owner perceived territory is acting offensively. The most common issues telling him or her that he or she is The dynamics of an offensive attack are in a dog-bite case are: being sued followed by a complaint that usually different from a defensive attack in ■ Is the victim’s wound(s) from a lists all of the reasons for the suit. At that one typically fi nds multiple wounds dog bite or another source? some point thereafter, discovery begins often on different parts of the body. The ■ Did the victim provoke the dog? where the plaintiff and the defendant wounds are more aggressive, deeper and ■ Was more than one dog involved? begin to gather facts that will support there is more tissue damage. Other Which dog did the biting? their case. Discovery usually consists dynamics found in a serious offensive dog ■ Did the incident happen the way the of taking depositions from the plaintiff attack is shaking, where the dog bites, victim or the dog owner indicated? and defendant, witnesses, treating holds on and shakes its victim and Experts are needed to establish doctors and experts. When the facts generally will not end the attack on its the veracity of these statements. of a case are strongly in dispute due own. Pack mentality can be particularly ■ Did the dog have a history of to confl icting testimony from both lethal. In 2003, an elderly woman was aggressive behavior to humans sides and the potential dollar value of exiting her car at home when she was and/or other animals? the case is high, various experts may viciously attacked by a pack of six dogs ■ Were the owners (caretakers, be retained by either or both sides in belonging to a neighbor. The owner had landlords, etc.) aware of order to help clarify important issues. been cited by animal services on multiple the dangerous propensities occasions for the unrestrained aggressive of the subject dog(s)? Canine Aggression behavior of his dogs. The victim was More than half of U.S. states have a Canine aggression is typically brutally attacked and suffered multiple strict liability statute that makes the dog either offensive or defensive. Most lacerations, contusions and avulsions over owner fully liable if his or her dog bites forms of canine aggression are fear- her entire body, which caused death by someone. Typically, the three defenses based responses such as territorial exsanguination. The owner of the dogs to strict liability are that the victim was aggression, maternal aggression, testifi ed that he didn’t know how long the trespassing at the time of the incident, protective aggression or food aggression attack had been going on but “they were the victim provoked the dog into biting in an attempt to deal with a real or chewing on her, all right.”24 The him or the defendant did not own the dog perceived threat. Note that dog-on- odontologist was able to match at least one at the time of the incident. It should be human aggression and dog-on-dog of the many bite marks to each of the dogs noted that someone who has been caring aggression are two distinct behaviors involved in the mauling29 (FIGURE 6). A for the dog can also be sued if it can be and that a dog that displays one will plea deal was rejected and he was shown that he or she has had the dog not necessarily display the other. convicted. He lost the appeal and died in his or her possession for a reasonable A dog that bites one time, usually in while serving a 12-year sentence.25 amount of time. An excellent resource

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is the Investigation, Management and witness that is completely neutral. Dogs deposition. The dog expert will evaluate Prevention of Animal Bites in California, simply do what dogs do under similar documents such as the dog’s veterinary a manual published by the California circumstances, as they are creatures of records, the animal control records, the Department of Public Health,26 and habit and have no ability to change their emergency medical records, photos of the web resources such as dogbitelaw.com. behavior because they are being evaluated. victim’s wounds, etc. When necessary, It is imperative that the evaluator the dog expert will inspect the scene The Experts not attempt to recreate the incident but of the incident and interview potential In issues regarding animal behavior, only create similar circumstances. It is witnesses, including the owner, neighbors, animal aggression, human/animal also important that the evaluator not veterinarian, forensic odontologist, interaction and wound analysis, an animal do anything that could be construed trainers, pet sitters, groomers, kennel expert with the right qualifi cations and as invasive or provocative, especially if operators, etc. Based on the dog expert’s experience in forensic investigation and the plaintiff claims that he or she did background and experience, he or she testimony can be very helpful in clarifying not provoke the dog. Ultimately, the may be qualifi ed to testify on canine specifi c issues. With regard to the actual purpose of the evaluation is to give a bite wounds. Even when qualifi ed as an etiology of the victim’s wounds, especially expert witness, the dog expert will often when the wounds are likely from a consult with a forensic odontologist in source other than a dog bite, a forensic order to discuss and either confi rm his or odontologist is best suited to evaluate It is imperative that the her analysis or entertain other theories the patterned injury. In cases regarding related to the issues at hand. Although only dog bites, a forensic odontologist evaluator not attempt the dog expert may be qualifi ed to testify or an experienced court-qualifi ed dog to recreate the incident about dog-bite wounds, he or she is not expert can offer expert opinions in court. but only create similar qualifi ed to testify about what else may In certain cases, the ideal scenario is have caused the victim’s wounds. for the forensic odontologist and the circumstances. dog expert to work in conjunction to The Forensic Odontologist present the best evidence to the jury. The same forensic principles for human odontological investigation apply The Dog Expert visual and experiential evaluation of similarly to animal cases. Animal cases A qualifi ed dog expert will have the the dog to the jury to help them make certainly can be more problematic because knowledge, background and forensic necessary decisions about the case. A of the aggressive behavior of animal experience to perform a complete poorly conceived or conducted evaluation attacks that can result in substantial analysis of the information available may create more questions than answers soft tissue mutilation and the diffi culty as well as follow the information trail and the opposing attorney will spare no in evidence interpretation. Because the to discover new pieces of evidence effort in pointing that out in court. animal cannot contribute verbally to that may clarify issues in the case. An In the end, the strongest pieces of the circumstances of the altercation, we important task for the dog expert is to do evidence in a dog-bite case are the dog must rely on the individuals involved a forensic evaluation of the dog as well and the bite wounds. The wounds are or eyewitness accounts, which are as an inspection of the scene. It is always direct physical evidence of how many notoriously inaccurate and biased. important to evaluate the temperament times the dog bit the victim, whether A team approach involving animal and behavior of each dog involved. the bites were inhibited (controlled experts, law enforcement, veterinarian, Another part of the evaluation is testing aggression), the intensity of the pathologists, DNA specialists, crime the owner’s control over his or her dog by aggression, whether the incident was scene technicians and other forensic having him or her give basic obedience defensive (offensive aggression), the partners can be assembled to investigate. commands both on leash and off leash possibility that the dog was provoked Social media is both pervasive and in a safe place. Although there will be and damages resulted to the victim. invasive — like it or not. One needs to varying accounts of the incident or prior Videotaping is recommended so be cognizant of social media “trying” incidents, the dog may likely be the only the evidence can be used at trial or cases in a public forum where activism

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was found with multiple contusions, was found to be in the shaved fur and superfi cial lacerations, multiple posterior there was hair in the feces. The original rib fractures, internal bleeding and a odontologist concluded that “the marks lacerated spleen while under the care (were) completely inconsistent with of her father. The child protection dog bite marks, either domestic or wild team and state’s attorney felt there was … without equivocation the markings FIGURE 7. Evidence in a criminal case. suffi cient cause to charge the father. seen on the deceased are not dog bite The patterned injuries on the child marks.” The prosecution’s pathologist can have immense impact. Case in point, were determined by the odontologist to testifi ed “as absurd as it is to think that in 2013 an activist group in New York be superfi cial dog bite marks that neither a polar bear attacked the victim, it is defended the case of Phineas, a golden the prosecution nor the defense disputed equally absurd that it’s dog wounds.” Labrador residing in a small town in (FIGURE 7). The issue was whether the Ultimately, other forensic specialists Missouri, that was accused of biting a dog was responsible for the extensive were appointed to investigate and girl while she played with friends. The internal injuries or if the father caused testifi ed contrary to the original fi ndings. events started out as a casual play day but the crushing injuries while attempting to After a long legal battle the charges morphed into an incident that polarized conceal his culpability by causing the dog against the pit bull owner were dropped the entire town and gained national to make the marks. The injuries on the and there was a multimillion-dollar and international notoriety. More than skin were superfi cial and the contention settlement for malicious prosecution, false 200,000 “experts” on Facebook opined by the state’s attorney was that the dog imprisonment and gross negligence.29 as to the validity of the expert opinions did not “bite” with suffi cient force to Stakeholders in crime cases that may and the proposed fate of Phineas. In cause the extensive internal injuries. involve animals may be compromising addition, there was considerable hearsay, There was no history of aggression from the investigation by assuming the inappropriate accusations, misinformation the dog and no indication that the dog evidence must be either animal or and even threatened civil disobedience was culpable in the life-threatening human related. It may well be both. directing the investigation. A dog injuries sustained by the infant. In Investigators should be prepared to specialist and forensic odontologist were fact, the dog was sleeping next to the distinguish between human and animal sought out as experts by the corporate calm child. A two-year investigation injuries and utilize cross-trained analysts. advocate. The social media campaign ensued culminating with a two-week Members of the odontology team may and litigation went on for more than a trial including testimony from several be called to assist in animal-on-animal or year. Ultimately, Phineas was exonerated medical examiners, a dog behaviorist, a human-on-animal abuse cases. Domestic and taken off doggie death row. He was forensic odontologist, law enforcement violence and animal criminal cases, some moved to a secure location only to go offi cers, radiologists, pediatric specialists involving biting, may involve human missing to an undisclosed new home.27 and other medical personnel. Ultimately, abuse, animal fi ghting, gang violence, The infl uence of e-opinions on outcomes the verdict returned was that the sexual abuse, hoarding, torture and a host cannot, and should not, be ignored. defendant was not guilty of all charges.28 of other sociopathic behaviors. A bite- The forensic odontologist should be Another more egregious case occurred mark case may expose serious underlying aware of deliberate attempts to obscure in Ontario, Canada, where a 7-year-old family or individual dysfunction and criminal activity by involving an animal. girl was found dead in her basement. The psychopathy and follow-up is paramount. A rush to judgment, bias in its many initial pathologist reported more than The American Human Society30 reported iterations, lack of critical evidence, 80 stab wounds from a knife or scissors. disturbing animal and domestic abuse failure to follow up on leads and many The mother was charged with second- violence facts: Sixty-eight percent of other considerations can lead to false degree murder, placed in isolation and her battered women report that there had conclusions. Another case in point other children removed from her custody. been violence toward their animals, 13 involved a law enforcement offi cer, a dog Coincidently, the neighbor’s pit bull dog percent of intentional animal abuse cases and a charge of child neglect and abuse was in the basement at the time of the involve domestic violence and 70 percent that occurred in Central Florida a few incident and had a “reddish” substance of animal abusers have records for other years ago. The two-month-old female on the fur and collar. The victim’s blood crimes. There is a long list of animal

