Knowledge and Attitudes of the Public in Saudi Arabia about Forensic Odontology during COVID-19
Background: Forensic odontology is the handling and examination of dental evidence and the accurate interpretation and preservation of dental findings in the interests of justice. The aim of this study was to assess the level of knowledge and attitudes of the public in Saudi Arabia about forensic odontology during COVID-19. Methods: A total of 784 adult participants from 17 cities answered a self-reported questionnaire in this cross-sectional study. The questionnaire was composed of 55 questions about their knowledge of and attitudes about forensic odontology and their willingness to register with a national dental registry. The questionnaire was validated and had a Cronbach’s alpha of 0.78 and 0.75. Results: The total knowledge score was 9.35 (out of 21), and standard deviation (SD) of 4.68. Adults and employed participants had significantly higher forensic odontology knowledge levels than older and retired participants (p<0.05). There was a moderate attitude toward the usefulness of forensic odontology during the COVID-19 pandemic, ranging from 36.61% to 61.48%. A total of 74.62% were willing to register with a national dental registry if one is established. Conclusion: The public in Saudi Arabia have relatively low levels of knowledge about forensic dentistry. They had a good attitude about participating in a national dental registry. Most of them agreed on the importance of using forensic odontology in global public health disasters such as the COVID-19 pandemic. However, forensic odontology still needs to be introduced to the public, with more efforts exerted toward educational and health promotion activities.
Knowledge, Forensic odontology, Forensic dentistry, COVID-19, Saudi Arabia
Forensic odontology, also known as forensic dentistry, is a challenging branch of forensic science that the World Dental Federation (FDI) defined as a specialized field of dentistry dealing with the proper handling and examination of dental evidence and with the accurate interpretation and preservation of dental findings in the interests of justice . It involves the application of dental sciences in the identification of unknown deceased individuals through the comparison of ante- and postmortem records . In particular, forensic odontology deals with the recognition of injuries to soft and hard oral tissue as a result of crime, rape, murder, or child abuse. But the primary applications for forensic odontology in bringing criminals to justice  are the identification of human remains through dental records and bite mark identification. This field of science provides the ability to determine the age, gender, and race of a victim, which can be used as evidence in resolving criminal cases . Furthermore, dental tissue provides an important source of DNA material, which is now becoming the gold standard in the field of forensic identification .
It is common for dental professionals to face malpractice cases in their practice. And in Saudi Arabia, during 2007– 2008, over 600 cases of medical error litigations were recorded. Out of these, 6% occurred in dentistry . Thus, an individual’s dental records, including radiographs, models, photographs, and clinical correspondence, are essential legal documents that serve as sources of information for dentists and patients, and which may be utilized as forensic evidence . Therefore, these records should be securely retained by general practitioners for the purposes of justice , but dental records have not received the same attention as fingerprints and facial photographic records by governmental registries . However, the development of a national dental registry would provide researchers with a large amount of data regarding the prevalence and correlations of different dental disorders. In addition, these data could be used by legal authorities as evidence if the need for a forensic dental investigation arises .
Despite the significance and numerous applications from this field to facilitate post-mortem confirmation of a victim’s identity, the literature indicates that forensic odontology is underdeveloped in many countries around the world, and action is needed to improve the utilization of this science . For example, A systematic review of recent cross-sectional studies regarding the levels of knowledge and practical application of forensic odontology among dentists in India revealed inadequacy and considerable variation in the practice of forensic odontology among dentists . In Saudi Arabia, studies have been conducted over the last few decades aimed at defining the level of knowledge and awareness about forensic odontology among dental professionals. This research included one study on a national scale , and other local studies in Riyadh [14–17] and the eastern region of Saudi Arabia . These studies indicated that dental professionals had low awareness and poor knowledge and attitude about forensic dental sciences, in addition to lack of practice of forensic odontology among dental professionals.
