Manner of Death

Assignment of a manner of death is also a required part of the death certification

process. Ostensibly, this is an attempt to classify the death as to the

circumstances by which death came about; unfortunately, this classification

is often problematic. There are five classical manner of death categories.21

•Homicide: Death caused by the intentional actions of another person.

•Suicide: Connotes a death due to one’s own intentional acts.

•Natural: Death due to natural disease processes only, with no contribution

from traumatic or external factors.

•Accident: Death due to unforeseen traumatic or external factors.

•Undetermined: The manner of death is not known or could not

be determined.

Some jurisdictions also add additional categories, such as unclassified,

therapeutic misadventure, etc., but these are not universal. The idea of a

manner of death classification is an American invention,31 and the manner

of death categories available for use in death certification are promulgated by

state vital records departments. Physicians, medical examiners, and coroners

are bound to and limited by these available choices.

The problem with manner of death classification is that the “pigeonholing”

of complex and disparate deaths into one of five (actually four) categories

is fraught with problems. One difficulty in reproducibly assigning an

appropriate manner of death category is the lack of agreement on definitions

for the classification terms. The brief definitions listed above are quite rudimentary

and broad, and are subject to considerable and substantive variationin various jurisdictions. For example, a homicide is generally considered to

be a death at the hands of another person, whereas suicide is death at one’s

own hands. Yet a death due to a motor vehicle crash is generally classified

as an accident, regardless of whether one or both of the drivers were at fault

or caused the crash. If a hunter fires at a target he believes to be a deer, but

inadvertently kills another hunter, many MEs will classify this death as a

homicide, since the rifle was purposely fired at a target, which was struck and killed. Others would consider it to be an accidental death since the

hunter did not intend to kill a human being. Some jurisdictions require that

intent to cause one’s own death be a factor in classifying a death as suicide.

Others require only that the act leading to death be intentional, regardless

of whether or not death was anticipated. For example, if a person is playing

Russian roulette with a partially loaded revolver and dies of a gunshot

wound of the head, many MEs would classify this as a suicide, without consideration

of whether or not the player actually intended to die, or just was

engaging in thoughtless, extremely risky behavior. Others would agree that

the death represents a suicide, but largely because of the high inherent risk of

the activity. Deaths due to acute intoxication by ethanol or other drugs are

usually classified as accidents unless suicidal intent is evident. But deaths due

to the chronic effects of the same drugs (cirrhosis, endocarditis, etc.) are typically

classified as natural deaths. These are but a few of the inconsistencies

and disagreements that may plague a manner of death determination. 

Cause of Death

Cause of death is a concept applied somewhat more strictly and precisely by

the medical examiner than by other physicians or the lay public.21 A number

of definitions of this term have been devised, but a simple one favored by the

author is “that disease, injury or event, but for which death would not have

occurred at the time it did.” In death certification, the first insult that begins

a cascading series of events leading to death is of primary interest. This is

referred to as the cause of death, or as the proximate cause of death. This is in

distinction to the subsequent resultant physiologic derangements caused by

this event. These derangements are often referred to as mechanisms of death

or the immediate causes of death.

For example, suppose an individual receives a gunshot wound that

injures the spinal cord and renders the victim quadriplegic. If, years later, he

or she succumbs to a urinary tract infection related to the paralytic bladder

caused by the spinal cord injury, the cause of death should be appropriately

certified as a “gunshot wound of the back,” or “urosepsis complicating

quadriplegia due to gunshot wound of back.” Many physicians, however,

would inappropriately list the cause of death as “urinary tract infection”

(a mechanism of death) without referencing the true cause of the condition,

the gunshot wound. The reasons for this are readily apparent, as most clinical

physicians are concerned with diagnosing and treating acute conditions that can be ameliorated by medical or surgical therapy. The medical examiner,

however, recognizes that the purpose of death certification is to provide statistical

information on primary causes of death, and that the lapse of time

between injury and death is of no importance in this documentation. 

Death Certification

A major common denominator in any modern death investigation system is

the documentation of death and the determination of its cause and manner,

also referred to as death certification. In early times, records of birth and

death were kept inconsistently, if at all, but in 1538, clergy in England were A major common denominator in any modern death investigation system is

the documentation of death and the determination of its cause and manner,

also referred to as death certification. In early times, records of birth and

death were kept inconsistently, if at all, but in 1538, clergy in England were death investigation systems

 function of governments instead of the church. This change was given further

 impetus during infectious epidemics of the nineteenth century, when it came

to be appreciated that it would be worthwhile to keep track of the numbers

of deaths occurring as an infectious contagion progressed.18 Subsequently,

governments around the world began to require registration and certification

of births and deaths. Modern death certification is a function of state

governments, and all jurisdictions in the United States have a common

requirement that the death of a person be officially documented, with attestation

of the cause and manner of death by a physician, medical examiner,

coroner, or other official. The document serving this purpose is referred to as

a death certificate, and requirements regarding its use and filing are set forth

by a state department of health, vital records, or equivalent.28 State deathcertificates tend to be fairly similar, as most are based on the U.S. Standard

Certificate of Death, which is in turn based on World Health Organization

recommendations. A typical state death certificate is shown in Table 4.2.

