Multimodal Characterization of Postmortem Pink Teeth in Indonesian Forensic Practice: Protocol for a Retrospective...

Postmortem pink teeth are an uncommon finding produced by color changes within dental tissues. They have been reported in several death contexts, including drowning, but neither their presence nor their intensity is specific for a cause of death. Inconsistent photographic, radiological, and histological methods have limited comparison across studies.

This study aims to describe a reproducible multimodal workflow for postmortem pink teeth and to estimate the feasibility, measurement reliability, and exploratory associations of protocol-specified photographic scores, cone beam computed tomography (CBCT) structural measurements, and histological distribution scores.

This is a retrospective laboratory case series using existing specimens and records from Indonesian forensic practice. Candidate teeth will undergo outcome-blind eligibility assessment for applicable ethics coverage, provenance, medicolegal custody, anonymous decedent linkage, and technical evaluability. Photography will be scored with the 3-level Score of Pink Teeth Color and Score of Pink Teeth Region scales. CBCT will quantify dentin thickness and pulp-to-tooth area ratio after long-axis reorientation; CBCT gray values will not be interpreted as tissue density. Hematoxylin-eosin sections will be scored by the farthest dentinal zone containing recognizable erythrocytes or blood-compatible pigmented material, without claiming chemical identification of hemoglobin. Two blinded raters will evaluate each modality. Analyses will emphasize descriptive estimates, weighted kappa, intraclass correlation coefficients, and exploratory Spearman correlations with bootstrap 95% confidence intervals. Multiple teeth from one decedent will be handled by decedent-level clustering when linkage is available. No diagnostic accuracy or cause-of-death prediction analysis is planned.

The working catalog contains 25 candidate teeth with existing photographic and CBCT records and available histopathological source materials. The Research Ethics Approval was renewed under No. 004123/KEP Ladokgi R.E. Martadinata/2026, valid from July 29, 2026 to July 29, 2027. The renewed approval describes the study as involving 25 postmortem pink-teeth samples. All candidate teeth will undergo outcome-blind eligibility assessment based on ethics coverage, provenance, medicolegal custody, decedent linkage, and technical evaluability. Protocol-locked remeasurement and blinded histological re-review will be completed only for eligible specimens before the final dataset is frozen. Reliability assessment and integrated analysis will be performed using the frozen analytic dataset.

The protocol prioritizes traceable acquisition, conservative biological interpretation, and reliability over diagnostic claims. It is intended to standardize documentation of a rare forensic finding and to identify methods suitable for subsequent prospective validation.