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the horrifi c results were not. The criminal trial was held in Los Angeles because of the incredible amount of publicity. Boyd Stephens, MD, the chief medical offi cer of San FIGURE 8. Bane, one of the Presa Canario dogs Francisco, testifi ed that Whipple that attacked Diane Whipple. sustained massive injuries on 77 areas of her body (FIGURE 9). Whipple died of asphyxiation and exsanguination. Dr. abusers who became infamous killers. FIGURE 9. Fatal bite marks caused by the Presa Stephens also stated that Whipple was Serial killer Keith Jesperson boasted, Canario dogs on Diane Whipple’s neck. killed in the same way a lion pounces on “No longer did I search for animals to its prey and sustained lacerations and mistreat. I now looked for people to kill. What makes this case so incredible cuts everywhere except for the soles of And I did. I killed over and over until I are the bizarre ancillary issues that came her feet and the top of her head. The was caught.”31 Biting and animal abuse is to light during the criminal trial that no most severe wounds were to her neck, a juvenile behavioral predictor of future, doubt affected both the tone of the trial, where her jugular vein was severed and more serious and deadly behaviors. public perception, media coverage and the her larynx was punctured. The forensic jury’s fi nal verdict. First, Diane Whipple, odontologist identifi ed several dog bites Criminal Case History: San Francisco a lesbian, was an attractive 33-year-old and indicated they matched the teeth of Dog Mauling lacrosse coach at St. Mary’s College. one of the two dogs that mauled Whipple. Arguably the most sensationalized At the time of the incident, it was not Prosecutors maintained that the dog attack in the U.S. is the 2001 Diane legal for a gay partner to sue for wrongful defendants knew their dogs were Whipple case. It had so many unique, death.33 Sharon Smith, Whipple’s partner, dangerous and did nothing to prevent horrifying, fascinating and bizarre became the fi rst gay person in the U.S. to Whipple’s death. The defense attorneys components that it can serve as the fi le a wrongful death civil suit on behalf of offered a different story. Based on the quintessential example of the complexities a partner.9 The defendants were criminal dog expert’s investigation there appeared of an animal attack culminating defense attorneys and the dogs were of a to be a good bit of grandstanding going in criminal and civil penalties. breed most people had never heard of prior on because of massive press attention. This case not only was a major to this incident. The dogs were owned by Contrary to the prosecution’s stand catalyst for what was to become “breed two convicts serving life sentences without that there were numerous examples of discrimination” by insurance carriers parole in a California maximum-security aggression prior to this incident, almost against breeds associated with higher bite prison. Both convicts were members of all of those turned out to be dog-on- rates,32 it also spawned multiple lawsuits: the white-supremacist Aryan Brotherhood dog aggression, which is not relatable ■ A criminal case against the terrorist group. To this day, some of the to dog-on-human aggression and would married defendants, Robert facts of what happened are still not clear not support knowledge by the owner of Noel and Marjorie Knoller, for but a general scenario of the events is the dog’s aggression toward humans. involuntary manslaughter and available from numerous accounts. For a The jury found Noel and Knoller fostering a mischievous animal detailed journalistic account of this case, guilty of involuntary manslaughter and that killed a human being. refer to the book Red Zone — Behind owning an animal causing the death ■ A separate charge of second-degree the Scenes Story of the San Francisco of a human being. Knoller was also murder against Knoller who was Dog Mauling by Aphrodite Jones.34 found guilty of second-degree murder. present and claimed to have control On Jan. 26, 2001, Diane Whipple The State Bar of California suspended over the dogs during the incident. was viciously attacked by two Presa their licenses to practice law and Noel ■ Two civil cases were fi led, one by Canario dogs belonging to Knoller was disbarred several years later. Sharon Smith, Whipple’s partner, and Noel (FIGURE 8). While what Another unusual aspect of this case is and the second by Whipple’s mother, actually happened within the estimated that Knoller fi led a successful appeal and against the owner of her apartment. 12-minute attack was in dispute, was awarded a new trial in May 2005.

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However, the Court of Appeals reversed Been Fixing Bike. articles.latimes.com/2004/jan/10/local/ 29. Dorian R. Bite Mark Evidence: A Color Atlas and Text. 2nd me-lion10. Accessed Aug. 21, 2014. ed., pp. 222-240. 2011, CRC Press, Boca Raton, Fla. that decision and reinstated the second- 5. Personal case fi le. 30. Human Society of the U.S. 2011. Animal Cruelty Facts degree murder conviction. Then on June 6. Dobuzinskis A. California Man Whose Pit Bull Killed Woman and Statistics — Statistics on the Victims and Current Legislation 1, 2007, the California Supreme Court Gets 15 Years to Life. www.reuters.com/article/2014/10/03/ Trends. www.humanesociety.org/issues/abuse_neglect/facts/ us-usa-dog-murder-idUSKCN0HS1NN20141003 Accessed animal_cruelty_facts_statistics.html. Accessed November rejected the Court of Appeal’s decision Oct. 15, 2014. 2012. and remanded the case back to the trial 7. Personal case fi le. 31. King V. Keith Hunter Jesperson. www.crimelibrary.com/ court for reconsideration. Finally, on 8. www.healthychildren.org/English/health-issues/conditions/ serial_killers/predators/jesperson_5.html. Accessed October from-insects-animals/Pages/Animal-Bites.aspx. Accessed Oct. 2014. Sept. 22, 2008, the court reinstated the 15, 2014. 32. Breed Disowned by Homeowners’ Insurance Corp. www. conviction for second-degree murder 9. Abrahamian FM, Goldstein EJ. Microbiology of Animal Bite animallaw.info/article/case-against-dog-breed-discrimination- and sentenced Knoller again to 15 years Wound Infection. Clin Microbiol Rev, 2011 Apr;24(2):231- homeowners-insurance-companies. University of Connecticut 246. School of Law 2004. to life. In 2010, the First District Court 10. APPA releases 2013-14 National Pet Owners Survey. 33. Minter S. Expanding Wrongful Death Statutes and Other of Appeal unanimously upheld Knoller’s media.americanpetproducts.org/press.php?include=144262. Death Benefi ts to same sex partners. http://www.americanbar. conviction and she is currently serving Accessed March 10, 2014. org/publications/human_rights_magazine_home/human_ 11. Antenucci A, Kli D. nypost.com/2014/04/10/more- rights_vol30_2003/summer2003/hr_summer03_expanding. her sentence at Valley State Prison young-women-choosing-dogs-over-motherhood. Accessed Oct. html. for Women in Chowchilla, Calif. 12, 2014. 34. Jones A. Red Zone — The Behind-the-Scenes Story of the 12. Randolf M. Compensating an Owner when a Dog Is San Francisco Dog Mauling. July 1, 2003. Injured or Killed. www.nolo.com/legal-encyclopedia/free- Summary books/dog-book/chapter9-6.html. Accessed Sept. 6, 2014. THE CORRESPONDING AUTHOR, Kenneth Cohrn, DDS, MAGD, With increasing incidence of human/ 13. Bernitz H, et al. The individualization of a dog bite mark: DABFO, can be reached at [email protected]. animal confrontation and the potential a case study highlighting the bite mark analysis, with emphasis on diff erences between dog and human bite marks. Int J Legal for injury or even death, dentists who Med 2012 May;126(3):441-6. doi: 10.1007/s00414-011- choose to work in the forensic sciences 0575-4. Epub 2011 May 3. may be called upon to utilize their 14. Dog Bite Liability. Insurance Information Institute, May 2014. www.iii.org/issue-update/dog-bite-liability. Accessed skills and training to render opinions in May 2013. criminal and civil cases. Dentists acting 15. Reconstructive Plastic Surgery Statistics. www. as forensic odontologists work best in plasticsurgery.org/Documents/news-resources/statistics/2013- statistics/reconstructive-procedures-national-trends-2013.pdf. a cooperative environment combining Accessed May 2013. their skills with those of other experts 16. Strict Liability: Dog-Bite Statutes. www.nolo.com/legal- such as attorneys, law enforcement, encyclopedia/dog-bite-statutes.html. Accessed Oct. 25, 2014. 17. dogbitelaw.com/california/liability-based-on-the-dog-bite- medical examiners and qualifi ed experts statute-in-california.html. Accessed Oct. 23, 2014. with specialized knowledge of the various 18. Hillson, S. Teeth. 2nd ed., p. 46. New York, Cambridge animal species involved. In dog-bite University Press. 2005. 19. Willis B. Scotching the Myth. scotcats.online.fr/abc/ cases specifi cally, although some of the identifi cation/bitemarks.html. issues to be addressed can be within the 20. Tedeschi-Oliveira SV, et al. Intercanine Distance in the realm of both the forensic dentist and Analysis of Bite Marks: A Comparison of Human and Domestic Dog Dental Arches. J Forensic Odontostomatol 2011 Jul qualifi ed dog expert, the unique skill sets 1;29(1):30-36. of each can often serve to both enhance 21. www.abfo.org/resources/abfo-manual. August 2013. and support the fi ndings of the other. ■ 22. McGrath C. Bites: Human and Animal. www.carpa.org. au/Ref%20Manual%204th%20Ed/Emergency%20&%20 assessment/Bites_human_animal.pdf. Accessed Oct. 29, REFERENCES 2014. th 1. American Pet Products Association (APPA). 2013-2014 23. Manual of Forensic Odontology. 5 ed., CRC Press, Boca National Pet Owners Survey Statistics: Pet Ownership & Annual Raton, Fla. 2013. Expenses. americanpetproducts.org/Uploads/MemServices/ 24. Miller S. Pit Bulls Take Life. www.ocala.com/ 2013_14NPOSBackgroundandPurpose.pdf Accessed Sept. article/20031213/news/212130308. Accessed Nov. 2014. 9, 2014. 25. Personal case fi le. 2. quickfacts.census.gov/qfd/states/00000.html. Accessed 26. California Department of Public Health, Veterinary Public Oct. 9, 2014. Health Section. Investigation, Management and Prevention of rd 3. Harris D, Imperato PJ, Oken B. Dog Bites— An Unrecognized Animal Bites in California. 3 ed., April 2014. Epidemic. Bull NY Acad Med 50(9): 981-1000, Oct 1974. 27. Personal case fi le. 4. Hanley C, Yoshomo K, Anton, M. Mauled Man May Have 28. Personal case fi le

330 JUNE 2015 Specialists in the Sale and Appraisal of Dental Practices Practices Serving California Dentists since 1966 How much is your practice worth?? Wanted Selling or Buying, Call PPS today!