Despite all of these studies, there are limited data regarding public awareness about forensic odontology in Saudi Arabia on a national level. The only study was conducted in Riyadh city  and assessed the willingness of the public to register in a national dental registry. The results indicated that two-thirds of the respondents were willing to register. In fact, there has been an urgent press to investigate this aspect, especially during the COVID-19 pandemic, which has highlighted the beneficial aspects of forensic odontology today. One study highlighted the handling of dental tissues for forensic evidence during COVID-19 . However, in this regard in comparison to other publications in forensic medicine related to COVID-19 [20,21], there is a scarcity of articles focusing on the dental area, and researchers concluded that the importance of forensics has been underestimated during the COVID-19 pandemic. Consequently, the aim of this study was to assess the general public’s levels of knowledge and attitudes about forensic odontology during COVID-19 in Saudi Arabia.
Materials and Methods
This was a cross-sectional study design that was conducted between October and November 2020. A questionnaire measured the extent of knowledge and awareness among the public about forensic odontology during the COVID-19 pandemic in Saudi Arabia as part of a large research project on forensic dentistry. Inclusion criteria included male and female participants older than 18 years who lived in Saudi Arabia. Dental students, interns, and dentists were excluded. Using a convenience sampling methodology, a precision level of 5%, estimated prevalence of 50%, and confidence level of 95% yielding 385 participants were needed for this research. To overcome the non-response rate, a total of 1,000 participants were invited. Due to the current circumstances due to the COVID-19 pandemic, data collection was performed by sharing a Google link to a self-administered Arabic-language online questionnaire via social media platforms (WhatsApp, Twitter, Facebook, Instagram, and Snapchat) to a large segment of society in Saudi Arabia.
Questions were adopted from previous a questionnaire , and the questionnaire was tested and validated by the authors, with Cronbach’s alpha measured at 0.78 and 0.75. The questionnaire was validated through expertise research and by interviewing 10 participants in a pilot application to test the syntax, grammar, language, comprehension, flow, and organization, and then the questions were modified accordingly. The questionnaire can be answered in five to ten minutes.
Seven research assistants were responsible for distributing the questionnaire. In order to participate in this study, all participants were asked to indicate their approval of the informed consent by clicking on a button labeled “next” before being able to move on to completing the questionnaire. The questionnaire took about 10 minutes to complete. All data were treated anonymously, and any information about participants was eliminated. Participants who did not agree to the consent for this study were excluded. The questionnaire contained four parts and had a total of 55 questions. Part one consisted of 13 demographic items gathering the participant’s age, gender, nationality, occupation, level of education, marital status, dental information, the frequency of use of dental services, and whether they had been infected with COVID-19. Part two comprised 21 statements measuring the person’s level of knowledge about forensic dentistry. The questions were answered with “yes,” “no,” or “I do not know.” Each correct answer was given one point, and the answers were totaled for a maximum total score of 21 correct answers and a minimum of zero. Part three contained four questions to assess the participant’s attitudes about forensic odontology and its relationship to COVID-19. Part four had 16 questions aimed at assessing attitudes about forensic dentistry. The final question was about the participant’s willingness to enroll in a national dental registry. Ethical approval for this study was received from the research ethical committee for the Faculty of Dentistry, Umm Al Qura University, with the number 193-20.
Data analysis was conducted using Excel software and SPSS v.15 (IBM Inc., Armonk, NY, USA). Also calculated were descriptive statistics (count /percentages for categorical variables; mean/standard deviations or medians/inter-quartile ranges for continuous variables). Statistical significance was assessed via linear regression, chi-square, ANOVA, and t-test. The statistical significance level was set at a p-value of 0.05.
