The identification of unknown deceased individuals represents one of the most fundamental and challenging tasks in forensic medicine. In many parts of the world, including Pakistan, the issue of unidentified bodies has grown into a significant public health and medico-legal concern. Unidentified decedents—those whose identity cannot be established at the time of death—pose numerous challenges for law enforcement, the judiciary, and the families who may be searching for their missing loved ones. The inability to identify a deceased person not only hinders criminal investigations but also denies families the closure they desperately need, creating a cycle of grief and uncertainty that can persist for years. The Punjab province, being the most populous province of Pakistan, faces a disproportionately high number of such cases.

The problem of unidentified dead bodies has been formally recognized in Pakistani legal frameworks. Under the Police Rules, 1934, specifically Rule 22.79, police stations are required to maintain records of unidentified corpses and to circulate notices to various agencies to aid in identification [1]. However, the lack of a centralized, digitalized, and multidisciplinary forensic identification system continues to hamper efforts. Initiatives such as the "Shanakht" project in Sindh, which uses biometric fingerprinting and DNA analysis to identify unclaimed bodies, have shown promise, but such systems are not yet fully operational across Punjab [11, 18].

Forensic identification relies on a multidisciplinary approach, drawing upon the expertise of forensic pathologists, odontologists, anthropologists, and toxicologists. The primary objective is to establish a positive identification, which in most jurisdictions requires the matching of a sufficient number of unique or concordant features between the post-mortem findings and ante-mortem records [19]. Autopsy remains the cornerstone of this process, providing a systematic examination of the body to determine the cause and manner of death. It also yields critical identifiers such as sex, age, stature, and any unique anatomical features such as scars, tattoos, or previous surgical interventions. The Punjab Forensic Science Agency (PFSA) provides comprehensive autopsy services, including histopathology and radiology, to support this process [1].

When the body is decomposed, burned, or mutilated, traditional methods of visual identification and fingerprinting may become impossible. In such cases, the teeth and dental restorations become invaluable assets. Dental tissues are among the most durable structures in the human body, capable of withstanding extreme environmental conditions, including fire, trauma, and post-mortem degradation [5, 6]. Forensic odontology uses dental records—including written charts, radiographs, and photographs—to create a unique "dental fingerprint" for comparison [2, 4]. Endodontic and radiographic images, in particular, serve as an objective method of recording information that captures unique morphological features of teeth and surrounding structures [12]. Advanced imaging modalities like cone-beam computed tomography (CBCT) and 3D reconstruction have further enhanced the capability for dental identification, allowing for detailed assessment of craniofacial structures and aiding in age and sex estimation [12]. The INTERPOL protocols recognize dental radiographs as one of three primary identifiers, along with fingerprints and DNA [19].

Toxicological screening plays a dual role in the context of unidentified decedents. Firstly, it is crucial for determining the cause of death, such as in cases of poisoning or drug overdose—both of which are common in medico-legal cases in Punjab [8]. Secondly, toxicological findings may provide circumstantial evidence that aids in identification. The detection of specific drugs, particularly if linked to a known prescription or a known pattern of abuse, can help narrow down the pool of potential identities. However, forensic toxicology in decomposed or exhumed bodies presents considerable methodological and interpretative difficulties, including post-mortem redistribution and instability of substances [13]. The PFSA has established detailed protocols for the collection, preservation, and transport of toxicological specimens, recommending the use of vitreous humor, peripheral blood, urine, and other tissues to optimize analytical results [1].

In Punjab, forensic capacity has been growing. King Edward Medical University (KEMU) in Lahore is a premier institution with a well-established Department of Forensic Medicine and Toxicology, conducting a significant number of autopsies and medico-legal examinations [3]. Similarly, the Department of Forensic Medicine at Faisalabad Medical University (FMU) serves the central Punjab region, managing a high volume of medico-legal cases and providing autopsy services to multiple divisions [16]. The recent launch of a Certificate in Medico-legal Examination by the University of Health Sciences (UHS) in Lahore, in collaboration with the PFSA, is a significant step towards standardizing and improving the quality of medico-legal practice in the province [10].

Despite these developments, Pakistan faces persistent challenges in the identification of unknown bodies [17]. A significant proportion of deaths—particularly from road traffic accidents, violence, and undiagnosed medical conditions—remain unrecorded [14, 15]. A lack of standardized ante-mortem dental records, poor data linkage between health and law enforcement agencies, and limited use of advanced forensic tools like DNA profiling in routine practice continue to hamper identification efforts [2, 7, 9]. There is, therefore, an urgent need for a systematic evaluation of current practices in Punjab to identify gaps and propose evidence-based recommendations.