NORTHERNNORT CALIFORNIA SOUTHERN CALIFORNIA (415) 899-8580 – (800) 422-2818 (714) 832-0230 – (800) 695-2732 Raymond and Edna Irving Thomas Fitterer and Dean George [email protected] [email protected] www.PPSsellsDDS.com www.PPSDental.com California DRE License 1422122 California DRE License 324962 6085 PERIO PRACTICE – SAN FRANCISCO BAY AREA ANAHEIM HILLS Perfect merger candidate for nearby DDS from North Orange 2014 FROOHFWHG$2 Million. 7 Doctor days per week. Seller can work back. County to Yorba Linda. Grossing $400,000+. Seller will continue working with Buyer. Beautiful 8-op office. ARROWHEAD Great mountain practice. Hi identity location. Conservative 6083 MODESTO 2014 collected approximately $450,000. 2013 part-time owner with Associate grosses $400,000-$600,000. Digital x-rays. collections totaled $640,000. When Management devotes attention, practice Computers in ops. performs better. Digital 5 ops with digital Panorex. Nice blend between PPO BAKERSFIELD Emergency Situation. Widow needs help! Associate needed ASAP & HMO. until practice is sold. Call 714-832-0230. BAKERSFIELD AREA Small town. 4-op practice with building. Full 3rice 6082 TURLOCK Nice foundation to build upon. Part-time office $350,000 includes real estate. Renovations make property look new. collected $300,000+ in 2014. Everything new since 2008. 4-ops and digital. BAKERSFIELD Lady DDS grosses $800,000. Low overhead. Full 3rice $550,000. Convenient location. BAKERSFIELD Senior DDS retiring. $650,000gross. 5-ops in 3,000 sq.ft. 6081 SANTA CLARA El Camino Real location. 2014 collected $687,000 building also For Sale. 37% overhead, high Net. Full price $550,000. on 24-hour week. Available Profits of $305,000. -days of Hygiene. 5-ops in CLAREMONT-UPLAND Gross $500,000+. Refers $250,000 in Ortho, OS, 1,700 sq.ft.:LWKDWWHQWLRQWKLVFDQEHD0LOOLRQ\HDUSHUIRUPHU Endo. Hi identity. Seller can work back if acquired by Specialist. 6080 PLEASANTON - DUBLIN AREA 8+ days of Hygiene. $450,000 COLTON Grossed $30,000 last mth with Associate. 9-years left on great rent. invested in 6-op office. Consistent $900,000+ per year performer. Attractive Digital x-rays, intra oral camera. Owner nets $3,000+/mth without working. transition arrangements available. FXOO3ULFH$250,000. 6079 BERKELEY’S ALTA BATES MEDICAL VILLAGE – “SOLD” DENTAL LOCATIONS Bell and Bell Gardens Strong performer on Owner’s 24 hour week. 2014 collected $676,500. DIAMOND BAR Two Associates, part-time Owner collects $1.2+ Million/year. Patient foundation anchored by 4-days of Hygiene. Endo and OS referred. Successor works harder and nets $500,000. 2+ implant cases, 5+ OS cases referred Renowned Medical Village has regional draw. monthly. $6,000+/mth in cap checks. HAWTHORNE Located in strip center at busy intersection. 6-ops, 2 equipped in 6078 FRESNO Strip center practice on West Shaw Avenue. 2014’s 1,600 sq.ft. suite. Full 3rice $95,000. Collections totaled $383,000 with Profits of $192,000. Practice will do better HUNTINGTON PARK Hi identity. 65,000 autos/day. 3 ops. Gold Mine! FP $185,000. with Successor who devotes full attention here. 4-ops. Full Price $245,000. INDIO Dental building across from City Hall. City offering special tax incentives. 6077 PERIO PRACTICE – SAN FRANCISCO’S NORTH BAY Highly Great opportunity for DDS with vision. regarded and located in desirable family area. On 3.5 day week, revenues INLAND EMPIRE Grossing $10.6 Million. Some real property also included. were $1 Million in 2014 with profits of $400,000. Beautiful facility with IRVINE Great location. 5-ops. Busy DDS wants Solo Group Partner, 4-ops. IRVINE Solo Group Partner wanted. Buy 50%. Seller assures Buyer 45% net profit 6075 MONTEREY BAY AREA Digital, paperless and well positioned for on production of $450,000 first year. High end practice has Cerec and Cone Beam. future. 2014 collected $1.47 Million with Profits of $690,000. 7+ days of LA JOLLA HMO & PPO. 3-op office. 2-day week. Affluent community makes this Hygiene. First Quarter of 2015 collected $449,000. Extremely unique almost cash practice. Roll-up sleeves and go to work. Full Price $135,000! opportunity. LAKE FOREST 7 ops across street from major employer in Orange County. 6074 FREMONT – “SOLD” 2014 collected $643,000. 4 day Hygiene LOS ANGELES HMO practice doing $4+ Million. Includes real property. schedule booked 6-months out. Beautiful office. Full Price $325,000. MARINA DEL REY Gorgeous office. Grossing $650,000. MISSION HILLS Grossed $350,000, nets 50%. Senior DDS wants to work-back 6071 CHICO Strength is 4-day Hygiene schedule. Retiring DDS focuses on 2.5 days. Seller will finance. restorative. Endo, OS, Perio & Pedo referred. 2014 collected $450,000. NORCO – CHINO HILLS Recently upgraded 8-Op office. Cone Beam, Cerec, Beautiful 4 op office. Full 3rice $150,000. digital radiography, high end equipment. Will do $1.5 Million. Includes building. 6070 VISALIA Strong foundation and well-positioned for ambitious REDLANDS Full price $25,000. 25-year phone number and fictitious business successor. Strong Hygiene Department, beautiful facility, well equipped. name. Equip 3-ops for $25,000. Great rehab opportunity which will grow with TLC. Digital throughout. Not a Delta Premiere practice. REDLANDS Low overhead. Grosses $20,000+/mth. Lease at $1.00 sq.ft. FP $250,000. 6068 KINGSBURG Great family community south of Fresno. Owner RIALTO Dental building on 2.3 acres. Land shall soon have $8,000/mth in rent income. works relaxed schedule doing restorative dentistry. Endo & OS referred. 2014 SOUTH ORANGE COUNTY Grossing $700,000. Ocean view. 4-ops. FP$700,000. collected $250,000+. Strong Profits. 3 Ops. Full 3rice $135,000. TEMECULA Long established HMO grossing near $700,000. HMO checks 6067 MONTEREY - ADVANCED RESTORATIVE PRACTICE Strong $4,000 to $6,000 per month. Absentee owned. foundation for DDS desiring quality restorative practice. $310,000 invested TORRANCE Grosses $350,000 with older DDS. 3-ops plumbed, 2 equipped. here. Digital and paperless. 2014 collected $400,000. "Out-of-network” Beautiful A Class building. Full 3rice $250,000. practice. Considerable transition assistance available. Full 3rice $185,000. TORRANCE/GARDENA Established 31-years. Chinese DDS retiring. Very 6065 SAN LEANDRO – “SOLD” 2014 collected $438,000 on part-time profitable. Grosses $200,000. Lots referred out. TUSTIN Free standing dental building with 5 ops. Full 3rice $1.4 Million. schedule. Attractive 3 Op office with tranquil views of garden setting. TUSTIN Great location. 50% of building For Sale. Nearby DDS who flips their Digital radiography includes Panorex. practice into this building can add another $1 Million. Full 3rice for 2,000 sq.ft. is $1.1 Million. **FOUNDERS OF PRACTICE SALES** 12+ years of combined expertise and experience! WEST LA Grosses $1.2 Million. Seeks Korean Lady DDS for specialty team. Plan to grow to $2 Million/year. Quality office. Full 3rice for 1/3 of goodwill $350,000. 3,000+ Sales - - 10,000+ Appraisals YUCCA VALLEY Hi identity location. Small office. 8VHGWRGR$500,000. Needs **CONFIDENTIAL** TLC. Full 3rice $150,000 includes building. PPS Representatives do not give our business name when returning your calls. Specializing in selling and appraising dental practices for over 40 years!

LOS ANGELES COUNTY ORANGE COUNTY SAN DIEGO COUNTY

CANOGA PARK (GP) – Price Reduced!! Seller is ANAHEIM – Leasehold Improvements & Equipment VISTA - 35 years of goodwill. 4 fully computerized currently working 1 day/wk with ½ day of hygiene. 2 Only! 4 equipped operatories in a 1,680 sq office. equipped operatories. Grossed approximately equipped operatories. Property ID #4357. Property ID #4535. $883K in 2013. Has monthly revenues of $73K. CHATSWORTH (GP) – Price Reduced!! 5 equipped ALISO VIEJO (Pedo) – 3 chairs in open bay, 1 Property ID #4507. operatories. Grossed $918K in 2013. Projecng plumbed not equipped op. Grossed approximately approx. $948K for 2014. Buyer’s net of $398K. $340K in 2014. Great pracce. Property ID #5031. EL CENTRO (GP) – This pracce is located in a Property ID #4537. single story building. Building is for sale. 5 FULLERTON (GP) – Established in 2002. Projecng equipped operatories. Grossed approximately LOS ANGELES – 65 years of goodwill Grossed ap- $304K for 2014. Buyer’s net of $132K. Property ID proximately $350K in 2013. Buyer’s net of $71K. $554K for 2014. Buyer’s net of $189K. Property ID #5023. Please contact your CPS Agent for more details. #5010. Property ID #5008. SAN DIEGO COUNTY - Mul-Specialty pracce. 7 FULLERTON – Leasehold Improvement and Equip- equipped operatories in an approximately 4,464 LOS ANGELES - This pracce with over 30 Years of ment! On one the busiest intersecons of Fullerton. office. Grossed $1,700,000 in 2013 and projecng goodwill, and approximately 60% of it's income 3 equipped operatories. Some paent charts includ- approximately $1,900,000 for 2014 with monthly comes from capitaon. Property ID #5012. ed. Property ID #5028. revenues of $165,000. Property ID #4231. LOS ANGELES (GP) - 3 equipped operatories with GARDEN GROVE – 4 equipped ops and 1 plumbed digital x-rays in a 1,000 sq . office. The recepon (not equipped) op. Grossed approximately $436K in area was recently remodeled. Grossed approxi- 2014 Property ID #5043. mately $277,130 in 2014. Property ID #5040. HUNTINGTON BEACH - Leasehold Improvement and RIVERSIDE & SAN BERNARDINO COUNTY MISSION HILLS - Leasehold Improvements & Equip- Equipment Only! Modern Design. 3 equipped ops, 1 APPLE VALLEY (GP) – 3 equipped ops . Has monthly ment Only! 8 equipped Property ID #5014. plumbed not equipped. Was built in June 2014. revenues of $42K. Property ID #5044. Property ID #5032. MONTEREY PARK (GP) – Leasehold Improvements APPLE VALLEY - 8 equipped operatories. Seller is & Equipment Only! 3 equipped operatories. IRVINE - Leasehold Improvement and Equipment! working 3 days/wk, Associate 1 day/wk and O.S. 1x/ Property ID #4449. 10 equipped ops and 2 recepon areas. Property ID #5030. mo. Grossed $707K in 2013 and Projecng $722K PASADENA (GP) - 3 equipped ops. Grossed approx- for 2014. Property ID#5009. imately $335K for 2014. Property ID #5035. LAGUNA HILLS – 2 equipped ops. Approximately 20- 25 new paents/mo. Ins/Cash/Cap (~$500/mo). HESPERIA (GP) – 4 equipped operatories. Seller RESEDA – 3 equipped operatories (stand up dens- Grossed approximately $319,024 in 2014. Property works 3 days/wk with 3 days of hygiene Grossed try). Projecng approximately $292,796 for 2014 ID #5033. with monthly revenues of $24K. Property ID#5017. $260K in 2013 and projecng approximately $336K ORANGE COUNTY PERIO – Price Reduced!! Grossed for 2014. Property ID #5007. ROSEMEAD – 2 equipped operatories, lab/ approximately $972K in 2013 and projecng approx- sterilizaon room, x-ray room, dark room and imately $1,016,000 for 2014 with a Buyer’s net of INDIAN WELLS – Leasehold Improvements and private office in a 790 sq suite. Projecng approxi- $260K. Please contact your CPS Agent for more Equipment Only!! Great opportunity for a TMJ, mately $119K for 2014. Low Sale Price! Property ID details. Property ID #5005. Sleep Apnea and GP. 4 equipped ops. Property ID #5019. #5041. RANCHO SANTA MARGARITA – Leasehold Improve- SANTA CLARITA (GP) – This turn-key pracce ment Only!! 4 plumbed not equipped operatories. PALM DESERT— 5 equipped ops. Have monthly Reestablished the pracce in September 2013. Property ID #4483. revenues of approximately $28K/mo. Property ID Great opportunity for a 1st me buyer. Property ID #4331. #5013. PALM SPRINGS – 3 equipped operatories with SANTA MONICA - 3 equipped operatories. Grossed Pracce Web soware and digital x-ray. Major $265,485 in 2013 and projecng approximately VENTURA, SANTA BARBARA & KINGS COUNTY equipment is approximately 2 years old. Suite is $265,796 for 2014. Property ID #5022. 1,200 sq . Seller is working 5 days/wk and sees SAN LUIS OBISPO COUNTY – 6 equipped ops. Has approximately 8-10 paents/day. Income source is TORRANCE – 3 equipped operatories, Grossed monthly revenues of $90K. Property ID #5037. approximately 25% insurance, 65% cash and 10% $321,051 in 2013. Pracce is averaging $28K in Den-cal. Does lile adversing. Please contact monthly revenue. Property ID #4477. VENTURA (GP) - 4 fully equipped operatories in a 1,862 (+ free bonus room) sq suite. Each operatory your CPS Agent for more informaon. Property ID TORRANCE – 5 equipped ops. Grossed approxi- has floor to ceiling windows for plenty of natural light . #4487. mately $493K for 2014. Property ID #5036. Grossed approximately $423K in 2014. Property ID RIVERSIDE – 6 ops. Projecng approximately $550K #5039. for 2014. Property ID # 5006.

