Age estimation by assessment of pulp chamber volume: a Bayesian network for the evaluation of dental evidence.

PURPOSE: The present study aimed to investigate the performance of a Bayesian method in the evaluation of dental age-related evidence collected by means of a geometrical approximation procedure of the pulp chamber volume. Measurement of this volume was based on three-dimensional cone beam computed tomography images. METHODS: The Bayesian method was applied by means of a probabilistic graphical model, namely a Bayesian network. Performance of that method was investigated in terms of accuracy and bias of the decisional outcomes. Influence of an informed elicitation of the prior belief of chronological age was also studied by means of a sensitivity analysis. RESULTS: Outcomes in terms of accuracy were adequate with standard requirements for forensic adult age estimation. Findings also indicated that the Bayesian method does not show a particular tendency towards under- or overestimation of the age variable. Outcomes of the sensitivity analysis showed that results on estimation are improved with a ration elicitation of the prior probabilities of age.

The iliac crest in forensic age estimation: evaluation of three methods in pelvis X-rays.

Age assessment in children and young adults is a relevant forensic issue. It is requested not only in evaluating criminal responsibility in youths without proper identification documents, often in relation to age thresholds, but also for release of a residency permit, and asylum seekers of minors. The analysis of the Risser sign and the iliac crest ossification process has been proposed as a useful tool for forensic age estimation. We evaluated the applicability of three different age estimation methods on a sample of 497 pelvic radiographs of Italian individuals between 10 and 25 years of age. Each method showed high reliability for both reproducibility and repeatability. The staging technique inspired by Kreitner and Kellinghaus methods (KK-MS) is easier than the Risser method in applicability, as it is not affected by the variations of ossification. We observed that all subjects who attained stage 3c of KK-MS and 5 of Risser Fr were >14 years, suggesting the benefits of these methods for that age threshold. The applicability of the area measurement method, inspired by Cameriere's approach, ranged between 12 and 20 years, but the statistical analysis showed only a moderate correlation with age. In order to evaluate the possible use of this approach it is therefore necessary to clarify and exclude external factors influencing the parameter. In conclusion, the iliac crest ossification is of interest in age estimation for forensic purposes. The evaluation of the pelvis X-ray, in addition to the other common dental and skeletal methods, could become a useful supplementary tool in age estimation for the 14 year threshold in order to fulfill forensic-level requirements.

Hemidiaphragm Paralysis after Robotic Prostatectomy: Medical Malpractice or Unforeseeable Event?

The authors present a case of suspected malpractice linked to the onset of hemidiaphragm paralysis after robot-assisted radical prostatectomy (RARP). The approach to the case is shown from a medico-legal point of view. It is demonstrated how, after a thorough review of the literature, this was not a case of medical malpractice but an unforeseeable event. This paper aims at contributing to the very few reports dealing with the onset of hemidiaphragm paralysis after RARP, thus fostering clinical knowledge of these rare events and meanwhile providing useful data for the medico-legal handling in case of alleged negligence of surgeons.

A novel methodology for the objective ascertainment of psychic and existential damage.

Personal injury is a legal term for a physical or psychic injury suffered by the plaintiff under civil and/or tort law. With reference to non-pecuniary damages, the evidence itself of physical and/or psychic injury is not sufficient for damage compensation. The process of ascertaining impairments and/or disabilities which pertain to the "personal sphere" of the individual, such as pain and suffering, loss of amenity, and/or psycho-existential damage, poses particular difficulties in relation to the obtainment of scientific evidence. The "immateriality" and the subjective connotation of the personal sphere are, in themselves, critical issues. The clinical data obtained from the neuropsychological ascertainment find their essential prerequisite in the active participation of the examinee who, in legally relevant contexts (criminal law, civil law, insurance), may be "affected" by personal interests. The present manuscript presents a novel interdisciplinary methodology, experimented on a series of judicial and extra-judicial cases, aimed at the attainment of objectivity and accuracy eligible in relation to the judicial settlement of cases and other matters involving the ascertainment of peculiar aspects of non-pecuniary damage.

Padova Charter on personal injury and damage under civil-tort law : Medico-legal guidelines on methods of ascertainment and criteria of evaluation.