This study aims to evaluate the combined efficacy of autopsy findings, dental record analysis, and toxicological screening in establishing the identity of unidentified decedents in Punjab, Pakistan. By analyzing a large cohort of cases from two major forensic centers, we intend to assess the relative contribution of each discipline, identify the most common causes of death and demographic patterns, and evaluate the practical utility of dental records and toxicology in a resource-constrained setting. The findings of this study are expected to inform policy recommendations for improving the forensic identification system in Punjab and to contribute to the growing body of knowledge on multidisciplinary forensic practice in South Asia.

Study Design and Setting This was a cross-sectional, descriptive study conducted at the Department of Forensic Medicine & Toxicology, King Edward Medical University (KEMU), Lahore, and the Department of Forensic Medicine, Punjab Medical College/Faisalabad Medical University (FMU), Faisalabad. Both institutions serve as major tertiary referral centers for medico-legal autopsies in their respective regions. The study was conducted from January 2025 to June 2025, a total of 6 months. Study Population The study population consisted of all unidentified decedents (bodies brought for post-mortem examination without any identifying documents or known identity) who were brought to the participating forensic departments during the 6-month study period. Cases were included if the identity was not known at the time of the autopsy and if a complete autopsy could be performed. Cases with advanced decomposition to the extent that no viable samples for toxicological or dental analysis could be obtained were excluded, as were cases where the body was claimed before the completion of the autopsy. Data Collection A structured, pre-tested data collection proforma was designed to capture all relevant information. Data were collected by the principal investigator and trained research assistants (forensic residents) through a systematic review of autopsy reports, police records, and laboratory reports. The following data were recorded: Demographic Data Age (estimated by autopsy findings), sex, and estimated time since death. Autopsy Findings External and internal examination findings, including: External identifiers: Scars, tattoos, birthmarks, and clothing. Anthropometric measurements: Height, weight, and head circumference. Pathological lesions: Injuries, diseases, and congenital anomalies. Cause and manner of death. Dental Examination Post-mortem dental examination was performed by a forensic odontologist. This included: Dental charting: Recording of all teeth (presence, absence, caries, restorations, and prosthetic appliances). Post-mortem dental radiography: Orthopantomograms (OPG) and intraoral periapical radiographs (IOPA) were taken where possible. Comparison with ante-mortem dental records: Ante-mortem records were sought from the PFSA database, NADRA, and by contacting dental clinics via the police and family tracing. Toxicological Screening Standard toxicological samples (blood, urine, and vitreous humor) were collected per PFSA guidelines [1]. Specimens were transported to the PFSA forensic toxicology laboratory. Screening was performed using Gas Chromatography-Mass Spectrometry (GC-MS) and Liquid Chromatography-Mass Spectrometry (LC-MS/MS). Identification Procedure Identification was attempted using a stepwise approach: Step 1: Visual and Biometric Identification: Attempts were made through fingerprinting and visual recognition by family members or police. Step 2: Dental Comparison: If Step 1 failed, post-mortem dental records were compared with available ante-mortem records. Identification was considered "positive" if there was a sufficient number (≥ 5) of concordant dental features with no unexplained discrepancies [19]. Step 3: DNA Analysis: DNA analysis was performed in cases where dental comparison was inconclusive or not possible, using standard short tandem repeat (STR) profiling and comparison with familial DNA samples. For the purpose of this study, "successful identification" was defined as the establishment of a confirmed identity through any of the above methods. The relative contribution of each discipline (autopsy, dental, toxicology) to the identification process was assessed. Statistical Analysis Data were entered into a Microsoft Excel spreadsheet and analyzed using SPSS version 26.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were used to summarize demographic and categorical variables, which were expressed as frequencies and percentages. Continuous variables were expressed as mean ± standard deviation. Chi-square tests were used to determine associations between identification success and the number of forensic modalities used. A p-value of <0.05 was considered statistically significant.