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CONTACT US FOR A FREE CONSULTATION WWW.CALPRACTICESALES.COM Phone: (714) 639-2775 CA DRE #00491323 RM Matters CDA JOURNAL, VOL 43, Nº6

Report Employee Injuries Immediately TDIC Risk Management Staff

orkers’ compensation medical treatment and make medical covers a broad care available to injured employees. and multifaceted TDIC advises dentists to report legal spectrum, “If an employee reports workers’ compensation claims, but a few essential an injury, report the claim. even if they dispute the injury. Wpractices can help dentists manage “TDIC only has 90 days to investigate an employee injury at work. You are required to make and issue a denial, if appropriate, for a Key considerations include reporting medical treatment available disputed claim,” Boyd said, noting that the injury right away, authorizing medical and provide a claim form it is not up to the dentist to discern care, avoiding judgment about the injury, if the injury is real or credible. “If an maintaining open communication to the employee.” employee reports an injury, report with the injured employee and the claim. You are required to make treating the injured employee fairly. medical treatment available and provide Some policyholders mistakenly a claim form to the employee.” believe that not reporting employee injuries to the insurance company is a good business decision. “Many times employers do not report claims on a timely basis,” said Deborah Boyd, workers’ compensation claims manager with The Dentists Insurance You are not a policy number. Company. “The law requires industrial injuries to be reported as soon as the employer has knowledge of an injury.” And at The Dentists Insurance Company, we won’t treat you like When reporting an employee injury, one because we are not like other insurance companies. We were be prepared with as much information as immediately possible, including started by, and only protect, dentists. A singular focus that leads the name of the employee, date, time to an unparalleled knowledge of your profession and how to best and location of the injury as well as protect you. It also means that TDIC is in your corner, because with a description of what happened. us, you’re never a policy number. You are a dentist. While workers’ compensation laws vary from state to state, statutes generally require employers to give a workers’ compensation claim form to the employee Contact the Risk Management Advice Line at 800.733.0634. within one working day after the work- related injury or illness is reported. State- specifi c workers’ compensation information is available on the U.S. Department of Labor’s website at dol.gov/owcp/dfec/regs/ Protecting dentists. compliance/wc.htm. Request immediate ® return of the form from the employee It’s all we do. and forward the claim form, along with thedentists.com a report of occupational injury or illness, to the insurance claims representative within one working day. Employers are required to authorize appropriate

JUNE 2015 333 JUNE 2015 RM MATTERS

CDA JOURNAL, VOL 43, Nº6

If you dispute that an injury occurred, administer benefi ts according to regulations. liability is to treat an employee fi ling report the claim and tell the claims If an employee is off work due to the a workers’ compensation claim or representative you are disputing the injury. injury, TDIC recommends that dentists returning to work after an injury the “We will conduct the appropriate maintain communication during the same as other employees. Boyd said to investigation,” Boyd said. “If our period of disability. The employee should be aware of reprimands or disciplinary investigation reveals that no benefi ts are keep the dentist advised about the date action to an employee with an open due, we will deny the claim. While the that he or she expects to return to work. workers’ compensation claim. A record employee will have recourse to overturn TDIC recommends that dentists address of dates, times and a brief description the denial, a late report may preclude us “out-of-offi ce” status in their offi ce policy. of incidents will keep information from being able to defend a claim denial.” “In other words, have an offi ce policy straight in the event of a claim. Similarly, employers are advised that that is clear and tells the employee A reasonable effort needs to be workers’ compensation is “no fault” and what is expected anytime they are out made to accommodate temporary work that an injured employee is covered even if of the offi ce on leave,” Boyd said. restrictions and provide transitional the employer thinks the injury was caused Fair and equal treatment of an injured work (light duty) while the employee by employee behavior. Generally, workers’ employee is important to avoid allegations heals from the injury, and employers are compensation in all states provides coverage of retaliation or discrimination against the encouraged to document these efforts. for medical bills and lost wages for workers employee. Workers’ compensation laws Termination of an employee with who are injured on the job, regardless of are state specifi c, but most jurisdictions an open workers’ compensation claim fault. In exchange, workers are not able to have antidiscrimination laws protecting is risky and may cause the employee sue an employer for a work-related injury. employees from retaliatory action when to fi le a claim seeking additional After fi ling a workers’ compensation fi ling a workers’ compensation claim. compensation for discrimination. claim, the insurance company will begin to For employers, the key to avoiding Dentists are strongly advised to consult an attorney before any consideration of dismissing an employee who has fi led a workers’ compensation claim. “While workers’ compensation is the exclusive remedy for workplace injuries, and your employee can’t sue you in civil court for damages, your employee can sue you in civil court for wrongful termination or disability discrimination,” Boyd said. “Civil employment lawsuits are costly to defend. In addition to payment for damages, claimants can recover their attorneys’ fees in these types of actions. Therefore plaintiffs’ attorneys are often motivated to take these cases to trial even if the actual damages aren’t particularly large.” Also important is that the defense of a workers’ compensation discrimination claim and any associated penalties imposed by a judge are not covered by workers’ compensation insurance policies. Some workers’ compensation insurance policies explicitly exclude workers’ compensation discrimination claims, and there is no duty to defend them. ■

Consult with trained analysts about workers’ compensation and other dental practice topics on TDIC’s Risk Management Advice Line 800.733.0634.

334 JUNE 2015 QUESTIONS MOST OFTEN ASKED BY SELLERS:

1. Can I get all cash for the sale of my practice?

2. If I decide to assist the Buyer with financing, how can I be guaranteed payment of the balance of the sales price?

3. Can I sell my practice and continue to work on a part time basis?

4. How can I most successfully transfer my patients to the new dentist?

5. What if I have some reservation about a prospective Buyer of my practice?

6. How can I be certain my Broker will demonstrate absolute discretion in handling the transaction in all aspects, including dealing with personnel and patients?

7. What are the tax and legal ramifications when a dental practice is sold? QUESTIONS MOST OFTEN ASKED BY BUYERS:

1. Can I afford to buy a dental practice?

Can I afford not to buy a dental practice? LEE SKARIN 2. INC. & ASSOCIATES

3. What are ALL of the benefits of owning a practice?

4. What kinds of assets will help me qualify for financing the purchase of a practice?

5. Is it possible to purchase a practice without a personal cash investment?

6. What kinds of things should a Buyer consider when evaluating a practice?

7. What are the tax consequences for the Buyer when purchasing a practice? 2IÀFHV Lee Skarin & Associates have been successfully assisting Sellers and Buyers of Dental Practices for nearly 30 years in providing the answers to these and other 805.777.7707 questions that have been of concern to Dentists. 818.991.6552 Call at anytime for a no obligation response to any or all of your questions Visit our website for current listings: www.LeeSkarinandAssociates.com 800.752.7461 CA DRE #00863149 DENTAL PRACTICE BROKERAGE Making your transition a reality.