Compensation for personal damage, defined as any pecuniary or non-pecuniary loss causally related to a personal injury under civil-tort law, is strictly based on the local jurisdiction and therefore varies significantly across the world. This manuscript presents the first "International Guidelines on Medico-Legal Methods of Ascertainment and Criteria of Evaluation of Personal Injury and Damage under Civil-Tort Law". This consensus document, which includes a step-by-step illustrated explanation of flow charts articulated in eight sequential steps and a comprehensive description of the ascertainment methodology and the criteria of evaluation, has been developed by an International Working Group composed of juridical and medico-legal experts and adopted as Guidelines by the International Academy of Legal Medicine (IALM).

Age estimation for forensic purposes in Italy: ethical issues.

Age assessment in children and young adults is a relevant medicolegal issue due to the gradual increase of persons devoid of proper identification documents in European countries. Because of the illegal immigration and growing crime rates among children and adolescents, age estimation for forensic purposes is often required. The scientific research and the extensive experience of forensic experts in the last decades focused on the use of radiographic methods addressed to evaluate the degree of skeletal or dental development as the most accurate parameters to estimate the chronological age of children and adolescents. This paper analyzes the ethical issues related to age estimation procedures based on radiographic methods, showing how the ethical principles of beneficence, nonmalevolence, justice, and autonomy may be guaranteed during the execution of the age assessment in forensic practice. The procedure might be conducted in accordance with international guidelines and protocols, though they need a higher homogenization and standardization. A strong collaboration between various scientific societies of professionals (forensic odontologists, forensic pathologists, forensic anthropologist, radiologists, pediatricians, and psychologists), who have been involved in age estimation for years, is needed to reach this goal.

Ethical implications of Italian legislation on 'epilepsy and driving'.

The laws concerning driving licences and epilepsy in different countries are very diverse with regard to the criteria for issuance or renewal of licences, and also the methods of evaluating fitness. In 2011, a law was issued in Italy implementing the European directives on driving licences, including provisions for mandatory notification that a driver is epileptic. This was established regardless of the European rules that require compulsory notification only of patients. The Federation of Italian Boards of Physicians has made recommendations against mandated physician reporting, resulting in a current confusion between legal and ethical recommendations to medical doctors. The mandatory notification enacted by Italian law raises ethical concerns about disparities in access to care and possible violations of the right to confidentiality of patient information. Moreover, the law discussed here fails to emphasise the importance of physicians ensuring compliance by the patient, by sharing the correct information about the risks associated with illegal driving and by obtaining information from the patient through regular check-ups. An urgent revision of the law is required to implement the duty of the physician to provide information and to ensure that the rule about mandatory notification should be erased in favour of optional self-reporting by epileptics as the preferred way to notify the licensing authority. The implementation of these measures could correct the dichotomy between the law and the ethical recommendations for medical doctors and protect the rights of people with epilepsy as well as those of any other patients whose pathology or impairment could imply a risk to the community.

An unusual case of incaprettamento.

Incaprettamento is a ritual strangulation that represents a method of homicide typical of the Italian Mafia. While the victim is in the prone position, he/she is bound by one end of a rope, creating a slipknot around the throat, while the other end is used to tie the limbs behind the back. Forensic investigations reveal that in most cases, the binding of the extremities and the positioning of the victim are carried out after death due to others means and are intended to hold somebody in contempt and to punish betrayers. When the victim is tied while alive, the death is caused by self-strangulation because it is impossible to maintain the legs in this forced position. Here, we describe in detail a case with a lot of similarities to incaprettamento, although we define it as atypical because of the unusual methods of the actual binding and the circumstances in which death occurred. In fact, the investigation of the crime scene, the external and internal findings, and the histologic examination result show that this is a crime of passion.

Trends in endodontic claims in Italy.

According to the scant data available in the literature, endodontic claims are common among dental professional liability cases and the second most common type of claim. This study aimed to describe the characteristics of endodontic claims in Italy and the most frequently disputed errors, and the discussion below includes consideration of ethical and medico-legal aspects thereof. We retrospectively analysed 120 technical reports written on cases of professional malpractice in endodontics in the last 5 years. The complainant patients were males in 22.5% of the cases, while females made up the remaining 77.5%. In the dentist sample, male operators were more often involved in litigation cases (80%) than female operators. The most frequently claimed technical errors were: lack of a complete filling of root canal/s (71.7%), the perforation of tooth structure (12.7%), extrusion of sealing materials beyond the apex of the tooth (9.6%) and the fracture of an endodontic instrument (5.9%). In 1.7% of cases it was found that the expert did not make any errors performing the endodontic therapy. In only very few cases (2.7%) no therapy was considered necessary, while the most common therapeutic solution involved in endodontic misconduct was tooth extraction (53.0%). In many cases the dentist preferred to extract the endodontically undertreated tooth and substitute it prosthetically rather than trying to re-treat it. The discrepancy between the total number of cases examined and those that eventually go to court leads us to believe that the majority of endodontic malpractice cases are resolved in out-of-court settlements.