This study involved data from 784 participants, with a response rate of 78.4% from Saudi Arabia. Demographic data, including gender, age, nationality, city, region, marital status, education level, working status, existence of oral problems, usual treatment provider, frequency of dental visits, and history of infection with COVID-19 are shown in Table 1.
|Type of Variable||Variable||n||%|
|Age||Less than 30 years||173||22.07|
|More than 50 years||271||34.57|
|Education level||High school or not educated||128||16.33|
|University and higher||656||83.67|
|Usual care provider||Government||106||13.52|
|Frequency of visits to the dental clinic||Never||14||1.79|
|Only when there is pain/problem||678||86.48|
|History of COVID19 infection||Yes||29||3.7|
Table 1: Participants’ demographic data.
Participants were asked 21 questions related to forensic odontology to assess their levels of knowledge, and the total knowledge score was 9.35 and standard deviation (SD) of 4.68. The items and participants’ answers are shown in Table 2.
|Forensic odontology aids in
investigating bite attacks
|I do not know||171||21.81|
|Forensic odontology aids in estimating
the age of an individual
|I do not know||140||17.86|
|Forensic odontology can determine the
dental disease history of an individual
|I do not know||194||24.74|
|All individuals have the same jaw structures||Yes||101||12.88|
|I do not know||192||24.49|
|Forensic odontology aids in determining
some social health-related lifestyle factors
|I do not know||246||31.38|
|Forensic odontology aids in investigating
physical abuse (domestic violence)
|I do not know||278||35.46|
|Forensic odontology aids in investigating
the victims of fatal accidents
|I do not know||306||39.03|
|Everyone has a unique teeth imprint||Yes*||408||52.04|
|I do not know||312||39.8|
|Forensic odontology helps in
|I do not know||304||38.78|
|DNA can be extracted from
the teeth of live individuals
|I do not know||365||46.56|
|Forensic odontology can
identify the sex of an individual
|I do not know||334||42.6|
|Each individual has a unique
|I do not know||375||47.83|
|Forensic odontology aids in
investigating sexual abuse
|I do not know||367||46.81|
|Forensic odontology aids in
|I do not know||408||52.04|
|Forensic odontology doesn’t aid with
parental neglect of children’s teeth
|I do not know||271||34.57|
|DNA cannot be extracted from dead bodies||Yes||112||14.29|
|I do not know||420||53.57|
|Forensic odontology aids in determining
the socioeconomic status of an individual
|I do not know||285||36.35|
|In forensic odontology, it is not necessary to take infection
control measures when dealing with dead bodies
|I do not know||385||49.11|
|Forensic odontology doesn’t apply to live
survivors of accidents
|I do not know||468||59.69|
|Forensic odontology aids in determining the
nature of someone’s occupation
|I do not know||393||50.13|
|Each individual has the same lip prints or lines||Yes||400||51.02|
|I do not know||315||40.18|
Table 2: Forensic odontology knowledge items.
When participants were asked in one question to rate their perception of their general level of knowledge about forensic odontology on a scale of 10 points (where 10 was the highest level of knowledge), participants had a median score of 4.64 (SD=2.81). Simple linear regression showed that there was a significant relationship between participants’ perception of knowledge and actual total knowledge score (p < 0.001, r-squared=0.429).
Using t-test and ANOVA, the total score of knowledge was assessed in relation to gender, age, nationality, marital status, working status, and history of oral problems, usual care provider, and history of COVID-19. The results showed relationships with the total knowledge score only for the age group and work status, as shown in Table 3.
|Variable||Category||Forensic odontology knowledge scores||p-value|
|Age||Less than 30 years||9.43||4.76||0.014*|
|More than 50 years||8.66||4.68|
|Education level||High school or not educated||9.02||4.73||0.379|
|University and higher||9.42||4.68|
|History of oral problems||Yes||9.5||4.58||0.461|
|Usual care provider||Government||9.54||4.04||0.661|
|History of COVID-19||Yes||9.03||5.1||0.71|
** Only employed participants scored significantly higher than retired participants.
Table 3: The relationships between forensic odontology knowledge scores and demographic variables.
