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Post Mortem Pink Teeth and Pseudo Pink Nails in a Case of Suicidal Hanging

Article  in  Pathology and Laboratory Medicine · January 2021

DOI: 10.11648/j.plm.20210501.11

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Pathology and Laboratory Medicine
2021; 5(1): 1-5
http://www.sciencepublishinggroup.com/j/plm
doi: 10.11648/j.plm.20210501.11
ISSN: 2640-446X (Print); ISSN: 2640-4478 (Online)

Post Mortem Pink Teeth and Pseudo Pink Nails in a Case of

Suicidal Hanging
Pawan Mittal
Demonstrator, Department of Forensic Medicine, Bhagat Phool Singh Medical College for Women, Sonipat, India

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To cite this article:

Pawan Mittal. Post Mortem Pink Teeth and Pseudo Pink Nails in a Case of Suicidal Hanging. Pathology and Laboratory Medicine.
Vol. 5, No. 1, 2021, pp. 1-5. doi: 10.11648/j.plm.20210501.11

Received: January 4, 2021; Accepted: January 12, 2021; Published: January 22, 2021

Abstract: A postmortem case of suicide by hanging is described where pink teeth and pink nails were found during autopsy.
One highly putrefied dead body belonging to a middle aged man was found hanging from the branch of a tree amidst a forest.
Multiple permanent teeth and bilateral little fingernails displayed pink discolorations. After considering the circumstances of
the case and autopsy findings including the ambiguity over pink tissue phenomenon, the cause of death was finally given as
ante mortem hanging. The pink teeth phenomenon [PTP] is an infrequent and dubiously explained finding in forensic literature
while a single case report exists in relation to pink nails. Although many authors have stressed that post-mortem pink teeth
should not be considered as a reliable dental parameter for determining the cause of death, the results of other studies have
shown that the pink teeth commonly occur in cases of asphyxia such as strangulation, drowning or suffocation. The finding,
although initially related to an intravitam cranial congestion, was subsequently refuted on account of its discovery in non-
asphyxial and other modes of deaths. A potential role of postmortem hypostatic congestion in this regard has been proposed
especially in drowned corpses due to their frequent floatation in a head down position. A moist and humid environmental
milieu along with certain degree of putrefaction has been considered as a prerequisite for the enhancement of the process. The
repeated discovery of the finding in autopsy cases has been almost a continuing conundrum for the pathologists. The pink
tissue phenomenon mandates a sound and goal oriented investigation in order to clarify its role in ascertaining the cause of
death.
Keywords: Pink Teeth, Pink Nail, Dentine, Asphyxia, Hemoglobin, Congestion

We hereby report the phenomenon of postmortem pink

1. Introduction teeth and an additional finding simulating pink nails in a
Permanent or transient pigmentation of the teeth can occur middle aged man, who committed suicide by hanging.
due to extrinsic or intrinsic causes [1]. The changes can be
generalized or localized [2]. The term 'pink tooth' refers to a 2. Case Details
pink to red coloration of the dentine, which becomes
particularly deep towards the cement enamel junction and 2.1. History
fading off towards both ends [2]. The first description of pink The case belongs to a 45 years old married male,
teeth phenomenon [PTP] was made by Thomas Bell in 1829 shopkeeper by profession, with a long history of depression
[1]. However, the path gnomic value of pink teeth has been since his mother’s demise. Any history of medication or
more than doubtful since it has been described in a variety of physical illness was absent. About 6 days before discovery of
unnatural and violent deaths such as asphyxiation, blunt, his dead body, he had left home as a routine but did not come
sharp and gunshot trauma, poisonings and intoxications [2-7], back, unless one day a stranger passing through a distant
as well as with unknown/unsolved cause and manner of forest noticed a foul smelling putrefied body hanging from a
deaths [8] and archeological situations [9]. tree and informed the local police. The police reached the
Similar discoloration has been also described in a case spot and conducted the inquest on the grounds of an
involving multiple fingernails in a mummified body [10].
2 Pawan Mittal: Post Mortem Pink Teeth and Pseudo Pink Nails in a Case of Suicidal Hanging