Many states are also moving toward a standardized digital death registration

process that promises to make gathering of demographic and epidemiologic

data much simpler and more effective. 

Modern American Death Investigation Systems

As will be seen subsequently, the systems of death investigation in the United

States are widely varied. However, they generally share a number of mission

components in common. To paraphrase DiMaio and DiMaio,21 the various

components of a death investigation system are as follows:

1. Determine the cause of death, and how the death came about

2. Identify the decedent

3. Determine the time of death and injury

4. Collect evidence from the body that may be useful in the police

investigation

5. Document injuries that are present, or their absence

6. Deduce how injuries occurred

7. Document any natural disease present

8. Document or exclude any causative or contributory factors in the death

9. Provide testimony in court as needed

In spite of the widespread distribution and long history of the office of

the coroner, as medical science and the understanding of death have become

more complex, shortcomings of the system have became apparent. Most

obvious is the fact that most coroner jurisdictions do not require a coroner

to be a physician. Obviously, a nonphysician is in a poor position to render

a medical opinion on the cause of death, a determination that is manifestly

the practice of medicine. The likelihood of omissions or misinterpretations is

increased in such jurisdictions where the responsibility for this duty is vested

in someone other than a trained physician. Second, coroners are elected

officials in the United States. The necessity of maintaining public electoral

support has long been considered a potential impediment to the development

and maintenance of absolute impartiality in death investigation by coroners.

Death investigators must often make very hard and controversial decisions

that are difficult for families, local political forces, and others to accept. In

theory, at least, an appointed official, as opposed to an elected one, can make

such decisions without the fear of alienating a voting block necessary for his

or her continued employment in the position.

Proponents of the coroner system respond that the nonmedical coroner

functions as an administrator and quasi-judicial agent, and can employ physicians

to perform examinations and make medical decisions under his or

her directions. However, since the coroner retains ultimate authority for the

investigation and determination of the circumstances and cause of death,

the possibility that such an individual will exercise that authority to veto or

influence the medical decision of an employed physician still remains. Some

coroner proponents also point to the greater political authority of an elected

death investigation systems 

The Coroner System

Though the cause of death was undoubtedly investigated in ancient times,

it was likely an ancillary duty of tribal elders, magistrates, priests, or other

authorities. The first instance of an official office charged with the investigation of death, as we know it today, was probably the English coroner.

Though officials with this responsibility are reported as far back as 871 A.D.,

in the time of Alfred the Great, the beginning of the coroner system in

England is generally taken to have been in 1194, with the publication of

the Articles of Eyre, the Eyre being a system of roving “circuit” justices in

England in the twelfth century. These itenerant judges traversed the land to

hear cases and dispense justice, but due to the long intervals between their

visits (an average of seven years), it was necessary to have local officials

perform careful investigations and keep records of offenses so that the cases

could effectively be brought before the justices when they finally did arrive.

Without proper records, many cases were never tried. This would not do, as

many of them involved production of revenues for the monarch, at that time

Richard the Lionhearted. Richard, a Norman king, was an absentee ruler

with a penchant for expensive foreign wars that placed a heavy strain on the

royal coffers. In addition to his travels and the need to equip large numbers

of troops, he also managed to become captured and imprisoned in Germany

during his return from the Holy Land in 1192. A huge ransom was required

to secure his release and return to England in 1194. These expenses created

an acute need for revenues, so no stone was left unturned in a desire to collect

all taxes and other dues to which the Crown was entitled under the law. There

were many such assessments, creatively applied in the name of law and order,

to enrich the king at the expense of his subjects.

It was customary at that time to seize the property of felons, and because

suicide was considered a crime against God, the property of those taking

their own lives was also forfeited to the Crown. Furthermore, villages were

penalized with a fine, or amercement, whenever a murder or other legal

infraction occurred in their jurisdictions, a punishment for allowing civil

disturbances to occur or for not properly following the complex system of

laws in the realm. Sometimes the victims of these murders were members of

the conquering Norman class who were unfortunate enough to find themselves

in the midst of local Saxons bent on revenge. To prevent having large

numbers of its Norman noblemen dispatched by the indigenous population,

the Crown levied a fine known as the lex murdrorum on the lord of any village

or territory in which a Norman was killed. And naturally this fine was passed

on to the populace in the form of a tax. Even the object actually causing a

death (referred to as a deodand) was subject to presentation to the Eyre, and

it could be confiscated in the name of the Crown because of its culpability in

the death or injury of a person. So if a person were injured or killed by a cart,

animal, or farm implement, this item would likely be appropriated by the

court, possibly depriving a farmer of the means of his livelihood. 