Dr. Lee Dr. Thomas Dr. Dennis Dr. Russell Jim Kerri Mario Jaci Steve Thinh Maddox Wagner Hoover Okihara Engel McCullough Molina Hardison Caudill Tran LIC #01801165 LIC #01418359 LIC #0123804 LIC #01886221 LIC #01898522 LIC #01382259 LIC #01423762 LIC #01927713 LIC #00411157 LIC #01863784 (949) 675-5578 (916) 812-3255 (209) 605-9039 (619) 694-7077 (925) 330-2207 (949) 566-3056 (949) 675-5578 (949) 675-5578 (951) 314-5542 (949) 675-5578 25 Years in Business 40 Years in Business 36 Years in Business 33 Years in Business 42 Years in Business 35 Years in Business 35 Years in Business 26 Years in Business 25 Years in Business 11 Years in Business

PRACTICE SALES • PARTNERSHIPS • MERGERS • VALUATIONS/APPRAISALS • ASSOCIATESHIPS • CONTINUING EDUCATION

NORTHERN CALIFORNIA PLUMAS COUNTY: General Dentistry. BANNING: General Practice. 6+ Ops. TORRANCE: General Dentistry. 3 Ops, 2 Seller wants to retire ASAP, selling for Paperless, Digital, EagleSoft. 8 Days Hyg/ Equipped. Est 19+ years. 2013 GR of $333K BAY AREA: Perio Practice. 2,120 sq. ft. $95,000. 5 Ops, 4 Equipped. #CA240 Week. 2013 GR $1.5MM+. #CA183 with $176K adj. net. #CA213 w/6 Ops, Digital, Endoscope, Piezosurgery, Dentrix. #CA167 SACRAMENTO: 7 Equip Ops in 2,400 sq. BEVERLY HILLS: Small boutique UPLAND: NEW LISTING! General CASTRO VALLEY: Practice & Building. ft., 1 add’l Op Plumbed. Digital X-ray, Pano, practice, 2 Ops, 1 Equipped, Open Dental, Practice. 4 Ops, 3 Equipped. 25+ years of Approx. 1,800 sq. ft., 3 Ops, 1 add’l Plumbed. Softdent software. 2014 GR $626K+. #CA250 Digital, 2014 GR $120K on 3 days/wk.. Goodwill. 2014 GR of $221K with room to #CA215 grow. #CA254 2014 GR $373K, 4 day week. #CA251 SACRAMENTO: PPO practice, 8 Ops in FOLSOM: 2,420 sq. ft. w/5Ops, Shick Digital 3,700 sq. ft., Seller retiring. #CA238 BEVERLY HILLS: 5 Ops, EagleSoft, VICTORVILLE: General Practice. 3 Ops, 3 X-Rays, non-digital Pano, Carestream/Softdent IN ESCROW! Digital, CEREC. Long-term staff, newer Plumbed, 2,150 sq. ft., Est. 34 Years, SoftDent. software. #CA235 SACRAMENTO: Prosth. Practice. OWNER equipment. 2013 GR 1.2M, adj. net. of $406K. 2013 GR $313K w/adj. net. $147K #CA149 #CA210 FOLSOM: FACILITY ONLY 1,200 sq. DECEASED. 4 Ops, 2,075 sq. ft. w/Digital WEST COVINA: NEW LISTING! ft. w/3 Ops, digital X-rays & pano, new Pano & Mac Practice software. 2014 GR GREATER LOS ANGELES: Perio General Practice with 4 Ops in a retail center compressor #CA209 $960K+. #CA247 Practice. 5 Ops. 34 Years of Goodwill. Call for location. Dentrix, Digital, 35 years of goodwill. More Information. #CA173 2014GR of $402K #CA233 GREATER SACRAMENTO: General SAN FRANCISCO: General Dentistry. 3 Practice. 1,500 sq. ft., 5 Ops (4 Equipped), Ops, 2 Equipped, 780 sq. ft., 2013 GR $854K HUNTINGTON BEACH: General WEST LOS ANGELES: NEW LISTING! Dexis Digital X-rays, Dentrix software. #CA191 Practice., 3 Ops. Dentrix, Digital, Laser, Intra- General Practice, 4 Ops, newly built-out suite, #CA239 IN ESCROW! SANTA CRUZ COUNTY: General Oral. Est.23 Years. #CA194 IN ESCROW! desirable high rise. 50+ years goodwill. FFS. 2014 GR $651K. #CA226 GREATER SACRAMENTO: General Dentistry. 3 Ops, 1,100 sq. ft., Schick Digital. IRVINE: NEW LISTING! General Practice. 7 Ops, 3,079 sq. ft. (Shared w/2nd Dentrix. GR $338K #CA550 Practice, 5 Ops, 4 Equipped. PPO/FFS, GR of WEST HOLLYWOOD: General Practice, DDS – Separate Practices), 2013 GR $974K. SANTA ROSA: General Dentistry & $314K on a 3-day work week. #CA241 4 Ops, Mediadent, Intra-Oral Camera, Digital, #CA140 Building. 3 Ops. 2013 GR $542K w/Adj. Net Laser, 5 yr old equip. 2014 GR of $613K . LOS ANGELES: General Practice. 9 Ops, #CA212 IN ESCROW! GREATER SACRAMENTO: General $182K #CA200 6 Equipped. Dentrix, Digital. Est.16 Years. Practice. 2,100 sq. ft. w/6 Ops, Dentrix WALNUT CREEK: PRICE REDUCED! 2013 GR 824K w/adj. net. $355K #CA197 SAN DIEGO software, X-rays. Combined 2013 GR of Prosth Practice. 3 Ops, Full Lab. 2013 GR IN ESCROW! $1.1M. #CA237 CENTRAL SAN DIEGO: NEW IN ESCROW! $399K w/adj. net. $143K #CAM540 LOS ANGELES: General Practice. 4 Ops, 3 IN ESCROW! LISTING! Very busy 6 Op General Practice GREATER SAN JOAQUIN: Pedo Practice. Equipped, Est. 60+ years in prof. bldg.. 2013 with room to expand to 9 Ops. PPO, Dentrix, Pano, Digital X-ray, 3 chairs. 2014 GR approx.. CENTRAL CALIFORNIA GR of $824K with $355K adj. net. #CA211 Digital. 2014 GR 1.7M. #CA231 $700K. #CA230 CENTRAL COAST: 6 Ops, 8 days of N. ORANGE COUNTY: NEW LISTING! DOWNTOWN: NEW LISTING! GREATER SAN JOSE: Perio Practice. General Practice. 4Ops, Beautiful design, great Leasehold sale. Modern and chic downtown Fiscal-year GR $1.3M. 5 Ops, 2 add’l hygiene/wk. 2013 GR of $2.3M and $804K in adj. net. Dentrix, Digital, Paperless. #CA208 location near freeway & shopping #CA234 RI¿FHLQSULPHORFDWLRQRSVURRPWR Plumbed, in same loc. 28 years. #CA219 expand. #CA232 IN ESCROW! FRESNO: General Dentistry Partnership. PALM DESERT: NEW LISTING! Perio/ Implant Practice. 6 Ops, 5 Equipped, Dentrix, LA MESA: NEW LISTING! General MARIN COUNTY: Mill Valley. 1,260 sq. ft., 2013 Partnership GR $4.7M. Selling Partner Digital, Pano, 20+ years of goodwill. 2014 GR Practice. 4 Ops. 3 Equipped, FFS/PPO, 3 Ops, 1 add’l Plumbed. Dentrix, Digital X-ray, 2013 Net Inc. $368K. #CA196 $805K with $339K adj. net. #CA245 Dentrix, Digital. 2013 GR $342K , similar in Intra-Oral. #CA224 IN ESCROW! FRESNO: General Practice. 4 Ops, 1,739 sq. PALM DESERT: NEW LISTING! 2014. #CA227 IN ESCROW! MENDOCINO COAST: General Practice. ft., CEREC, 61% Overhead. 2013 GR $740K+. #CA20 IN ESCROW! General Practice, 5 Ops, Est. for 32 years, LA MESA: General Practice. 3 Ops, 2,000 4 Ops, 2,376 sq. ft. Dentrix, CAD/CAM. 2013 6 days of hygiene/week/ GR of $824K and GR $1M+. #CA181 sq. ft. in a Prof. Bldg.. Dentrix, Laser, Digital. FRESNO: 5 Ops, 4 Equipped, 1,400 sq. ft., w/ $339K adj. net. #CA245 2012 GR $396KSOLD w/adj. net. $155K. #CA127 N. COAST: Endo Practice. 6 Ops, 5 Plumbed, Pano, Dentrix software, all digital. 3 years GR averaging $409,000. Priced to sell. #CA243 SANTA ANA: 6 Ops, Dentrix, Dexis, Pano, N. COUNTY COASTAL: NEW 3,300 sq. ft.. Digital X-ray, Microscopes, Laser. GR just over $1M in 2013, higher in EndoVision software. #CA214 IN ESCROW! LISTING! General Practice, 3 Ops, digital, 2014. #CA221 IN ESCROW! Dentrix, FFS/PPO. 2014 GR of $530K with N. EAST BAY: PRICE REDUCED $77K! PORTERVILLE: General Dentistry, 6 Ops. S. ORANGE COUNTY: General Practice. $228K adj. net. #CA253 General Practice + Bldg. 7 Ops. 2,324 sq. ft. 2014GR $555K, 7 year old equipment, retail 5 Ops. EagleSoft, Schick, Intra-Oral. 2013 2012 GR $885K. #CA108 center. #CA223 N. COUNTY INLAND: NEW LISTING! GR $400K w/adj. net. $136K #CA192 IN TUOLUMNE COUNTY: General Practice General Practice & bldg, 4 Ops, PPO/FFS, NORTHERN CALIFORNIA: Perio ESCROW! Digital, Pano, Cerec. GR over $1M. #CA216 Practice, Partnership Position. 6 Ops, 1,500 & Bldg. 6 Ops, 2,000 sq. ft., 2013 GR $1MM+ sq. ft. Dentrix. Owner Financing Available. #CA197 IN ESCROW! S. ORANGE COUNTY: NEW LISTING! SAN DIEGO: General Practice. 3 Ops. FFS, #CA168 Pedo Practice with 4 Ops, 1 year new PracticeWorks. Located in Central San Diego. SOUTHERN CALIFORNIA equipment, digital, Pano/ $236K GR with room 2014 GR $187K. #CA161 NORTHERN CALIFORNIA: Endo to grow. #CA222 Practice. 3 Ops, 1 Plumbed, 1,200 sq. ft., ANAHEIM: General Practice & Bldg. 6 Ops, SANTEE: NEW LISTING! General FFS/ 2 Microscopes, Digital. 2013 GR $319K+ 3 Equipped, 3 Plumbed. Near Disneyland. Est. SOUTH BAY, LOS ANGELES: NEW PPO Practice, 6 Ops, retail center, Dentrix, #CA158 IN ESCROW! 39 years. #CA186 LISTING! General Dentistry. 3 Ops, Dentrix, Digital, $780K GR in 2014. 7 days of hyg/ ANAHEIM: 4 Ops, 5 add’l available, Dexis, Pano, mostly FFS, 8 days hyg/week. week, long-term staff. #CA228 NORTHERN CALIFORNIA: Endo $1.1M GR in 2013. #CA218 Practice. 4 Ops, 1 Add’l Available, 1,021 sq. ft., SoftDent, Digital X-rays and Digital Pano. S. BAY AREA, SAN DIEGO: General 2013 GR $337K #CA169 2013 GR 237K. #CA207 IN ESCROW! SOUTH PASADENA: NEW LISTING! Dentistry, 3 Ops, 4 days hyg/wk. Retail center, BAKERSFIELD: General Practice. 4 Ops. General Dentistry. 4 Ops, 3 Equipped, Dentrix, Digital Pano, PPO & FFS. Proj. GR OAKLAND: General Practice. Piedmont paperless, digital, est. 37 years. 2014 GR 'LVWULFW2SVLQVKDUHGRI¿FHZVTIW Pano. Est. 20+ Years. 2013 GR $521K. 2014 $562K. #CA206 #CA193 $856K with $271K adj. net. #CA244 GR$453K. #CA217 IN ESCROW! OUT OF CALIFORNIA PLEASANTON: Facility Only, Former Endo BALDWIN PARK: General Practice. 5 TEMECULA: General Practice. 6 Ops. Ofc, Good GP Startup. 2 Ops, 1 Plumbed & Ops, 4 Equipped. 2013 GR $286K w/Adj Net EagleSoft, 14 Workstations, Digital, CEREC, HAWAII (MAUI): PRICE REDUCED! Partially Eq. 975 sq. ft., #CA195 $133K. #CA176 Pano. Est.26 Years, Long-Term Staff. #CA174 General Practice. 4 Ops, Approx. 1,200 sq. ft., IN ESCROW! GR $636K #20101