unknown body committing suicide by hanging. Identification 2.3. Autopsy Details

and history of the deceased were established 2 days after its
discovery, by means of a newspaper details. The dead body was brought for postmortem examination
on next day. A pale brownish ligature mark was present
2.2. Crime Scene Findings around the neck, on the background of a darkened and peeled
off epidermis, taking the course and pattern of ligature that
The scene was descriptive of an apparently decomposed was already visible at the scene. It carried a fixed atypical
male body, hanging from the branch of a tree amidst a forest knot over left mastoid region and was loose around the neck.
[Figure 1]. The ligature consisted of a pink cotton male parna The neck was slightly compressed. The mouth was wide
[scarf] that was carrying an atypical knot over the left open. The eyeballs were distorted, black and parched. Hyoid
mastoid-occipital region thereby causing a slight neck tilt to bone and laryngeal cartilages were ossified and intact, as well
the right and downwards. Toes of the right foot were just as the tracheal rings. Carotids and jugulars vessels lacked any
touching the ground while the left foot was dangling free in ecchymoses or intimal tears. Cervical vertebrae were intact.
the air. No part of the body was in contact with the tree. The Soft tissues and muscles of neck were free of any blood
deceased was wearing a multicolored checked shirt and a extravasations. The facial skin above ligature was darkened
grayish formal pant which were overstretched while a golden along with changes of partial mummification. Facial features
watch was visible around left wrist. The feet were bare. Scalp were identifiable with difficulty. Oral cavity was full of
hairs were overtly smudged with eggs of flies, primarily over maggots while patches of fungus along with clusters of eggs
the occiput. Flies were settled over the clothes while few of flies were randomly distributed around head and neck.
maggots could be seen over the face. Facial skin was Heavy maggot infestation had created sieve like areas all
seemingly parched, dark reddish to blackish, suggestive of an over the body. Degloving of the hands and feet was present.
incipient or overt mummification. Identification was difficult Slight hemolytic congestion over clavicular periosteal
from facial features alone, although a tattoo mark on the surface of left stern mastoid muscle’s origin was present.
middle front of left forearm turned out to be of immense help. Ventral aspects of intervertebral discs between L1 to L4
As per police information, the surroundings were shaded, lumbar vertebrae depicted dark reddish hemolytic stripes,
warm, and slightly humid having free access of air. The body reminiscent of Simon’s bleeding, while the finding was
was visible through long standing bamboo twigs and plants. missing on upper as well as lower discs [Figure 2].
The four limbs were flexed and abducted apart, due to
gaseous distension.
Overall the scene had an impression of a classical hanging.
A suicide note was recovered from back pocket of his pant,
clearly stating his reasons for giving up life. The spouse
confirmed of the personal possession of ligature by the
deceased.

Figure 2. Dark red hemolytic staining of lumbar intervertebral discs

[reminiscent of Simon’s bleed]; absent in the discs situated above and below.

No additional body injury was present. On the basis of

circumstantial facts and autopsy findings, the cause of death
was given as ante mortem hanging. Toxicology results were
negative.
Upon dental examination, multiple maxillary and
mandibular teeth, especially anterior and majority of the right
posterior, depicted pink tooth phenomenon [Figure 3]. The
Figure 1. Crime scene image showing dead body hanging from a tree with discoloration was more intense over neck and root regions
an atypical knot over left side of the neck along with a right and down tilt. while fading towards on either ends. The available teeth were
Putrefaction is established. Facial skin appears to be mummified. loosened in the sockets and showed considerable attrition
over occlusal surface with exposed dentine.
 Pathology and Laboratory Medicine 2021; 5(1): 1-5 3