Early Death Investigation

The most primitive societies likely had a well-developed sense of the causative

relationship of trauma, old age, and illness to death, and early “investigations”occurred even in tribal societies to determine why a member of the family

group had died, though they were more likely to invoke superstition or

magical thinking instead of the “rational” methods employed by modern

societies.2–4 Early Mesopotamian civilizations, and those of ancient Egypt,

Greece, and India, had well-developed legal codes (the earliest being the Code

of Hammurabi, 2200 B.C.), and these laws often referenced medical issues,

such as duties of physicians, allowable fees, the viability of the fetus, and discussions

of injuries. These cultures also had well-developed medical systems,

but there is little or no reference in their extant writings to suggest that medical

practitioners were regularly involved in the investigation of death. Rather,

common sense and experience were applied by various officials, magistrates,

or priests in an attempt to explain why and how individuals died. Some of the

earliest death investigations probably involved deaths due to suicide, which

most societies have considered to be an unacceptable act for religious or

superstitious reasons.5 Taking one’s own life might result in denial of funeral

rites, reprisals against the decedent’s family, or other penalties, so a rudimentary

death investigation was necessary in such cases to determine if a death

was self-inflicted.

The earliest written documentation specifically related to formal death

investigation has been discovered in archaeological excavations in China.6

Here, bamboo strips unearthed and dated from the period of the Ch’in

Dynasty (221–207 B.C.) have been found inscribed with writings giving

instructions to civil servants charged with the examination of corpses who

died under suspicious circumstances.

Death investigation in ancient Athens was largely a private matter instead

of a concern of the state.7 As such, investigations by a governing body were

not consistent, and Greek physicians were apparently not involved in certification

or investigation of death, though there are reported instances of their

testimony in legal proceedings involving injury. 

Death Investigation Systems

Introduction

Throughout human history, the inevitability of death has inspired not only

a sense of fear, but also a paradoxical sense of fascination and curiosity. It is

no surprise then that the investigation of death has a long and varied history,

intimately involved with the rise and governance of human populations. The

sociologist Stefan Timmermans1 has noted that death is not an individual

event, but a social one, and every developed society has had an interest in the

phenomenon, be it from a legal or public health viewpoint in modern populations,

or as part of a mythic or superstitious worldview in earlier societies.

Beliefs about the phenomenon of death have also been inexorably linked to

religious systems throughout history.2–4 

Expert Testimony in Criminal and Civil Litigation

Forensic odontologists are frequently called to give sworn testimony in depositions

and courtrooms. The testimony may involve the previously mentioned

areas of dental identification, bitemark analysis, or age estimation. Dentists

participating in forensic casework should expect that at some point they will

be required to provide sworn testimony.

Forensic dentists also may be called to provide an opinion in standard

of care, personal injury, dental fraud, or other civil cases. These cases, as

with other forensic cases, require the evaluation of material and the development

of an opinion concerning the case. Dental experts are not hired guns,

or advocates for one point of view. Dental experts must be advocates for

the truth and endeavor to find that truth by the application of their special

knowledge and skills. The unwavering goal of the forensic dental expert must

be impartiality, thoroughness, and accuracy (see Chapter 16).

Age Estimation

Researchers have studied the processes of human aging by many different

methods. These include developmental, histological, biochemical, and

anthropological techniques. Anthropologists analyze the fusion of the cranial

sutures of the skull, the development of the long bones, features of the pelvic

girdle, and along with forensic dentists, features of the teeth. These techniques

can be valuable when creating a profile for an unidentified person, whether

living or deceased. Estimating an individual’s age can also be helpful in assisting

law enforcement agencies in determining the attainment of the year of

majority of a living individual that will ultimately affect the individual’s treatment

in the legal system as either a child or an adult. 

Abuse

Identification and reporting of abuse is a complex and emotional area.

Healthcare practitioners are required by law in most jurisdictions to report

suspected cases of abuse. The head and neck area is a common target in

abuse. Extraoral injuries consistent in shape and appearance to a hand or

object are identifiable. Intraoral trauma can occur as the result of strikes to

the face, causing torn frena and fractured, mobile, or avulsed teeth. Intraoral

soft tissue pathology may be noted following forced feeding or forced fellatio.

Some cases may require the consideration of whether extensive or rampant

caries are a result of the caregivers’ lack of knowledge or stem from neglect

or abuse. In areas where access to dental care is an issue there will likely be

a higher caries incidence that could further exacerbate the determination of

whether reporting of abuse may be necessary. Deciding to report suspected

abuse requires sound judgment, especially considering that the parent or

guardian may be the perpetrator. If a report is initiated, the ensuing investigation

will be difficult for all concerned (see Chapter 15). 

