Dental age estimation methods applied to Indian children and adolescents: A systematic review and meta-analysis

Country-specific systematic reviews and meta-analyses have been proposed to compile the available literature and rank methods based on their performance for a target population. India is a country with a vast scientific literature on dental age estimation. This systematic review aimed to provide evidence to help the decision of experts regarding the method of choice for dental age estimation in India. The research protocol was registered in Open Science Framework. Literature Search was performed in Embase, LILACS, MedLine (via PubMed), SciELO, Scopus and Web of Science. Grey Literature was searched in Google Scholar and ProQuest. Observational cross-sectional studies that compared chronological and estimated ages using Demirjian (original [DEM] and Chaillet's modification [modified-DEM]) and Acharya (ACH) methods were included. JBI tool was used to assess the risk of bias. The search detected 9799 studies, out of which 56 were eligible (n=13,107 panoramic radiographs of Indian individuals). Low risk of bias was registered for 48 studies, while 8 presented a moderate risk of bias. The meta-analysis showed a standardized mean difference between chronological and estimated ages of -0.11 (95%CI: -0.29; 0.07), 0.74 (95%CI: 0.39; 1.09), and -0.01 (95%CI: -0.23; 0.22) years for DEM, modified-DEM and ACH, respectively. High heterogeneity (I2=88-93%) was observed across studies for all the methods, including subgroup analyses based on sex. This study ranked ACH, DEM and modified-DEM (from the best to the worse) performances in the Indian population.

Radiographic morphology of canines tested for sexual dimorphism via convolutional-neural-network-based artificial intelligence

The permanent left mandibular canines have been used for sexual dimorphism when human identification is necessary. Controversy remains whether the morphology of these teeth is actually useful to distinguish males and females. This study aimed to assess the sexual dimorphism of canines by means of a pioneering artificial intelligence approach to this end. A sample of 13,046 teeth radiographically registered from 5838 males and 7208 females between the ages of 6 and 22.99 years was collected. The images were annotated using Darwin V7 software. DenseNet121 was used and tested based on binary answers regarding the sex (male or female) of the individuals for 17 age categories of one year each (i.e. 6-6.99, 7.7.99… 22.22.99). Accuracy rates, receiver operating characteristic (ROC) curves and confusion matrices were used to quantify and express the artificial intelligence's classification performance. The accuracy rates across age categories were between 57-76% (mean: 68%±5%). The area under the curve (AUC) of the ROC analysis was between 0.58 and 0.77. The best performances were observed around the age of 12 years, while the worst were around the age of 7 years. The morphological analysis of canines for sex estimation should be restricted and allowed in practice only when other sources of dimorphic anatomic features are not available.

Applying artificial intelligence to determination of legal age of majority from radiographic data

Forensic odontologists use biological patterns to estimate chronological age for the judicial system. The age of majority is a legally significant period with a limited set of reliable oral landmarks. Currently, experts rely on the questionable development of third molars to assess whether litigants can be prosecuted as legal adults. Identification of new and novel patterns may illuminate features more dependably indicative of chronological age, which have, until now, remained unseen. Unfortunately, biased perceptions and limited cognitive capacity compromise the ability of researchers to notice new patterns. The present study demonstrates how artificial intelligence can break through identification barriers and generate new estimation modalities. A convolutional neural network was trained with 4003 panoramic-radiographs to sort subjects into 'under-18' and 'over-18' age categories. The resultant architecture identified legal adults with a high predictive accuracy equally balanced between precision, specificity and recall. Moving forward, AI-based methods could improve courtroom efficiency, stand as automated assessment methods and contribute to our understanding of biological ageing.

Effect of impaction on third molar development and age estimation-A study in a Lebanese population

BACKGROUND

The effect of impaction on third molar development is disputable as the scientific literature is not uniform. In parallel, population-specific studies have been encouraged in dental age estimation. This study aimed to investigate the effect of impaction on third molar formation in a sample of Lebanese individuals.

MATERIALS AND METHODS

The sample consisted of 518 panoramic radiographs of females (n=229) and males (n=289) between 15 and 23.9 years. Mandibular third molars were classified based on their position as non-impacted and impacted (with horizontal, vertical, mesioangular, and distoangular impaction). Dental development was classified according to Demirjian's 8-level staging system.