Demographic Characteristics

A total of 412 unidentified decedents were included in the study during the 6-month period. The demographic characteristics of the study population are presented in Table 1. The majority of decedents were male (68.2%), with a male-to-female ratio of approximately 2.1:1. The most common age group was 21–40 years (42.7%), followed by 41–60 years (27.4%). Road traffic accidents (RTAs) were the leading cause of death (38.6%), followed by firearm injuries (24.3%) and blunt force trauma (16.5%). Poisoning accounted for 8.7% of cases, while 11.9% died from other causes, including drowning, burns, and natural diseases. The mean estimated time since death at the time of autopsy was 4.7 ± 6.2 days.

Table 1: Demographic Characteristics and Cause of Death of Unidentified Decedents in Punjab (N=412)

Identification Success and Multidisciplinary Approach

Successful identification was achieved in 67.5% (n=278) of cases. The impact of a multidisciplinary approach on identification rates is shown in Table 2. The combination of all three disciplines (autopsy + dental + toxicology) yielded the highest identification rate of 84.3%. The combination of autopsy and dental records had a 72.1% success rate, while autopsy alone had the lowest rate of 55.4%. The association between identification success and the number of disciplines used was highly statistically significant (p < 0.001), demonstrating the additive benefit of each forensic modality.

Table 2: Identification Success Rate by Multidisciplinary Approach

Note: Chi-square test for trend = 28.6, p < 0.001

Dental Identification

The results of the dental examination and identification are presented in Table 3. Dental records were available for only 34.7% (n=143) of all decedents. However, in cases where ante-mortem records were available and a comparison could be made, the match rate was exceptionally high at 91.2%. Concordant features most commonly used for identification included the presence and morphology of dental restorations (81.5%), tooth morphology and positioning (72.3%), and the presence of endodontic treatments (root canal fillings) (45.9%). The mean number of concordant features used for positive identification was 8.4 ± 3.1 (range 5 to 14).

Table 3: Dental Identification Results

Figure 1: OPG image showing multiple restorations and a distinctive root canal treatment in tooth  (lower right first molar), which was used to confirm the identity of a 34-year-old male victim of a road traffic accident by matching with his ante-mortem OPG obtained from a private dental clinic.

Figure 2: Comparison of post-mortem (left) and ante-mortem (right) periapical radiographs of tooth, showing an exact match in the morphology of the root canal filling, a unique feature that established the identity in a case of a completely burned body.

Toxicological Screening

Toxicological screening was performed in 63.1% (n=260) of cases, as sample availability allowed. The results are presented in Table 4. Toxicology was positive for at least one substance in 49.6% (n=129) of the tested cases, which represents 31.3% of all 412 cases. Among the positive cases, the most commonly detected substances were alcohol (ethanol) (42.6%), opioids (28.7%), and benzodiazepines (18.3%). Alcohol was the most frequently detected substance in poisoning cases (44.4%), followed by organophosphate pesticides (22.2%). Toxicology provided a direct cause of death (poisoning) in 8.7% (n=36) of all cases. In a subset of cases, toxicological findings provided circumstantial clues (e.g., detection of a specific drug associated with a missing person's known medical history) that contributed to narrowing the field of potential identities.

Table 4: Toxicological Screening Results

Graph 1: Bar chart illustrating the significant increase in identification success rate as the number of forensic disciplines used increases, from 55.4% for autopsy alone to 84.3% for the full triad of autopsy, dental, and toxicology.

Graph 2: Pie chart showing the distribution of substances detected in cases where toxicology was positive. The majority are accounted for by Alcohol (42.6%), Opioids (28.7%), and Benzodiazepines (18.3%).

This study provides a comprehensive analysis of the multidisciplinary approach to identifying unidentified decedents in Punjab, Pakistan. The findings underscore the critical importance of integrating forensic medicine, dentistry, and toxicology in medico-legal death investigations. With an overall identification success rate of 67.5%, the study demonstrates that a collaborative approach significantly enhances the likelihood of returning a name to an unknown body, a process that is vital for families, the legal system, and public health.

Demographic and Epidemiological Insights

The demographic profile of unidentified decedents in this study, with a preponderance of young adult males (21–40 years, 42.7%) and a male-to-female ratio of over 2:1, is consistent with patterns reported in similar settings globally and in South Asia. This demographic typically reflects the most economically active and mobile segment of the population, who are more likely to be involved in road traffic accidents, occupational hazards, and interpersonal violence.