NORTHERN CALIFORNIA OFFICE NEW SOUTHERN CALIFORNIA OFFICE 1.800.519.3458 www.henryscheinppt.com 1.888.685.8100 Henry Schein Corporate Broker #01230466 Regulatory Compliance CDA JOURNAL, VOL 43, Nº6

Uses and Disclosures of Patient Health Information:

Part II CDA Practice Support

he rules under which a dental Law enforcement without a subpoena. ■ To respond to requests for practice may use or disclose Sometimes law enforcement will information about a crime victim. patient health information request a patient’s information from a ■ To alert law enforcement (PHI) for public benefi t and dental practice. Although it is prudent of a suspicious death. interest activities is the subject to insist upon a subpoena, HIPAA ■ To provide evidence of Tof this article. Last month’s article permits a dentist, without patient criminal conduct. reviewed HIPAA and state rules for authorization, to release protected Before providing the requested required and incidental disclosures, as health information to law enforcement information, verify the identity and well as permissible uses and disclosures under the following circumstances: credentials of the individual receiving it. for treatment, payment and business ■ To report injuries resulting from Mandated reporting. The obligation operations. In all but required criminal acts or deadly weapons. of a licensed dental professional to circumstances, a dental practice should ■ To respond to court orders, search disclose possible domestic abuse, use or disclose the minimum necessary warrants, court-issued subpoenas violence, neglect, criminal activity and information to accomplish the purpose or regulatory agency order. other legal violations involving patients of the use or disclosure of information. ■ To respond to requests for information to appropriate agencies is not hindered HIPAA and state law permit the use to identify or locate suspects, fugitives, in any way by HIPAA or California law. or disclosure of PHI without a patient’s witnesses or missing persons. Patient authorization is not necessary. authorization to third parties that benefi t the public or perform in the public’s interest, but only in specifi c circumstances. Other circumstances involving the same third parties may require a patient’s When Looking To Invest In Professional authorization to use PHI. Below are the third parties and the circumstances Dental Space Dental Professionals Choose under which patient authorization is or is not required to use or disclosure PHI. Subpoenas, court orders and administrative orders. A dental practice must disclose PHI pursuant to a legally Linda Brown executed subpoena issued by a state or federal court, board, commission 30 Years of Experience Serving or administrative agency. Subpoenas the Dental Community Proven and search warrants presented by law enforcement do not require patient Record of Performance authorization for the production of PHI. If presented with a civil suit subpoena, a • Dental Office Leasing and Sales dental practice may disclose information • Investment Properties if the subpoena is issued by a California For your next move, or federal court and is accompanied contact: LINDA BROWN • Owner/User Properties with either the patient’s authorization • Locations Throughout or documentation that the patient has Direct: (818) 466-0221 been informed of the subpoena. A dental Southern California practice should contact legal counsel if Office: (818) 593-3800 questions arise about a subpoena. An Email: [email protected] administrative order issued by a state Web: www.TOLD.com or federal board, commission or agency Cal BRE: 01465757 is typically accompanied by a patient’s authorization for release of information.

JUNE 2015 337 JUNE 2015 REGULATORY COMPLIANCE

CDA JOURNAL, VOL 43, Nº6

Coroner. California law requires, and organ or tissue donation, child or elder Social services agencies. If a minor HIPAA permits, health care providers abuse, suicide, poisoning, accident, patient is in the temporary custody of to release information upon a coroner’s sudden infant death, suspicious deaths, a social service agency or probation request to help identify the deceased, unknown deaths or criminal deaths. department or is a ward of the locate next of kin or investigate deaths Authorization by the patient or a court, a dental practice may release that may involve public health concerns, patient’s representative is not required. to those entities PHI necessary for coordinating health care services and treatment for the patient. Public health agencies. Incidences of communicable diseases, such as TB and measles, must be reported to a local public health agency. The report does not require patient authorization. Dental practices may provide, without patient authorization, patient information to

Paul Maimone local, state and federal health agencies for NOW IS THE BEST TIME IN YEARS Broker/Owner the purpose of preventing or controlling TO BUY OR SELL A PRACTICE! disease, public health investigations and public health surveillance. Dental ARCADIA – (4) op comput G.P. Located in a well known Prof. Bldg. on a main thoroughfare. practices also may report adverse Cash/Ins/PPO pt base. Annual Gross Collect $300K+ on a (3) day week. NEW BAKERSFIELD #29 - (4) op comput G.P. (3) ops eqt’d, (1) add. plumbed. Located in a free events involving drugs or devices to stand bldg. Cash/Ins/PPO. Digital x-rays. Annual Gross Collect $300K+ p.t. Seller moving. NEW the FDA MedWatch program. ENCINO – (3) op comput G.P. located in a prof bldg. on a main thoroughfare. Annual Gross Serious threat to health or safety. A Collect $150K+ p.t. Cash/Ins/PPO. Below market Lease. Great Starter or Satellite. Seller retiring. LANCASTER – (5) op comput. G.P. & Single Use Bldg. Be your own Landlord. (3) ops eqt’d dentist may disclose minimum necessary (2) add plumbed. Located in a free stand bldg. on a main thoroughfare. Cash/Ins/PPO pts. Gross PHI when he or she believes such Collect $300K+ on a (2) day wk. Digital. Total payment $4K/mos w $30K down. WOW! disclosure will prevent a serious or LA VERNE – (7) op comput. G.P. (3) ops eqt’d (4) add plumbed. Located in a busy shop. ctr. w exposure/visibility & signage. Cash/Ins/PPO. Digital X-rays. 2014 Gross Collect ~ $390K. imminent threat to a person or persons. MONTEREY PARK – (6) op comput G.P. located in a street front suite on a main thoroughfare Such disclosures may be made without w exposure & visibility. Cash/Ins/PPO. Annual Gross Collect $250K+ p.t. Seller retiring. NEW patient authorization to an entity that PASADENA – Nearly New Turnkey Office w some charts. Newer eqt. Gorgeous! RANCHO CUCAMONGA - (4) op comput. G.P. in a strip ctr. w visibility. (3) ops eqt’d (4th) op can prevent or lessen the threat. plumbed. Annual Gross Collect $185K+ on 2.5 days/wk. Cash/Ins/PPO pts. Seller moving. Research. Before allowing PHI to be SHERMAN OAKS – (3) op comput G.P. in a well known, easily accessible Med/Dental bldg. Cash/Ins/PPO. Annual Gross Collect $180K+ p.t. Great Starter or Satellite. Seller retiring. used without patient authorization for So. KERN COUNTY – (6) op comput. G.P. located in a Bakersfield suburb in a small strip ctr. w research, a dental practice is obligated exposure/visibility. Pano eqt’d. Limited competition. Cash/Ins/PPO pts. Annual Gross Collect. to ensure the researcher has provided Approx. $350K p.t. Seller is moving and is motivated. NEW SANTA ANA - absentee owned (6) op fully eqt’d G.P. First floor street front location on a main it with certain assurances required by thoroughfare. Exposure/visibility/signage. Cash/Ins/PPO. No HMO & No Denti-Cal. Pano eqt’d HIPAA (see hhs.gov/ocr/privacy/hipaa/ & Computerized. 2014 Gross Collect. of $549K+ on a (3½) to (4) day Associate run week. NEW understanding/special/research). A SOUTHWEST RIVERSIDE COUNTY - (5) op comput. G.P. (4) ops eqt’d/5th plumbed. 2015 Project Gross Collect $400K+. Cash/Ins/PPO. Located in a smaller prof. bldg. in a condo which dental practice also may use or disclose can be purchased or leased. Seller giving up private pract. to accept institutional position. NEW for research purposes and without TUSTIN - (4) op comput. G.P. (3) eqt’d/4th plumbed. Located in a busy shop ctr. on a main thoroughfare. Exposure, visibility & signage. Digital x-rays & CEREC. Annual Gross Collect patient authorization a limited data $460K+ on an easy 4½ day week. Cash/Ins/PPO. No Denti-Cal or HMO. Growth potential. NEW set of PHI. A limited data set does WEST SAN FERNANDO VALLEY - (4) op comput. G.P. w modern equipt. Located in a not include 16 specifi ed identifi ers. smaller prof. bldg. on a main thoroughfare. Cash/Ins/PPO pts. Annual Gross Collect $750K+ on a (4) day week. Excell. long term lease, outstanding signage, & great off street parking. SOLD Miscellaneous. PHI may be disclosed UPCOMING PRACTICES: Bakersfield, Beverly Hills, Central Coast, Covina, Montebello, without patient authorization as Oxnard, Pomona, San Gabriel, SFV, Temecula, Thousand Oaks, Torrance, Visalia & Valencia. authorized by workers’ compensation D&M SERVICES: laws and Cal/OSHA. ■ QQ Practice Sales and Appraisals Practice Search & Matching Services Q Practice and Equipment Financing Q Locate and Negotiate Dental Lease Space Regulatory Compliance appears monthly Q Expert Witness Court Testimony Q Medical/Dental Bldg. Sales & Leasing Q Pre - Death and Disability Planning Q Pre - Sale Planning and features resources about laws and P.O. Box #6681, WOODLAND HILLS, CA. 91365 regulations that impact dental practices. Visit Toll Free 866.425.1877 Outside So. CA or 818.591.1401 www.dmpractice.com cda.org/practicesupport for more than 600 Serving CA Since 1994 CA BRE Broker License # 01172430 practice support resources, including practice management, employment practices, dental CA Representative for the National Association of Practice Brokers (NAPB) benefi t plans and regulatory compliance.

