Wednesday, 28 June 2017

Grenfell Tower, dental forensics, and the state of NHS dentistry

Please don't read this blog if you may be upset or offended by discussion about the fate of the Grenfell Tower residents. This is my own personal opinion.

I'm sure, like me, you're well aware of the recent tragedy of the devastating fire at Grenfell Tower in London two weeks ago. I was shocked by the scenes which seemed impossible in a developed country, and have been incredulous at the inadequacy of the fire systems and flammable nature of the cladding and how that could have been allowed. Estimates today put the number of dead at 80, but from the start there has been strong wording that the real death toll may never be known, and some victims may never be identified.

It's fairly easy to realise that the poor people who were caught in the fire may be burned beyond recognition. Identification by sight may work for anybody overcome by fumes and smoke, but I'm guessing  the fierceness of the fire will have mostly caused damage way beyond that. Those corpses will be fragile and probably difficult to safely move. This is often where dental identification comes in. Just yesterday I had an email alert from my indemnity society with a reminder about confidentiality of dental records and their release to police for assistance in identification, which I assume has been precipitated by a high number of requests following the tragedy. I've also heard that practices near Grenfell Tower have been asked to search their records by postcode.

I've had an interest in dental forensics for many years. Before I trained as a dentist I quite fancied the idea of being a pathologist, but realising it was a long route which first involved medicine I decided against it. At dental school we had several lectures about dental forensics, and the forensic department at Leeds was, I believe, very good. I particularly remember that they were involved in identifying a lot of the people who perished in the Bradford stadium fire in 1985, four years before I became a dental student. (As an aside, when I worked at Bradford St Luke's Hospital we shared a ward with the Plastic Surgery team, who had developed new techniques of treating extensive burns because of the number of victims from the incident. Advances in trauma management often happen as a result of large scale disasters or wars.) As well as identifying bodies forensic dentistry can be used in many ways. For example bite mark assessment can confirm and help convict an attacker,  approximate age can be determined by dental development, and minerals taken into the teeth as they develop might indicate a country of residence. Dental identification helps in many cases where the victim can't be visually identified, for example extensive trauma to the face and head, burns, or prolonged submersion in water. I know a large team of dentists helped with identifying bodies after the Boxing Day tsunami in 2004.

So how do dental records help? If I am remembering correctly x-rays are usually taken before any more detailed examination. This is useful where bodies are fragile as they can be x-rayed without disturbing them too much. Then the mouth might be examined to check for the teeth present and any fillings, and any damage that might have occurred at the time of death or afterwards. X-rays and records can be compared to existing records to look for a match. Now, this is where it gets tricky because unlike a DNA or fingerprint database there is not a national dental records database. Dental records are held by the treating dentist, and not passed around with the patient like your GP records are. Some dentists still have paper records, though most will now have a computerised system. Even then x-rays don't really work like fingerprints, I'm not aware of a way of matching records or x-rays against a large database of people.

This means the best way to identify someone is to have an idea of their identity in the first place. Ask their dentist for their dental records, and then compare the records to the information you have. Occasionally the dental press send round a dental chart and an artist's impression of an unidentified body, but even if they have some quite unusual features this is quite a shot in the dark.

Cast your mind back to the Grenfell Tower residents. Some are known to be missing and their known flat and location found will help. Some may be in different flats, some may not have been expected to be there at all. Many are in social housing and low socioeconomic groups and some are refugees. How many of these are regular dental attenders? I suspect that many will not visit the dentist unless in pain, some may never have had dental care. NHS dental access is generally poor, I don't know the statistics for Kensington and the area around Grenfell, but across the UK the number of NHS dentists is falling and waiting lists are increasing. The residents are unlikely to have been in a position to pay for private care. Like much of the NHS, dentistry is underfunded and the system is broken. In some ways I feel that if there is money for the NHS is should be spent on hospitals, nurses and doctors, and NHS dentistry should be limited to urgent care in those that need it most and can't afford private care. Yes, I'd love NHS dentistry for all, but I realise the pot is limited, unless Theresa really HAS got a magic money tree.

So, if we have an idea who the potential victims are, we also need to know if they have seen a dentist and which dentist. We also need them to have had a dental charting, an x-ray (ideally several), and not have just attended for an emergency. We need the dentist in question to have accurately charted the teeth, kept the records and the x-rays safe, and be able to retrieve them. We have to keep records for 11 years, but if someone hasn't attended for a while they might be archived, in storage, and of course computer systems sometimes fail and paper records sometimes get lost or damaged.

Is it important we know who the victims are? Can't we just have a list of missing-presumed-dead? I'm sure friends and family need to know to be able to grieve. A death certificate is needed for the legalities to be able to be carried out after a death, insurance, financial settlements, inheritance, and later remarriage of the spouse. I also remember reading something about people taking advantage of a large-scale tragedy to disappear, something that is known to have happened after 9/11. So yes, I think it is important, and I know that many forensic dentists, pathologists and forensic scientists will have to deal for months to come with the grisly nature of the aftermath of the terrible fire. I don't apologise for the grim nature of this blog, I hope you have found it interesting and informative. Please join me in wishing strength to those dealing with loss and anyone in contact with them.

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