3. Discussion
Although the phenomenon of pink teeth has been known
since 1829, when it was first described by Bell, its
application in forensic medicine has been limited [1, 11].
There are several theories to explain the phenomenon of pink
teeth and all of them suggest that the pink color is induced by
the presence of hemoglobin inside the pulp chamber, due to
the accumulation of blood in the cephalic segment [2, 12].
The appearance of pink staining in isolated tooth has been
known in living cases of typhoid fever, porphyria and post-
endodontic procedures [13-15]. The coloration has been
Figure 3. Multiple pink teeth, especially involving anterior and right rows. predominantly found in postmortem cases of asphyxial and
Note the non-pink right maxillary canine and first premolar in between pink other congestive modes of deaths that cause increased
teeth. cephalic venous pressure leading to rupture of vessels and
leakage of blood in the pulp chamber [16, 17].
A dental chart including details of pink teeth has been The occurrence and the long time stability of the pink
prepared [Figure 4]. colour has been attributed to special anatomical conditions of
Additionally, a superficial pink discoloration involving dentin such as the existence of porous structures in the form
nails of bilateral little fingers was found. The finding initially of dentinal tubules in the hard and dense dentin [10]. The
raised the suspicion of a true pink nail phenomenon, but on leakage of hemoglobin or derivatives into the dentinal
closer scrutiny the surfaces were seemingly rough and gritty tubules associated with autolysis, temperature, humidity and
on touch while the discoloration was found to be located the position in which the bodies were found, are considered
superficially [Figure 5]. Furthermore, the colour was easily to assist in the development of pink teeth [2, 18]. Therefore,
scratched and cleaned off by means of a scalpel and absolute they are most often found in drowning asphyxiation [12, 18].
alcohol, thereby revealing it to be the nail paint/varnish. The Mechanical asphyxia by strangulation and hanging
underlying blackish nail bed became clearly visible that was significantly increase the incidence of pink tooth formation,
further confirmed by nail removal. Therebythe pink staining due to blood stagnation in the cephalic segment [7, 11, 12,
of both nails proved to be a simulation rather than a medico- 19].
legally relevant finding. Due to discovery of pink teeth in autopsy cases of deaths
A postmortem interval of 7 to 10 days was opined on the from bleeding gunshot, blunt and sharp injuries as well as
basis of the history and postmortem changes. intoxications, poisonings, negative autopsy and archeological
situations, it has been repeatedly declared as a non-specific
phenomenon [6, 8, 9, 11, 12, 18, 20].
A large amount of blood on account of congestion or
hemorrhage must be present in the pulp chamber in order to
release enough hemoglobin derivatives to penetrate the hard
tissues of the teeth [20]. The phenomenon has been explained
through in vitro studies by using cadaver blood and sectioned
tooth [21]and also by instilling blood and hemolysed
erythrocytes into the pulp chambers [22]. The finding may
Figure 4. Dental chart along with details of pink teeth.
involve from a single to virtually every tooth in the either or
Key: both jaws [22, 23]. The pigmentation is more prominent in
√: Tooth Present; [-]: Tooth missing with absorbed socket the anterior teeth with single roots than the posterior teeth
P+: PTP present; P-: PTP absent with multiple roots [24, 25]. Teeth with cavities are less pink
[PTP: Pink Teeth Phenomenon] than healthy teeth, due to an initial reduction in pulp volume
and subsequent reduced amount of blood in the pulp chamber
[5]. Furthermore completely unstained teeth have been
discovered in between pink teeth [4, 5, 20], even with
anterior teeth unaffected [4]. In our case, right maxillary
canine and first premolar were free of any pink discoloration.
The preferential staining of a few teeth over the other has
been suggested on the basis of dependent position of the head
[20]. The role of a hypostatic phenomenon, although, has
been doubted in a study showing pink discoloration in the
non dependent/contra lateral teeth [4]. In our case, although
Figure 5. Pink nail paint applied over left little finger [right fingernail was to exactly delineate an intravitam congestion [due to venous
also polished], simulating pink nail phenomenon.
4 Pawan Mittal: Post Mortem Pink Teeth and Pseudo Pink Nails in a Case of Suicidal Hanging

occlusion] from the hypostatic process was not possible but been recovered after prolonged post mortem interval, such as
an absence of left sided [posterior] pink teeth suggest putrefied corpses or cases depicting various modifications of
hypostasis to be the predominant process that occurred due to decomposition and their formation is a time dependent
right and downward tilt of the neck. A nearly free hanging phenomenon.
position of the body further points towards an ischemic The non-specificity and the long time stability of the pink
mechanism of death, although it is more of a knot-location discoloration suggests that pink teeth are not completely
dependent phenomenon [26]. In this regard a leading role of uncommon in putrefied corpses.
degree of putrefaction along with atmospheric moisture and
humidity and body position have been proposed as leading 4. Conclusion
factors for the occurrence of pink teeth [2, 16].
Ortmann and Du Chesne have described similar pink In our case, changes of putrefaction in the head, right and
discolorations in the teeth as well as nails of bilateral thumbs dependent neck position favoring hypostatic accumulation of
and left little finger in a putrefied and partially mummified blood, presence of warm and humid surroundings and a
female corpse which was found in a forest and died due to dubiously involved congestive process; all together must
combined effect of trimipramin intoxication, hypothermia have contributed to the formation of pink teeth. The pink
and pneumonia [10]. The application of nail varnish was fingernails finally turned out to be artificially applied nail
ruled out by cleaning them with acetone while the real cause paint; it shall be appropriate to label them as “Pseudo Pink
was demonstrated in the nail beds after removal of the nails. Nails”. A cursory and heedless observation may result in
Furthermore, the subungual tissue did not reveal any CO-Hb mislabeling such artefacts as true pink phenomenon which
by gas chromatography [10]. Our case revealed simulation of may result in legal jeopardize. The postmortem pink teeth
the pink nail phenomenon, an indication furthermore, to and pink nail phenomenon must be studied in order to
anticipate utmost care while dealing with such cases. understand their importance in medico-legal context, as up to
The pink teeth finding has a biological predilection for now their exact relationship with the cause of death is not
young ages where dentinal tubules have a larger diameter in known. Till then we maintain that these are non-specific
comparison to older teeth [5]. Another factor is a constant findings and must not be misinterpreted in medico-legal
reduction in the volume of the pulp and pulp chamber space investigations.
due to the deposition of secondary dentin as the person ages
[27]. Conflicts of Interest
The increased fibrinolytic activity in the pulp chamber in
situations of sudden, unnatural and violent deaths facilitates The author does not have any possible conflicts of interest.
the breakdown of coagulated blood or prevents postmortem
coagulation in the pulp chamber and with the hemolysis of
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