338 JUNE 2015 “Matching the Right Dentist CARROLL to the Right Practice” &COMPANY CComplete Evaluation of Dental Practices & All Aspects of Buying and Selling Transactions

4068 MARIN COUNTY GP Well established and respected, quality general practice located in desirable Marin County location. Office has convenient ample parking, overlooking a beautiful park like setting adjacent to a peaceful creek. Owner/Doctor is ready to transition into retirement. Office contains 5 ops in ~1,300 sq. ft. Gross receipts average $1.2M annually with less than 4 doctor days/week. Adjusted net averaging ~ $400K for last 2 years. Doctor has experienced many gratifying years treating exemplary patients and requires an experienced G.P. with minimum of 2-5 years of experience. Mike Carroll & Pamela Carroll-Gardiner 4078 LOS ALTOS GP Seller relocating and offering established 35 4043 SANTA ROSA GP year old general practice in highly desirable area. 1,230 sq. ft. office with 3 fully equipped Well-established, well respected general dental ops. 2014 GR $500K+ Approx. 2 1/2 doctor- practice located within a lovely professional days. Asking $350K. center in the heart of town.

Beautifully landscaped grounds with ample parking, 4051 CENTRAL COAST PROSTHO Condo is also available for purchase.
Owner/ Well-established practice located in doctor
works 3.5 days a week with 3.5 days of California’s gorgeous Central Coast area. hygiene.


Gross receipts average $750-$800K Beautifully appointed, spacious 1,568 sq.ft. every year with an adjstd net of almost office with 4 fully equipped ops, pros lab and $300K.

Seller is willing to assist Buyer for a other amenities. Situated just minutes from smooth transition.

Asking price for practice the ocean and <5 miles away from one of only $495K. California’s historic Mission Cities, this 4076 MORGAN HILL GP practice is nestled in a highly desirable community. 2013 gross receipts were $1.2M+ Absolutely beautiful and modern; established and 2014 is annualized at $1.3M+ on a 4 day practice in well-known Professional Center. doctor workweek, w/4 days of hygiene/week. State-of-the-art office in approx. 1,000 sq. ft. Approx. 15 new patients a month and ~1,500 3 fully equipped ops, with room for a 4th op. active patients (all fee-for-service). Owner/ 300+ active patients. Gross Receipts approx. doctor is willing to help Buyer for smooth $245K. Ideal turn-key operation. Asking transition. $215K. 4054 MID-PENINSULA ORTHO 4075 PETALUMA GP This established orthodontic practice is located Carroll & Company Established GP located in Petaluma in in desirable centrally located area with a solid 2055 Woodside Road, Ste 160 stunning 1,856 sq. ft. seller owned facility in economic base, numerous amenities & diverse class A, 2 story, 10 year-old professional Redwood City, CA 94061 residents. The SOLDoffice is state-of-the-art with 5 building. State-of-the-art office includes 6 ops, (open bay) ops in approximately 1,600 sq. ft. Phone: staff lounge, reception area, private office, Both practice and building are for sale. Asking business office, lab area, sterilization area, $591K practice, $937K building. 650.362.7004 consult room, separate storage area, bathroom 650.362.7005 plus private bathroom. 4 doctor-days & 4 UPCOMING: 650.362.7006 hygiene days/wk. Avg. GR $640K. Asking San Jose GP Email: $490K. Bay Area Perio [email protected]

Website: www.carrollandco.info CA DRE #00777682 800.641.4179 [email protected] WESTERNPRACTICESALES.COM

BAY AREA BAY AREA CONTINUED NORTHERN CALIFORNIA CONTINUED What separates AC-335 SAN FRANCISCO: Two great practices for the price of one! Call for Details!! DN-409 SAN JOSE Facility: Desirable neighborhood HG-298 REDDING FOOTHILLS: HEALTH FORCES us from other AC-417 SAN FRANCISCO Facility: Turn-Key Op- w/ fantasc visibility! 1,400 sf w/ 7 ops. $95k SALE! Prac- portunity! 555 sf w/ 2 ops + 1 add’l. Call for DN-408 SAN JOSE: Seller is rering and is passing ce $100k / Real Estate $250k brokerage firms? Details! this onto you! 1,300 sf w/ 2 ops + 2 add’l. $75k HN-213 ALTURAS: AG-053: 3,000 sf w/ 9 ops + 1 add’l. PRIME LOCA- DC-419 NEWARK Facility: Locaon, Locaon, Loca- $115k TION! $595k on! 1,400 sf w/ 4 op. $140k HN-280 NORTHEASTERN CA: $110k AG-402 SOUTH SAN FRANCISCO: Seller Highly Moti-

NORTHERN CALIFORNIA HN-290 PLACERVILLE: Excellent Merger Op! vated! All New Upgrades! 1050 sf w/ 3 ops $250k

