Forensic Odontology: Knowledge and Attitude of Dental Students in Ajman University, United Arab Emirates

A total of 276 dental students contributed to this study. The highest percentage of correct responses stated by the students was related to the estimation of individuals’ age and estimation of dental age based on radiograph and eruption status. However, there were clear deficiencies in students’ knowledge in relation to other aspects such as gender identification and lip-print, palatal rugae as an indicator in forensic identification. A high percentage (84.8%) had no formal education in the field of forensic odontology. Moreover, 93.1% of the students agreed that their present knowledge about forensic odontology is inadequate. Most of the participants (95.0%) agreed upon the necessity of adding a module on forensic odontology to the current curriculum.


INTRODUCTION
Forensic odontology is defined by the World Dental Federation as that branch of dentistry that deals with the proper investigation of dental evidence and with the appropriate evaluation and presentation of dental findings so as to ease the justice system [1]. This makes dental professionals exceptional and more important than others, especially in disastrous events [2]. The multiple functions of this distinctive discipline can range from the identification of human remains to mass disas-ter management, including but not limited to the assessment of patterned skin injuries, bite marks, in addition to the use of dental materials in the inspection of evidence [2]. Dental identifications have always played a key role in victims' proof of identity during catastrophic events.
It has been recommended that dental practitioners should have the essential skills and knowledge about forensic odontology, for instance, they should be aware of how to handle dental records, DNA analysis of the teeth, radiographs, teeth morphology, and anatomy [3]. In cases where a fingerprint record or physical identification is unavailable, then dental practitioners should take charge of crime investigations [4]. Dentists do have legal and professional responsibilities to generate and maintain dental records, which both serve the best interests of patients and contribute to the continuity of their dental care [5].
Dental records play a significant role in cadaver identification, which has been totally disintegrated and is difficult to identify visually. When this happens, a range of dental identification methods are used. This is attributed to the fact that dental tissues and dental restorations are resistant in nature, due to the changes caused by temperature and decomposition, which make them the most reliable source of DNA, that will be of enormous aid to identify an individual [6]. The success of identification depends on the accessibility and accuracy of these patients' records. Regrettably, due to dentists' negligence of maintaining proper records, resulting in ambiguity, dental identification sometimes becomes hard to achieve [7].
In spite of the significance of this field in criminal justice, the literature shows that forensic odontology is under-estimated in many countries; further exposures are needed to improve the utilization of this science [8]. Health personnel are often challenged with forensic cases; thus, the deficiency in the information about forensic cases might preclude the identification of such cases. Healthcare professionals who come across forensic cases should be well equipped to diagnose such an event [9].
Previous studies conducted in the United Arab Emirates (UAE) assessed dental students' knowledge and attitude in relation to other topics such as oral health [10] and child abuse [11]. However, no study examined the knowledge and attitude of dental students and interns in relation to forensic odontology. The objective of this study was to assess the level of knowledge and attitude toward forensic odontology among dental students in Ajman University -UAE, and to determine students' opinions on the current dental curriculum.

MATERIALS AND METHODS
This study was conducted among dental students in one of the main dental colleges in the United Arab Emirates, namely: Ajman University (AU), during the period from January 2020 to March 2020. Only dental students in their final year and internship were invited to participate. This study was approved by the ethics committee of AU University (reference number D-F-H-2020-01-23). Prior to conducting the study, the students were informed that their participation was voluntary. No identity related information was gathered. This study used an online self-administrated questionnaire in the English language on software from Microsoft Forms. The questionnaire consisted of a set of 15 questions that was customized based on previously published studies [12 -14]. The questionnaire was divided into three parts; the first part included questions related to students' knowledge about forensic odontology. The second part investigated the respondent's source of information in forensic odontology and requested them to self-assess their level of knowledge and confidence in handling forensic dental cases. While the last part of the questionnaire was designed to determine students' opinion in the current dental curriculum and assess their interest in pursuing further study in forensic odontology.
The questionnaire was pre-tested on ten students before the commencement of the study to ensure that all of the questions are directly understood by the students. The pre-testing showed a very clear understanding of the provided questions. The weblink of the questionnaire was distributed to all dental students in the final year and internship through their batch's email addresses with a covering letter to explain the purpose of the study, and to assure all participants of the anonymity of their responses. The average time to complete the survey was approximately five minutes. All the data were entered into Microsoft Excel, and then the data were analyzed using SPSS windows version 23.0 (SPSS Inc., Chicago, IL, USA). The responses received were categorized as nominal data.

RESULTS
A total of 276 dental students participated in this study (response rate, 92.9%), which included 153 undergraduates, and 123 interns. The percentage of correct responses for each question varied, as presented in Table 1. The highest percentage of correct replies was reported in Question 1 (245, 88.8%), 2 (230, 83.3%) and 3 (237, 85.9%), which was all related to the estimation of individuals' age and estimation of dental age based on radiograph and eruption status. However, the lowest proportion of correct responses was reported in questions 6 (28, 10.1%), 4 (78, 28.3%), 5 (100, 36.2%) and 9 (138, 50.0%). This shows that dental students had knowledge deficiencies that were mainly related to the significance of forensic odontology on other features such as gender identification, lip-print, and palatal rugae as an indicator in forensic identification and documentation.
Most (84.8%) of the dental students did not receive formal education in forensic odontology. Only ten percent of the participants pointed out that their source of information about forensic odontology was a dental school. While around half of the students who participated, obtained their information from the media. The majority (93.1%) of them would think that they do not have adequate knowledge in forensic odontology. Additionally, around 91.3% lack the confidence of handling forensic dental cases ( Table 2). Most of the participants agreed upon the necessity of adding a module on forensic odontology to the current curriculum. However, only one-quarter of the students were interested in pursuing forensic in higher studies ( Table 3).