The finding that Road Traffic Accidents (RTAs) are the leading cause of death (38.6%) aligns with Pakistan's status as a country with substantial challenges regarding road traffic injuries [14]. Poor road infrastructure, lack of traffic enforcement, and limited emergency healthcare contribute to high mortality, particularly in the context of hit-and-run incidents where the victim's identity is often unknown [14]. Firearm injuries (24.3%) and blunt force trauma (16.5%) are also significant, reflecting the high prevalence of violence and conflict in certain regions. These patterns highlight the need for law enforcement to prioritize the investigation of these specific types of cases and for health authorities to improve trauma care systems [14, 15].

The Synergistic Value of a Multidisciplinary Approach

The most compelling finding of this study is the clear, stepwise increase in identification success with the addition of each forensic discipline. The success rate escalated from 55.4% with autopsy alone to 84.3% when dental and toxicological analyses were combined. This additive effect is highly statistically significant (p < 0.001) and provides strong empirical evidence for the implementation of comprehensive forensic services. Autopsy alone, while essential for determining the cause and manner of death, only provides a limited set of identifiers (age, sex, stature, external marks) that are insufficient for positive identification in a significant proportion of cases. Without the unique features offered by dental comparisons or the circumstantial clues from toxicology, the closure process for the families of the deceased is often hindered.

The importance of a structured, hierarchical approach cannot be overstated. Initial identification attempts should rely on visual recognition and fingerprinting, as these are the fastest and cheapest methods. When these fail, as they often do in decomposed or mutilated bodies, the forensic odontologist becomes an essential consultant. Dental evidence provides an invaluable tool, and post-treatment endodontic radiographs are an especially rich source of features on which individuation can be achieved [12]. While this study found a high match rate (91.2%), the low overall availability of ante-mortem dental records (34.7%) is a critical bottleneck that severely limits the utility of forensic odontology in the region. This finding aligns with the observations of Sharma et al., who noted that dental radiology plays a vital role in forensic odontology but requires robust ante-mortem data infrastructure [12].

The Role of Forensic Odontology in the Pakistani Context

In the Pakistani context, where DNA profiling is often expensive and time-consuming, dental identification offers a cost-effective and rapid alternative for many cases [5, 6]. The durability of teeth makes them an excellent source of identifying features in burned, decomposed, or skeletonized remains [5, 6]. However, the study underscores a significant challenge: the lack of a centralized dental records database and the poor quality of dental records maintained by private and public dental clinics [2, 4, 7]. While the PFSA maintains detailed protocols for the collection, preservation, and transport of evidence, including the handling of toxicology specimens [1], there is no equivalent standardized national system for dental records [5]. The "Shanakht" project in Sindh has shown that biometric and DNA databases can be successfully used for this purpose, but a similar comprehensive, province-wide system is required for dental records [11, 18].

The successful identification in cases where records are available (91.2%) demonstrates that this method is highly reliable. The presence of distinctive features such as endodontic treatments (root canal fillings) and complex restorations offers a large number of concordant points for comparison. The high mean number of concordant features (8.4) indicates that dental records, particularly radiographs, are unique enough to be considered a primary identifier on par with fingerprints, as recognized by INTERPOL [19]. The establishment of a digital dental record repository in Punjab, coupled with mandatory dental charting and digital radiography in all dental practice settings, would dramatically increase the potential for future identifications [2]. The University of Health Sciences' recent initiative to launch a medico-legal training course is a promising step, and it should include comprehensive training for dental surgeons in forensic odontology, with a focus on proper record-keeping and radiographic comparison techniques [10].

The Contribution of Forensic Toxicology

Toxicology provides valuable information that serves a dual purpose: determining the cause of death and providing circumstantial clues for identification. This study found that toxicology was positive in a significant proportion of cases (49.6% of tested cases, representing 31.3% of all cases), with alcohol, opioids, and benzodiazepines being the most frequently detected substances. The detection of alcohol in 42.6% of positive toxicology cases highlights the role of intoxication in fatal accidents and violence. The high prevalence of opioids (28.7%) is a stark indicator of the growing drug abuse problem in Pakistan, which is often associated with high-risk behaviors and subsequent mortality.

In the context of identification, toxicological screening can provide crucial circumstantial evidence. For instance, the detection of a specific combination of drugs might point to a known medical condition in a missing person, or the presence of a unique drug of abuse could link the deceased to a known group or location. The methodological challenges inherent in analyzing decomposed specimens are well-recognized, particularly the issue of post-mortem redistribution and substance instability [13]. The PFSA's detailed guidelines on sample collection, requiring the use of vitreous humor, peripheral blood, and tissues, are essential for maximizing the validity of the results [1]. The use of advanced techniques like GC-MS and LC-MS/MS, as described in this study, is critical for the sensitive and specific detection of a wide range of drugs.