Pulmonary Cement Embolism After Kyphoplasty.

Pulmonary polymethylmethacrylate (PMMA) cement embolism after kyphoplasty (KP) surgery is a quite frequent event as well as the pulmonary embolization of central venous catheter fragment. This report shows the case of a subject who, after KP, developed pulmonary embolism and who underwent thoracic surgery. After hospital discharge, the subject advanced a claim for damages toward the hospital where he was operated, complaining sensation of tenderness at the chest surgical scar and esthetic damage. To understand the nature of the embolism (either central venous catheter fragment or cement), chemical investigations were then ordered. Spectrometry identified the PMMA cement used for KP. When doubts rise about the origin of the embolized material, chemical investigations may reveal important data not only for clinical but also for forensic purposes.

Combining dental and skeletal evidence in age classification: Pilot study in a sample of Italian sub-adults.

BACKGROUND: Dental and skeletal maturation have proved to be reliable evidence for estimating age of children and prior studies and internationally accredited guidelines recommend to evaluate both evidence in the same subject to reduce error in age prediction. Nevertheless the ethical and legal justification of procedures that imply a double exposition of children stands as a relevant issue. This study aims to evaluate the accuracy of age estimation provided by a combination of skeletal and dental methods applied in the same sample of children. MATERIALS AND METHODS: The sample consisted of 274 orthopantomographies and left hand-wrist X-rays of Italian children, (aged between 6 and 17years) taken on the same day. Greulich and Pyle's (GP), Tanner-Whitehouse's version 3 (TW3) and Willems' (W) and the Demirjian's (D) methods were respectively applied for estimating skeletal and dental age. A combination of skeletal and dental age estimates through Linear Discriminant Analysis (LDA) is proposed to obtain a classifier respect to an age threshold. RESULTS: The combination of D and TW3 obtained an improvement of accuracy in classifying female subjects respect to the 12years threshold respect to the original methods (from about 77% using either original methods to 83.3% combining TW3+D) as well as a consistent reduction of false positives rate (from 17% to 21% for original methods to 5.6% with TW3+D). For males the LDA classifier (based on TW3 and W) enable a small improvement in accuracy, whilst the decreasing of false positives was as noticeable as for females (from 17.6 to 14.1% for original methods to 6.2% combining TW3+W). CONCLUSIONS: Although the study is influenced by the limited size and the uneven age distribution of the sample, the present findings support the conclusion that age assessment procedures based on both dental and skeletal age estimation can improve the accuracy and reduce the occurrence of false positives.

Comparison of the diagnostic accuracy, sensitivity and specificity of four odontological methods for age evaluation in Italian children at the age threshold of 14 years using ROC curves.

The age threshold of 14 years is relevant in Italy as the minimum age for criminal responsibility. It is of utmost importance to evaluate the diagnostic accuracy of every odontological method for age evaluation considering the sensitivity, or the ability to estimate the true positive cases, and the specificity, or the ability to estimate the true negative cases. The research aims to compare the specificity and sensitivity of four commonly adopted methods of dental age estimation - Demirjian, Haavikko, Willems and Cameriere - in a sample of Italian children aged between 11 and 16 years, with an age threshold of 14 years, using receiver operating characteristic curves and the area under the curve (AUC). In addition, new decision criteria are developed to increase the accuracy of the methods. Among the four odontological methods for age estimation adopted in the research, the Cameriere method showed the highest AUC in both female and male cohorts. The Cameriere method shows a high degree of accuracy at the age threshold of 14 years. To adopt the Cameriere method to estimate the 14-year age threshold more accurately, however, it is suggested - according to the Youden index - that the decision criterion be set at the lower value of 12.928 for females and 13.258 years for males, obtaining a sensitivity of 85% and specificity of 88% in females, and a sensitivity of 77% and specificity of 92% in males. If a specificity level >90% is needed, the cut-off point should be set at 12.959 years (82% sensitivity) for females.

Dental Ritual Mutilations and Forensic Odontologist Practice: a Review of the Literature.