DISCUSSION
This study was conducted to assess dental students' knowledge and attitude in relation to forensic odontology in order to define the educational needs related to this topic. There are many studies carried out on forensic odontology in other countries [13,15], but no study was conducted in the UAE among dental students. Therefore, this study was the first of its kind in UAE, which targets undergraduate and intern dental students. However, the limitations of this study should be considered when interpreting the findings; the sample utilized was drawn from one educational institution, therefore, it does not represent all dental students in the United Arab Emirates. Further studies should be carried out at other dental colleges in the UAE.  Table 3. Students willing to study forensic dentistry. This study revealed that there was a lack of knowledge and awareness of forensic odontology among dental students. Similar findings have been reported by other researchers [13,14]. In forensic odontology, age is considered as one of the crucial indicators in assessing the identity of an individual. Estimation of the human age is a process implemented by archaeologists, anthropologists, and forensic scientists [15 -17]. The majority of dental students agreed that forensic odontology help in estimating an individual's age. A range of approaches are used to identify the dental age, including the radiographic method, histological method, and visual method [18]. Fortunately, the majority of the participants were aware of the fact that dental age can be estimated by radiograph and eruption status. This finding is in contrast to previous studies [19,20]. However, around three-quarters of the students were unaware that forensic odontology assists in the identification of the victims' gender. A similar observation was noted by .
Possessing a critical eye is a necessity for all dentists when legal authorities require forensic consultation [21]. Palatal rugae have been shown to be extremely distinct and constant in shape throughout life [22,23]. When identification of an individual by other methods is difficult, palatal rugae may thus be considered as an alternative source of information. Only 36.2% of the dental students in this study acknowledged this fact. Additionally, one-quarter of the students were unaware that bite marks aid in identifying criminals. Although bite marks are definite to an individual, no two people have the exact identical dentition in relation to teeth arrangement and dimension [24]. Furthermore, the significance of forensic odontology can be attributed to the fact that dental tissues are resistant in nature, and able to withstand the extreme temperature and decomposition, which makes them an appropriate source for DNA material [25]. Around threequarters of the respondents agreed that DNA could be obtained from a deceased person's teeth.
Dental records are considered as an essential aid in identification of persons who are victims of an illegal act. The dental record might act as a future reference for the dentist when needed, but unfortunately, it is not constantly preserved for a forensic purpose [26]. In the current study, only half of the dental students agreed that maintaining dental records is an essential component in human identification. This insufficient knowledge highlights the necessity for proper education and further training [27]. Dentists should know not only the importance of preparing an accurate dental record but also the importance of preserving these records.
The majority of respondents reported that they did not have forensic odontology as part of their academic curriculum, which would have a negative impact on the progress and advancement of the field. Similar observation has been noted by other researchers [13,28]. However, their knowledge can be enriched by initiating forensic dentistry as a subject in the dental curriculum at both undergraduates and postgraduates levels. All dental institutes should consider offering formal training in forensic odontology in order to upgrade the knowledge and skills of their graduates, supported by workshops, seminars, conferences and continuing dental education programs.
Almost half of the students reported that their source of information in forensic odontology is from the media. Media plays a definitive role in creating awareness among the public [29]. The same holds true for the present study. Additionally, journals and conferences continue to remain as one of the most reliable and correct sources of this knowledge. However, the focus should be on the worrying finding that the majority of students in this study think that they do not have adequate knowledge or confidence in handling forensic dental cases. However, 95% of the students welcomed the idea of adding a module on forensic odontology to the current undergraduate curriculum. Whereas, only one-quarter of them are interested in pursuing higher studies in forensic odontology; that might be attributed to the limited work opportunities for this specialty in UAE.
This study provides a baseline for the upcoming studies in the United Arab Emirates. Findings from this study might be considered as a reference for endorsing the area of forensic odontology in the undergraduate training of dental students. Thus, the undergraduate program must be improved by including preclinical lectures on forensic odontology, followed by clinical training and a field trip to forensic departments. These recommendations might have a positive impact on students' knowledge and awareness concerning forensic odontology

CONCLUSION
Our study revealed inadequate knowledge among dental students. This lack of knowledge among them attributed to the lack of formal training, and lack of forensic odontology as a part of dental curriculum in Ajman University, United Arab Emirates. This situation, however, can be handeled if necessary steps are taken. Forensic odontology must be introduced to the undergraduate curriculum to enhance students' capabilities in handling medico-legal cases in the future.

ETHICS APPROVAL AND CONSENT TO PARTI-CIPATE
The current study was approved by the ethics committee of Ajman University , Saudi Arabia(reference number D-FH-2020-01-23).

HUMAN AND ANIMAL RIGHTS
Not applicable.

CONSENT FOR PUBLICATION
Informed consent was obtained from all individual participants included in the study.

AVAILABILITY OF DATA AND MATERIALS
The data that support the findings of this study are available from the corresponding author, [R.H], upon reasonable request.

FUNDING
None.

CONFLICT OF INTEREST
The author declares no conflict of interest, financial or otherwise.