Participants’ answers to the attitude questions are displayed in Table 4. The attitudes toward the establishment of a national dental registry are shown in Table 5. A total of 585 (74.62%) were willing to register in a national dental record if one were to be established.
|Statement||Agree N (%)||Neutral N (%)||Disagree N (%)|
|During the COVID-19 pandemic, the practice of forensic odontology requires extra infection control precautions.||482 (61.48)||199 (25.38)||103 (13.14)|
|Forensic odontology is important during pandemics that result in high mortality rates, such as the COVID-19 pandemic.||324 (41.33)||298 (38.01)||162 (20.66)|
|Forensic odontology can help in determining the identity of a corpse during the COVID-19 pandemic.||304 (38.78)||322 (41.07)||158 (20.15)|
|There is need for forensic odontology to deal with the COVID-19 pandemic.||287 (36.61)||324 (41.33)||173 (22.07)|
Table 4: Participant attitudes about forensic odontology during the COVID-19 pandemic.
|Statement||Agree N (%)||Neutral N (%)||Disagree N (%)|
|I believe dental records should be linked to my medical and personal profile.||629 (80.23)||116 (14.8)||39 (4.97)|
|I believe Saudi dentists are able to maintain my privacy and confidentiality in a national dental registry.||619 (78.95)||135 (17.22)||30 (3.83)|
|A dental registry should be maintained and controlled by the government.||521 (66.45)||184 (23.47)||79 (10.08)|
|I believe Saudi dentists have the knowledge to assess my dental profile.||515 (65.69)||208 (26.53)||61 (7.78)|
|I believe that Saudi dentists would be competent at creating a record of my dental profile in a national dental registry.||513 (65.43)||218 (27.81)||53 (6.76)|
|I believe that the results of forensic odontology are scientifically reliable.||524 (66.84)||214 (27.3)||46 (5.87)|
|I believe that forensic odontology is an accurate and sensitive method for the identification of victims.||494 (63.01)||210 (26.79)||80 (10.2)|
|I am willing to provide my dental profile in case I am involved in a legal case.||493 (62.88)||210 (26.79)||81 (10.33)|
|I believe that forensic odontology is an accurate and sensitive method for the identification of unknown victims.||454 (57.91)||250 (31.89)||80 (10.2)|
|I believe that a national dental registry can assist with law enforcement.||444 (56.63)||259 (33.04)||81 (10.33)|
|I believe that forensic odontology is an accurate and sensitive method of identifying criminals.||438 (55.87)||250 (31.89)||96 (12.24)|
|National dental records can be of tremendous help with facing pandemics such as COVID-19.||340 (43.37)||324 (41.33)||120 (15.31)|
|I should have the right to refuse to register in a national dental registry.||329 (41.96)||297 (37.88)||158 (20.15)|
|If I enroll in a national dental registry, I should have the right to withdraw my dental record from it in the future.||325 (41.45)||309 (39.41)||150 (19.13)|
|I think my dental records file in the national dental records is liable to be hacked and my personal information would be released.||253 (32.27)||325 (41.45)||206 (26.28)|
Table 5: Participant attitudes about statements related to establishing a national dental registry for use in forensic dentistry.
This study revealed that the public in Saudi Arabia have relatively little knowledge about forensic dentistry but have good attitudes about participating in a national dental registry. There was a considerable proportion of participants who agreed on the importance of forensic odontology’s use in global public health disasters such as the COVID-19 pandemic. Nevertheless, forensic odontology still needs to be introduced to the public via more efforts aimed at educational and health promotional activities.
We would like to thank participants to answer the study questionnaire.
Lists of Abbreviations
• Coronavirus disease 2019 (COVID-19).
• World Dental Federation (FDI).
• Standard deviation (SD).
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2General Dentist, Jeddah, Saudi Arabia
Received Date: Aug 24, 2021 / Accepted Date: Sep 07, 2021 /