RESULTS

Most teeth presented mesioangular impaction (#38=29.7%, #48=33%). Developing third molars were predominantly distributed between stages D and G. The mean age of most developmental stages was higher among impacted teeth, meaning that third molar mineralization could be slower in the presence of impaction. In general, the delayed dental development did not have statistically significant effects (P<0.05). However, descriptive data pointed out differences between (impacted and non-impacted) mean ages of >12 months-suggesting a potential clinical significance (despite the lack of a statistical one). Furthermore, differences changed based on sex and side (#38/#48).

CONCLUSION

Therefore, dental age estimation from third molars in the selected Lebanese population should preferably be performed in non-impacted third molars whenever available.

Ear identification: A multi-ethnic study sample

The external human ear is considered to be highly variable among individuals. Hence, forensic applications could be explored for human identification. This research compares the usefulness of Cameriere's ear identification method, in samples originating from six different countries (Brazil, India, Japan, Russia, South Africa and Turkey) in order to examine possible differences in their accuracy values. A sample of 2,225 photographs of the external human ear (1,134 left and 1,091 right ears) from 1,411 individuals (633 females and 778 males) was collected. The samples included healthy subjects with no systemic disorders and without any craniofacial trauma, maxillofacial abnormalities, auricular anomalies, ear diseases or previous auricular surgery. Cameriere's ear identification method was applied and measurements were performed on the images of each ear, considering four anatomic regions: helix, antihelix, concha, and lobe. The quantified measurement values were converted into a proposed coded number system. A search for identical codes was accomplished to find out the distinctiveness of the morphology of the human ear. The combined codes of left and right ears of each of the 814 subjects were not repeated in this multi-ethnic study sample. Dirichlet's distribution and the inherent study equation showed that the probability of two different individuals having the same code (false-positive identification) was found to be <0.0007. Because of the distinctive metrics of the ratios of external human ears, studies with Cameriere's ear identification method may be valuable for human identification. Studying the differences between the left and right ears of the same individual and across different ethnic groups could contribute to the development of supplementary tools for human identification.

Assessing higher education students' critical thinking with the PENCRISAL test - Portuguese short version: a psychometric study

The development of critical thinking in higher education is fundamental, preparing students to think well, find explanations, make decisions and solve problems. Given the importance of its promotion, its assessment is crucial, since the two are inseparable. Moreover, the number of instruments that are validated to assess critical thinking in the Portuguese language and culture are scarce. We present the validation psychometric study of the PENCRISAL test (short version) to the Portuguese language, a critical thinking assessment test for higher education students, designed and validated in Spain (full and short version), which presents adequate reliability and validity psychometric characteristics to assess key-dimensions of critical thinking. A sample of 225 Portuguese higher education students from three universities (two public and one private) performed a reduced version of the PANCRISAL test. The results obtained allowed replicating the Spanish reduced version in Portugal (only changing one of the six items), and the confirmatory factorial analysis permits to identify two factors intercorrelated, legitimizing the combination of the six items in a global score. This short version can be used as a screening test, and its potential is pointed out to assess students critical thinking to support teaching and research in higher education.

Anatomy of the mastoid triangle and morphometric sex differences

OBJECTIVE OF THE STUDY

This study aimed to quantify the area of the mastoid triangle (MT) and assess potential morphometric differences between males and females.

PATIENTS

The sample consisted of 244 dry human skulls, with biological sex known based on genetic analysis, collected from a medicolegal osteological database from Central-Western Brazil.

MATERIALS AND METHODS

The study was observational, analytical, and cross-sectional. The skulls were analyzed using Heron's equation to calculate the area of the MT. The landmarks connecting each of the sides of the triangle were: Porion (Po)>Mastoidale (Ma)>Asterion (Ast). Morphometric references were calculated and compared based on sex.

RESULTS

The area of the MT was nearly 14% larger in males compared to females (p<0.05). The mean MT area for the right and left sides of males were 684.11±93.25mm² and 668.94±111.95mm², respectively. In females, the mean MT for the right and left sides were 588.93±91.09mm² and 582.88±102.98mm², respectively. Right and left side measurements were significantly different (p<0.05), except for Po-Ast (p=0.232).

CONCLUSION

Morphometric features regarding the MT were slightly different between males and females. Application of the MT as a dimorphic tool should be adjuvant. Moreover, this tool should be considered carefully, especially because the sex-based differences were statistically significant, but discrete between males and females.