Challenges and Systemic Gaps

Despite the success rates, the study reveals several systemic challenges in the forensic identification system in Punjab [17]. Firstly, the low availability of ante-mortem records is a fundamental barrier [2]. Many patients, particularly from lower socioeconomic backgrounds, seek treatment from public sector hospitals where dental records are often poorly maintained or not filed [2, 7]. Secondly, the high volume of cases (412 over 6 months) and the limited human resources at the two participating centers create a significant workload, which can lead to backlogs and delays in the release of reports [3, 16].

Thirdly, there is a lack of a centralized, digitalized forensic data repository that can be accessed across provincial boundaries [9, 18]. While the PFSA provides state-of-the-art analytical services, communication and linkage between its laboratory results and field investigators remain a challenge [1, 18]. Fourthly, law enforcement agencies frequently fail to follow up on leads provided by forensic reports, including dental comparisons and toxicological results, due to a lack of training and inter-agency coordination [17, 18].

The legal framework, while providing for the maintenance of records of unidentified corpses, is outdated. The Police Rules, 1934, require notices about unidentified corpses to be circulated, but these methods are not optimized for modern digital systems. There is a need to update these rules to require the rapid digitalization of post-mortem data, including photographs, dental radiographs, and DNA profiles, and to mandate their upload to a central, searchable database [11, 18]. The recent judgment of the High Court of Sindh recognizing the need for digital records should be extended across the province [11]. The involvement of NADRA in the identification of unclaimed bodies offers a model for using national databases for identification, and similar collaboration should be fostered in Punjab [18].

Study Limitations

This study has several limitations that must be acknowledged. First, it is a cross-sectional, descriptive study that represents the experience of two major centers in Punjab; the findings may not be fully generalizable to the entire province, particularly rural areas with less forensic infrastructure. Second, the identification rates reported may vary depending on regional infrastructure, as many cases of unidentified decedents may not be brought to these tertiary centers. Third, the study relied on the availability and quality of records maintained at the centers, and the success rates may be influenced by the skill of the forensic practitioners involved.

Fourth, data on the precise role of toxicology in identification (beyond circumstantial clues) were not systematically documented. Fifth, the study period of 6 months may not be sufficient to account for seasonal or annual variations in patterns of death. Future studies should incorporate qualitative methods to explore barriers to effective multidisciplinary identification from the perspective of investigators, clinicians, and families,

This study demonstrates that a multidisciplinary approach combining autopsy, dental records, and toxicological screening significantly improves the identification rate of unidentified decedents in Punjab, Pakistan. The combination of all three disciplines achieved an identification success rate of 84.3%, compared with just 55.4% for autopsy alone. The strength of this approach lies in its ability to leverage the unique strengths of each discipline, providing a comprehensive picture of the deceased that can be matched against missing persons data. Forensic odontology is a highly effective method when ante-mortem records are available, with a 91.2% match rate in this study. However, the utility of this method is severely limited by the low availability of these records (34.7%). Toxicology not only helps determine the cause of death but also provides circumstantial evidence that can guide identification efforts. To enhance the forensic identification system in Punjab, the following recommendations are proposed: Establish a Centralized Digital Database for Dental Records: A provincial database should be created to house digital radiographs and dental charts from all public and private dental clinics, enabling rapid comparison in cases of unidentified decedents [2]. Implement Mandatory Standardized Forensic Documentation: Dental practitioners should be required to maintain high-quality, standardized records, including radiographs, to facilitate future forensic comparisons [2, 7]. Enhance Inter-Agency Coordination and Capacity: Strengthen coordination between the police, PFSA, NADRA, and forensic departments, and provide advanced training to medico-legal officers and dental surgeons in forensic odontology and toxicology [10, 18]. Update Legal Frameworks: Amend the Police Rules, 1934, to mandate the rapid digitalization and centralized uploading of post-mortem data, photographs, and dental radiographs of all unidentified decedents [11]. Expand the Multidisciplinary Approach: All medico-legal autopsies of unidentified decedents should include, at a minimum, a basic dental examination and toxicological screening, with the cost and resources allocated accordingly [19]. By implementing these reforms, Pakistan can make significant progress in addressing the problem of unidentified dead bodies, providing closure to grieving families and strengthening the rule of law.

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