AG-416 SAN CARLOS: Turn-Key located in a highly desirable community! 1,350 sf w/ 3 ops. $90k EN-340 SACRAMENTO: Large HMO pracce! 3,400 sf $210k Our extensive buyer BN-183 HAYWARD: Kick it up a notch by increasing w/ 10 ops and Plumbed for 1 add’l $950k database and the current very relaxed work schedule! 1,300 sf w/ EN-350 SACRAMENTO: The Perfect Merger Oppor- CENTRAL VALLEY 3 ops $150k tunity! Old-fashioned values and philosophy! 674 sf unsurpassed exposure BN-279 CONTRA COSTA COUNTY: 2-story. 1,350 sf w/ 1 op. $85k IG-067 STOCKTON: w/ 3 ops +1 add’l $60k EN-378 LINCOLN: quality pracce with a wonderful Steal of allows us to offer you a BC-361 OAKLAND: Established for over 23+ years! paent base! 1,369 sf w/ 2 op + 3 add’l. $170k the Century! Now ONLY $240k 2,200 sf w/ 7 ops. Now Only: $385k EN-379 ROSEVILLE: An amazing opportunity in the IG-367 MERCED: BC-381 PLEASANT HILL Facility: Open Floor Plan! locaon of your dreams! 1,040 sf w/ 3ops. $295k REDUCED! $325k 1,852 sf w/ 6 equipped ops! Move in Ready! $80k EN-391 SACRAMENTO: Opportunies like this one IN-297 MODESTO: BG-407: SAN LEANDRO: Prof bldg. Great signage! are “few and far between”! 1,200 sf w/ 4ops. $310k 1200 sf w/ 3 ops $150k EN-423 FOLSOM Oral Surgery Facility: Primed for PR: $475k / RE : $425k Beer success! 3,450 sf w/ 2 Lrg. Treatment Rooms. $100k IN-345 MODESTO: CC-390 SOLANO COUNTY: Near Travis AFB! Highly visible location! 950 sf w/ 3 ops $200k FN-181 NORTH COAST: Well respected FFS GP. $495k CG-366 SONOMA CO.: Vibrant, growing communi- Stable patient base. 1,000 sf w/3 ops $150k (25% IN-358 MODESTO: ty! 1,300+ sf w/ 4 ops. Over $760k in collections! int. in bldg. avail.) $350k Candidate FN-299 FERNDALE: Live and practice on the beau- IN-397 FRESNO/MADERA: $480k CN-344 N. SONOMA CO: Long-established, stellar tiful North Coast! 1,300 sf w/ 3 ops $225k (Real $480k reputaon! 2560 sf, w/ 6 ops $925k Estate: $309k) JN-295 VISALIA: CC-369 SAN RAFAEL: Perfect starter pracce oppor- FC-334 NORTHERN CA: Emphasis on prevenon. PR: $185k RE: $300k tunity! 900 sf w/ 3 ops. $350k 1,200 sf w/ 4 ops $480k / Real Estate Also Available! JC-349 FRESNO Beer DC-370 SAN JOSE Facility: Available with or without FC-343 NORTHERN CA: Quality & locaon are the patient charts! Move in Ready! Call for Details! keys to success! 1,200 sf w/ 3 ops + 1 add’l & 1 hyg. Call for Details! DG-351 PLEASANTON Facility: Don’t miss out! Re- Op. $500k (Real Estate $375k) JG-400 CLOVIS: duced to sell quickly! 1,000 sf w/ 3 ops. $69k GG-320 CHICO: Large, Unique, Originally designed Fit DG-394 LOS GATOS: Highest Quality of Dentistry! for more than 1 dds! 5,000 sf w/ 7 ops (+2 add’l) $465k Decades of Goodwill! 850 sf w/ 3 ops ONLY $280k $985k DG-401 SAN MATEO: Fantastic El Camino Real Loca- GG-386 REDDING: Practice & Real Estate! 2,860 sf SPECIALTY PRACTICES tion. 900 sf w/ 3 ops $125k w/ 4 ops. Plumbed for 2 add’l! $360k and $660k DG-341 SUNNYVALE/LOS GATOS Combined Sale: GN-201 CHICO: Beautiful practice, major thorough- I-7861 CENTRAL VALLEY Ortho: Contact our office for details. $605k fare, stellar reputation! 1,400 sf w/ 4 ops & room $370k Beer DG-396 SERRAMONTE AREA: Small Town Feel in for another $425k I-9461 CENTRAL VALLEY Ortho: Heart of SF. 850 sf & 4 ops $485k GN-244 OROVILLE: Gorgeous, Spacious. 2,500 sf $180k DN-311 PLEASANTON Facility: Great Locaon! 870 sf w/5 ops! Collections over $450k in 2013. $315k DG-264 SAN JOSE Ortho: w/ 3 ops + 1 add’l. NOW ONLY: $75k GN-258 REDDING: Prisne and aracve! Conven- REDUCED! iently located! 1,050 sf w/ 2 ops. $215k $245k Price DG-413 CUPERTINO: Rare Opportunity near APPLE “Spaceship” Campus! $1.15m GN-387 CHICO: Streamlined overhead and reasona- AC-325 SF Endo: DN-312 LIVERMORE Facility: Don’t miss out on this ble rent. 1,000 sf w/ 3 ops. $235k $250k one! 1,070 sf w/ 3 ops. REDUCED! $75k GN-399 REDDING: Loyal paent base and relaxed BC-336 CONTRA COSTA CO Perio: We are a proud member of: DN-353 ALAMEDA: Fantasc Opportunity with view workweek schedule. 1,440 sf w/3 ops. $150k Call for Details! of the estuary 2,060 sf w/ 5 ops. Now Only: $750k GN-404 SHASTA AREA: A fantasc place to live, work CC-346 SO MARIN CO Perio: DN-388 WATSONVILLE 2,393 sf w/ 4 ops + 4 add’l.. and raise a family! 1,500 sf w/3 ops $100k REDUCED! $199k Must Sell Quickly! All Reasonable Offers Considered! GN-418 REDDING: Goodwill Galore! Established for BN-393 PINOLE Pedo: DC-403 SANTA CRUZ: Well-established, modern, ~37 years and the seller is rering! 3,200 sf w/6 ops quality pracce! 1,335 sf w/ 4ops. $725k +2 add’l. $495k $1.2m Timothy G. Giroux, DDS is currently the Owner & ASK Broker at Western Practice Sales and a member of the nationally recognized dental organization, ADS Transitions. THE You may contact Dr Giroux at: [email protected] or BROKER 800.641.4179 BAY AREA How important is the active patient count? BAY AREA CONTINUED NORTHERN CALIFORNIA CONTINUED What separates AC-335 SAN FRANCISCO: DN-409 SAN JOSE Facility: HG-298 REDDING FOOTHILLS: HEALTH FORCES Recently this number has become a totally over-blown issue. It is simply one of us from other AC-417 SAN FRANCISCO Facility $95k SALE! Includes Cerec! 2,000 sf w/ 5 ops Prac- many metrics that a dentist can use to determine if the treatment philosophies are Call for DN-408 SAN JOSE ce $100k / Real Estate $250k similar. The due diligence process should be used to answer the most important brokerage firms? Details! $75k HN-213 ALTURAS: FFS practice is 2,200 sf w/ question a buyer can ask: What can I expect to produce/collect on this particular AG-053: DC-419 NEWARK Facility 3ops +1 add’l $115k patient base? Looking at the types of procedures, the number of prophys, the type $595k $140k HN-280 NORTHEASTERN CA: “Only Practice in of recall system AND a patient count should help answer that question. AG-402 SOUTH SAN FRANCISCO: Town” 900 sf w/ 2 ops $110k NORTHERN CALIFORNIA HN-290 PLACERVILLE: Excellent Merger Op! $250k As dentists, we do not even have a definition for an “active patient”. Generally, AG-416 SAN CARLOS: Embrace the lifestyle and build your success $90k EN-340 SACRAMENTO story here! FFS. 1,400 sf w/ 4 ops $210k most of us in the transition business have accepted the definition to mean any Our extensive buyer BN-183 HAYWARD: Kick it up a notch by increasing $950k patient that has been in the office for at least one visit in the past two years. database and the current very relaxed work schedule! EN-350 SACRAMENTO: The Perfect Merger Oppor- CENTRAL VALLEY Arguably that might not include the terrific patients that definitely get their major $150k tunity! treatment performed but may only show up every three years, or when something IG-067 STOCKTON: Fully computerized, pa- unsurpassed exposure BN-279 CONTRA COSTA COUNTY $85k breaks. It also counts the patients that are one-timers only who may not come back. $60k EN-378 LINCOLN perless, digital. 5,000 sf w/10 ops Steal of $170k the Century! Now ONLY $240k I have never seen a situation where the Seller truly believed he had less patients allows us to offer you a BC-361 OAKLAND: than what the Buyer counted! Now Only: $385k EN-379 ROSEVILLE IG-367 MERCED: Newly Remodeled, Paperless. BC-381 PLEASANT HILL Facility: $295k 1,550 sf w/4 ops REDUCED! $325k $80k EN-391 SACRAMENTO: IN-297 MODESTO: Prisne, contemporarily Every buyer is strongly encouraged to do their own chart count to make sure they BG-407: SAN LEANDRO: $310k designed medical/prof ctr. 1,980 sf w/ 4 ops. can duplicate the production on that particular patient base. Essentially their $150k EN-423 FOLSOM Oral Surgery Facility: PR: $475k / RE : $425k perceived number of patients is irrelevant to market price and is really only Beer $100k IN-345 MODESTO: Long-standing tradion of CC-390 SOLANO COUNTY: FN-181 NORTH COAST: quality care. 3016 sf w/ 5ops + 1 add’l. $495k relevant as it relates to them duplicating the production. This conclusion may $200k sound strange, but it is the reality of practice sales. Only the buyer can determine if CG-366 SONOMA CO.: $150k (25% IN-358 MODESTO: Pracce nets over 50%! int. in bldg. avail.) 1,200 sf, 3 ops+1 add’l. $350k a particular practice is a good fit. Candidate FN-299 FERNDALE: IN-397 FRESNO/MADERA: “the Perfect Loca- $480k CN-344 N. SONOMA CO: $225k (Real on”! 2,000 sf w/5ops. $480k In my seminars, we could present a patient case and ask for 10 dentists to give a $925k Estate: $309k) JN-295 VISALIA: Practice & Real Estate 2,000 treatment plan. We would probably have 10 different treatment plans, with some CC-369 SAN RAFAEL: FC-334 NORTHERN CA: sf w/ 5 ops PR: $185k RE: $300k possibly advising eventual full mouth reconstruction and others advising few $350k $480k Real Estate Also Available! JC-349 FRESNO: Well Respected Specialty FC-343 NORTHERN CA: Pracce limited to Dental Sleep Medicine. restorative needs, while watching the remaining teeth. I can also tell you that every Beer DC-370 SAN JOSE Facility: dentist believes that they are “just right” when it comes to their own treatment Call for Details! Call for Details! DG-351 PLEASANTON Facility: Don’t miss out! Re- $500k (Real Estate $375k) JG-400 CLOVIS: Best priced pracce on the plans. Therefore, I could place those 10 dentists in a practice purchase and I might duced to sell quickly! $69k GG-320 CHICO: market! Digital Pano, Cerec and $330k in get two failures, two wildly successful outcomes and six dentists that finish within Fit DG-394 LOS GATOS: PROFIT annually! $465k 15% of the original practice collections. ALL WITH THE SAME PATIENT ONLY $280k $985k BASE! The Practice Price is NOT based on the number of patients. It is based on SPECIALTY PRACTICES DG-401 SAN MATEO: GG-386 REDDING: the collections and profitability! $360k and $660k $125k DG-341 SUNNYVALE/LOS GATOS Combined Sale: GN-201 CHICO: I-7861 CENTRAL VALLEY Ortho: 2,000 sf, $605k open bay w/ 8 chairs. Fee-for-Service. $370k Every patient base is unique based on their needs and their ability to Beer DG-396 SERRAMONTE AREA: $425k I-9461 CENTRAL VALLEY Ortho: 1,650 sf w/5 pay. The number of patients may not be as important as the type of $485k GN-244 OROVILLE: chairs/bays & plumbed for 2 add’l $180k patients. DN-311 PLEASANTON Facility: $315k DG-264 SAN JOSE Ortho: $300-400k in build- NOW ONLY: $75k GN-258 REDDING: outs alone! 1800 sf w/ 5 chairs. REDUCED! Price DG-413 CUPERTINO: $215k $245k $1.15m GN-387 CHICO AC-325 SF Endo: TDO. Dexis. Central nitrous. DN-312 LIVERMORE Facility: 555 sf w/ 2 ops. $250k REDUCED! $75k GN-399 REDDING: BC-336 CONTRA COSTA CO Perio: 1,440sf, 4 DN-353 ALAMEDA: $150k ops +1 Great Location! Call for Details! Now Only: $750k GN-404 SHASTA AREA: CC-346 SO MARIN CO Perio: 1,142 sf w/ 3 ops. DN-388 WATSONVILLE . $100k Meticulously maintained! REDUCED! $199k Must Sell Quickly! All Reasonable Offers Considered! GN-418 REDDING: Goodwill Galore! BN-393 PINOLE Pedo: Streamlined pracce, DC-403 SANTA CRUZ: where every child counts themselves lucky to $725k $495k be a paent here! 2,000 sf w/ 5 ops. $1.2m Jon B. Noble, MBA Mona Chang, DDS John M. Cahill, MBA Edmond P. Cahill, JD Tech Trends CDA JOURNAL, VOL 43, Nº6

A look into the latest dental and general technology on the market

Adobe Fill & Sign (Adobe, Free) MyIdol (Huanshi Ltd., Free) Adobe Fill & Sign is a powerful app that takes digital documents You may have seen the life-like cartoon character images of your and gives users the ability to fi ll and sign them easily without friends on Facebook, with their face supplanted on a comic book the need to print them. After completing an optional profi le and version of themselves. Most likely, this came from a Chinese app signature information, users can import PDF forms or photos of that has sent the Internet into a frenzy. MyIdol allows users to scan forms into the app. PDF forms can come from the Web or from a photo of themselves and the app automatically designs an eerily other apps. Photos of forms can come from the camera roll or similar cartoon replica. Users can then select skin tone, hairstyle, a picture taken right from the device. When a form is loaded, clothing and more to make themselves more lifelike. The app takes it users simply tap on an area and start typing to fi ll out the form. to a comedic level when users can insert their character into unusual Annotations such as check boxes or bubbles can be made by a singing, dancing and action scenes, which are synced with music. tap-and-hold gesture. Signatures or initials can be added to the Humorous photos/emojis also can be created. As a caution to form by simply selecting an area and tapping on the pen. Quick potential users, note that the app’s language is set to Chinese. This tools that appear when tapping an area make it easy to edit and can make the navigation diffi cult, but anyone savvy enough with delete anything previously added. Areas can be automatically how apps operate can fi gure it out. fi lled by selecting information from the optional profi le and — Blake Ellington, Tech Trends Editor signature entries. Completed forms can be printed, messaged, emailed or shared with virtually any app. Users with an Adobe ID have the ability to store forms in the cloud. Technology Becoming Key Part of — Hubert Chan, DDS Construction Periscope (Twitter, Free) Technology has made its way into wearable items and cars, but now it is becoming a primary selling point for home builders. According Periscope for Twitter is a social media app that takes on live- to the Consumer Electronics Association (CEA), technology streaming video and makes it easy to use in the process. Periscope incorporation is a necessity these days in home construction. CEA requires a free account using Twitter credentials. Once an account conducted a study that found eight in 10 builders now off er clients is created, users will fi nd Periscope familiar because of its similarity features like structured wiring (84 percent), home theater (80 to Twitter. Users can choose to follow anyone with a Periscope percent) and monitored security systems (80 percent), according account. Live activity feeds of followed users as well as a public to a CEA statement. The study also found that broadband Internet feed can be viewed through the app. Notifi cations of followed is now a standard feature in homes, as nine in 10 new homes users when they broadcast are available. Users specify titles of are equipped with broadband cable — up from 69 percent in their broadcasts and whether the videos can be shared publicly or 2008, according to CEA. Shipment revenues in the U.S. consumer privately to select accounts. Instantly, the broadcast title appears in electronics market are expected to reach $223.2 billion in 2015 — the live activity feed timeline as well as notifi cations sent to those a 3 percent increase from 2014, according to CEA’s U.S. Consumer following the account. Periscope users who select the broadcast see Electronics Sales and Forecast. the live video. Users joining the broadcast appear as notifi cations on the video and can comment. Likes are recorded by users in the — Blake Ellington, Tech Trends Editor form of fl oating hearts that appear by tapping on the screen. The total number of users watching the broadcast at any one time is Would you like to write about new technology? displayed. Trending broadcasts are prominently displayed in the public live activity feed. Dentists interested in contributing to this section should contact Tech Trends Editor Blake Ellington at [email protected]. — Hubert Chan, DDS

342 JUNE 2015 Your convention.Your insider access.

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