30 years of the ABFO study: Reproduction in a Brazilian sample

The ABFO study on third molar development is a benchmark in the scientific literature of dental age estimation. In its 30th anniversary, the study has been reproduced in the present external validation. Standardized comparative outcomes were obtained and discussed across studies. The sample consisted of 1.087 panoramic radiographs of Brazilian females (n=542, 49.87%) and males (n=545, 50.13%) between 14 and 22.9 years. All available third molars were classified into developmental stages following Mincer's adaptation of Demirjian's system (8 sequential stages, from A to H). The mean chronological age of individuals within each stage was assessed. The probability of an individual being ≥ 18 years was calculated for each third molar, sex and stage. Maxillary and mandibular third molars showed a similar development with an agreement between stages of about 90%. In general, males developed 0.5 years (6 months) earlier than females. The probability of being an adult increased considerably when at least one third molar is in stage G. Maxillary third molars had higher coefficients of determination (right: 0.704; left: 0.702), showing that statistical models with these teeth could explain better the age estimation outcomes. The reproducibility of the ABFO study on third molar development led to reference tables and probability measures for the studied Brazilian population.

Intersection of forensic odontology and psychology

Forensic odontologists are expected to deal with challenging demands which can affect their mental health while dealing with forensic activities. This study aimed to explore the psychological impacts of forensic activities on forensic odontologists and students undertaking training. Firstly, it of an integrative review (part I) on the psychological effects of forensic odontology practice. The review was performed on Scopus, Medline and Web of Science. Next, an anonymous online survey using JISC Online Surveys tool (part II) was performed to assess the inherent opinions of forensic odontologists from the the International Organization for Forensic Odonto-Stomatology (IOFOS), and Association of Forensic Odontologists for Human Rights (AFOHR), and Dentify.me. Results were quantitatively evaluated by means of descriptive statistics and qualitatively upon reflection using Microsoft Office Excel (2010). Part I, only one full-text article out of 2235 (Webb et al., 2002) was found eligible indicating a low number of eligible studies. Part II, 75 forensic odontologists and 26 students (49.9% male; 50.5% female) from over 35 countries participated. Results showed that forensic dentists are more psychologically or emotionally affected by child abuse cases and least affected by age estimation cases. Most experienced forensic odontologists reported the lowest scores of discomforts. Males were more comfortable than women in dealing with stress. 80.77% (n= 21) of the students have not experienced any behavioural changes following mortuary sessions but 19.2% (n= 5) witnessed stress. All respondents support the inclusion of a module in Psychology or stress management in training programmes in Forensic Odontology. Suggestions to maintain mental health are considered by the respondents and topics to be taught suggested by a psychologist.

Age-at-death assessed with Lamendin's original and population-specific models in a modern Brazilian osteological collection

BACKGROUND

Estimating the age at death is a common procedure in the fields of forensic human identification and anthropological/archaeological investigations. Root translucency and periodontosis are regressive parameters used to estimate the age of adults, more specifically in Lamendin's method - established in 1992 in a French population. This study aimed to test the applicability and validity of Lamendin's method in a Brazilian osteological collection.

METHODS

The sample consisted of 74 single-rooted teeth obtained from 50 skeletal remains (mean age: 53.20 ± 16.17 years) from Southeast Brazil. Lamendin's method was applied to enable a comparison between chronological (CA) and estimated ages (EA). A new population-specific equation was designed for the studied sample and the outcomes were compared with those obtained with Lamendin's original equation.

RESULTS

The original methods led to a general underestimation of 11.32 years (8.83 years in males and 15.91 years in females). The method had a better performance among individuals between 40 and 59 years (mean differences between CA and EA: 4.8 years). The population-specific equation led to a mean overestimation of -2.04 years in males, and a mean underestimation of 3.77 years in females. Underestimations were considerably higher in other age groups.

CONCLUSION

Despite the apparent improvements, both the original and the population-specific equations revealed coefficients of concordance that were constantly low between CA and EA. These outcomes suggest restrictions to the application of Lamendin's method in the forensic field, especially for human identification. The method, however, seems to be applicable for anthropological/archaeological applications.

MDMA-Assisted Therapy for Treatment-Resistant Posttraumatic Stress Disorder (PTSD) – One step further toward a patient-centered treatment pathway

Introduction

PTSD is a chronic, debilitating condition with limited treatment efficacy. Accessing traumatic memories often leads to overwhelming distress, impacting treatment process. Current approved pharmacological treatments have exhibited small to moderate effects when compared with placebo. Evidence suggests 3,4,-methylene-dioxymethamphetamine(MDMA)-assisted psychotherapy as a viable option for refractory PTSD.