Bitemark Evidence Collection and Analysis

Bitemark analysis is the most complex and controversial area of forensic

odontology. Consequently, some forensic dentists are reluctant to enter into

this arena. Bitemarks can occur in a wide variety of substrates, although the

most common of these is, unfortunately, human skin. The proper documentation

of a bitemark is not overly complex, and the techniques for collecting

evidence are manageable by most forensic dentists with practice and attention

to detail. The bite site can be evaluated in the third dimension by using a

very accurate dental impression material and dental stones or resins to create

a solid model for viewing under magnification, light microscopy, or with

scanning electron microscopy. This three-dimensional model of the bitten

area can then be compared to suspects’ dental casts. Technique shortcomings

exist and include that solid models of bitemarks on skin are nonelastic. The

problems associated with bitemark analysis will be discussed more fully in

Chapter 14. 

Multiple Fatality Incident Management

A multiple fatality incident (MFI) develops when the number of fatalities in

the incident exceeds the number the medical examiner or coroner’s facilities

were designed to handle. The process of collection of dental information

on victims in a mass disaster is identical to the processes that are used in

the identification of a single fatality. The major difference in this process is

the potential magnitude of the event and the unique set of circumstances that

can surround the event. These may include the location, climate, and coverage

area of the event, for example, a plane crash in mountainous terrain, a

tsunami in a tropical area, the collapse of multistory structures in a major

city, or a hurricane in a coastal area. Each of these incidents has unique issues

that must be addressed with regard to recovery, processing, and storage of

remains. Each potential MFI will have its unique problems to overcome, but

accurately collecting and comparing the data is the common process in all of

these situations. 

Dental Identification

When considering the many processes that are involved in forensic dentistry,

most laypersons are familiar with identification of a deceased individual

through the comparison of dental radiographs. Identification by dental means

is a fast and reliable method. Dental identification is most often accomplished

by comparing postmortem dental radiographs from the unidentified person

with antemortem radiographs of a known individual. This process of dental

forensics is often interpreted on currently popular forensic television series

by the actor-dentist holding a dental radiograph backlit by the room lights

with the film overhead while standing in the elevator lobby. This generally

occurs following a brief evaluation of a body in the morgue. But, of course,

the actor-dentist is certain that the radiographs he was just handed for evaluation

are from the decedent. The positive identification is completed and

without further discussion the district attorney’s case theory is confirmed

and the suspect is incarcerated.

In real forensic cases the process of using dental radiographs and dental

charting can be an accurate and efficient method for making a positive identification

or exclusion. But, the comparison must be completed in a controlled

and methodical manner, with attention to the details of the dental structures

and restorations that may be seen in the radiographic comparison. A comparison

of an antemortem radiograph with a body in the morgue occurs only

in the virtual reality of television and film world.

In a dental identification, the initial goal of the forensic dentist is to obtain

a set of postmortem photographs, radiographs, and accurate dental charting

on the unidentified person. This can be a straightforward or difficult process,

depending on the condition of the postmortem specimen and the physical

resources available to the dentist. The problems most often involve limited

available resources in the morgue setting. 

Introduction

When the subject of forensic dentistry arises, the first reaction of many

people tends to be toward one of two extremes: either very cool or decidedly

gross. The public assumption seems to be that forensic dentistry deals

with “the dead.” This view is not totally inaccurate. Although the majority of

dental identification cases do involve the dead, there is much more involved,

including cases dealing with the living, in this interesting field of art and

science. With training, ongoing continuing education, and experience, the

forensic odontologist will find the application of this knowledge to be personally

rewarding. If dentists are interested but do not wish to pursue the

areas of forensic dentistry that are associated with “wet work,” they will find

that they can practice “dry fingered” forensic dentistry in their own offices

by accurately recording their patient’s oral information on an ongoing basis.

Forensic dentistry or forensic odontology involves several areas that will

be discussed generally in this chapter and explained in more detail in later

chapters. The general definition of this discipline is that forensic odontology

is the combination of the science and art of dentistry and the legal system,

a crossroads of dental science and law. The general topics to be discussed include the subdisciplines of forensic odontology, dental identification,

multiple fatality incident management, bitemarks, abuse, age estimation, and

expert testimony in criminal and civil litigation. 

Strenuous Cross-Examination, 1898

In 1898, a girl was found dead. A local dentist described the state of her

mouth and teeth. A missing girl’s family dentist in another town was located.

  

The body was disinterred and the dentist was able to identify his work. The

dentist complained about how strenuously and thoroughly the defense attorney

grilled him while he was on the witness stand.19 Many dentists still today

dread having to go into courts of law and give sworn testimony.