Objectives

Comprehensive review of early clinical research, proposed mechanisms, safety and emerging therapeutic models.

Methods

Eligible studies will be identified through strategic search of MEDLINE.

Results

Pre-clinical and imaging studies suggest memory reconsolidation and fear extinction as candidate psychological and neurological mechanisms, involving MDMA’s combined effects of increasing serotonergic activity, as well the release of oxytocin and brain-derived neurotrophic factor in key memory and emotional circuits. Resulting reduction in amygdala and insula activation and increasing connectivity between the amygdala and hippocampus may create a “tolerance window” of neuroplasticity for emotional engagement and reprocessing of traumatic memories during psychotherapy. Early clinical trials report impressive and durable reduction in PTSD symptoms, with a safety profile comparable to that of SSRIs. A recently completed randomized, double-blind, placebo-controlled phase 3 trial reported full remission of PTSD symptoms in 67% of patients at 2 months, with no increase in suicidality, cardiovascular events or abuse behavior. Emerging treatment models underline the importance of unmedicated therapeutic sessions for preparation for the experience and subsequent integration as essential for full benefit and safety of the clinical context.

Conclusions

The psychological impact associated with the COVID-19 pandemic is an reminder of the emotional and economic burden associated with PTSD. MDMA-assisted therapy may be a breakthrough approach meriting further multidisciplinary investment and clinical research.

Disclosure

No significant relationships.

Use of non-clinical smile images for human identification: a systematic review

Human identification using Forensic Dentistry occurs through comparative analysis of ante-mortem (AM) and post-mortem (PM) data. With the constant improvement of technology, photographs became a common source of AM data. When clinical dental records are not available, images showing the smile can be useful in human identification. The aim of this study was to investigate human identification techniques through the analysis of smile images in the available literature. Studies on human identification through the analysis of smile images were searched in the scientific literature. The search resulted in 4,043 studies. After screening, 14 studies were considered eligible. Eleven were case reports, two were pilot studies and one a technical note. From the eligible studies, in addition to the methodological data, information about the sample, used techniques and results regarding human identification were extracted. Three techniques were detected: direct comparison of morphological characteristics, AM/PM image overlap, and the analysis of smile lines. One or more associated techniques were used for human identification. Authors highlighted as a common limitation of the techniques the quality of the available images, the difficulty in reproducing PM the same images AM, and the eventual image modifications performed by the victim before posting in social media. Advantages included the low-cost aspect of the technique, as well as a potential fast and accurate procedure (depending on the quantity and quality of evidence). In general, studies considered the technique useful and adjuvant for human identification.

Non-accidental head and neck injuries in children and adolescents

Child abuse or maltreatment has been a global problem and research shows that more than half of the cases present with head and neck injuries. This study aimed to propose an online referencing platform for dental professionals to know more about signs of child abuse and neglect (CAN) and how suspicious head and neck injuries might look like in real-life scenarios by proposing a 3D design. The study was divided into two parts: i) Integrative literature review, ii) Survey. The first part included an integrative literature review to check if there are enough publications by dentists containing real-life images of injuries related to CAN. Using appropriate keywords and searching across four well-known databases 264 publications relevant to CAN were found, of which, only 3 contained real-life images. Part II of the study included a JISC online survey, consisting of two sections, amongst general dentists, pediatric and forensic dentists. The first section of the survey was about the basic knowledge related to CAN management. A total of 61 dentists from 10 different countries filled the survey, of which 83.1% had seen common head and neck injuries involved in CAN, 61% knew about the dentist's role in reporting such cases, and 66.1% were familiar with local law enforcements to contact. The second section of the survey involved going through real-life scenarios to check the participants understanding of how to tackle a real-life case concluding that only 4-10 participants managed to figure the aspects vital to check before reporting such cases which include a proper detailed history, any previous injuries and their stage of progression, clinical examination of injuries and finally whether the injuries are consistent with the history given. To conclude, there is insufficient representation of the real-life head and neck injuries for dentists to see related to child abuse. Also, all specialists agreed that they require further training regarding CAN management with real-life examples. To address this, a 3d model of commonly seen head and neck injuries in CAN along with some other tools, was created for training and educational purposes and was embedded in a website https://3datlasofchildabuse.webflow.io/.