BACKGROUND: Ethnic mutilations have a social and anthropological significance both in contemporary and past human behavior, influenced by geographic, religious and cultural factors which can greatly help forensic odontologist's practice in dental profiling process.Dental ritual mutilations and dental decorations were - and still are - practiced among many ethnic groups and cultures. Throughout the history of humanity, having healthy teeth has a symbolic meaning of youth, beauty and strength, but it can also have other meanings.Dental ritual mutilations were documented in many cultures in the past and were practiced mainly for religious rituals purposes, for esthetic reasons and because they represented a symbol of status or of belonging to a particular social group. Similar rituals are still performed. MATERIAL AND METHOD: The present paper is a systematic review of the literature reporting on dental ritual mutilations from the early 1960s and is included in Pubmed, Scopus and Googlescholar. The research was deliberately limited only to the ritual mutilations, which can be defined as "any irreversible impairment of the integrity of the human organism, made with a ritual purpose and without any curative aim". Therefore all the articles dealing with single or multiple dental self extractions of psychotic origins were excluded, as well as the infant oral mutilations, since the practice is deemed to have therapeutical effects among ethnic groups dedited to this practice. CONCLUSIONS: The knowledge of dental alteration due to oral mutilations can be a powerful tool for the identification procedures of living or dead persons or even in human remains especially providing relevant information about the ethnic origins and the cultural background of a subject. Some medical legal issues for the odontologist about dental mutilation are also addressed in the paper.

A new age estimation procedure based on the 3D CBCT study of the pulp cavity and hard tissues of the teeth for forensic purposes: A pilot study.

BACKGROUND: Dental age of adults can be estimated by the analysis of the progressive physiological and degenerative phenomena which affect dental tissues. The pulp-dentinal complex is one of the dental structures that show modifications related to age, mainly resulting in the reduction of the pulp chamber volume due to the continual deposition of secondary dentin. The study aims to evaluate the accuracy of a simple and conservative method for estimating the age of adults based on CBCT (Cone Beam Computed Tomography) analysis of the narrowing of the pulp chamber caused by secondary dentin deposition. MATERIALS AND METHODS: Two operators have randomly analyzed 148 CBCT (Scanora 3D - Soredex) and considered the upper left central incisor. The sample consists of 57 male individuals and 91 females aged between 10 and 80 years. This research was designed to simplify dental volume measurement through geometric approximation of the different parts of the tooth. The root and the pulp were assimilated to elliptical based cones and the crown to an elliptical based truncated cone and these volumes were calculated through measurements using Osirix(®) software (OnDemand 3D software CyberMed Inc.). The ratio between the pulp volume and the hard tissues volume (PHr) was assumed as a variable according to the following formula: PHr = V pulp/V ht. The proposed method based on geometric approximation of dental volumes was validated comparing volumes calculated using CBCT with physical measurements of real volumes of 3 teeth. RESULTS: The physical measurements revealed that the measurement procedures using CBCT produce a regular underestimation of real volumes, that ranges from 53% to 70%. Since the error occurs quite regularly both for pulp and for hard tissue volume, it tends to be eliminated when their ratio is considered. The PHr was statistically significant (p-value < 0.001) as a predictor for age estimation. The gender variable was not significantly correlated with age (p = 0.7694) and it was, therefore, excluded from the linear regression formula for age estimation: Age = -64.14 - 32.00*Ln PHr. The age cohorts between 30 to 59 years showed the highest accuracy in age prediction (residual errors 0.71, 2.88, and -5.86 years), whilst for other age cohorts the estimation error is similarly reported by applying other dental methods. CONCLUSION: The outcomes of this pilot study show that the narrowing of the pulp chamber is a reliable parameter for estimating the age of adults, and that CBCT is an easy and conservative approach that allows accurate calculation of tooth volumes. The proposed approach based on geometric approximation of upper central incisor volumes measured by CBCT remarkably reduced the operating time in comparison to other more complex and expensive techniques. The validation procedure in which real volumes are compared with those calculated using CBCT supports the accuracy of the experimented approach and the good inter-examiner agreement (ICC 0.99) demonstrates that the method is highly reproducible.

The Claims Management Committees trial: experience of an Italian hospital of the National Health System.

INTRODUCTION: In Italy, health care is mainly financed by earmarked central and regional taxes, with regions receiving their allocated share of resources from the National Health Fund. The Council of the Tuscany Region in 2009 began an experimentation aimed to enforce the extrajudicial conciliation. The Council established the Claims Management Committees (CMC) for civil liability in the Tuscan Health Service. The CMC trial provides that the damages are compensated directly by the hospital, removing the cost of liability insurance. The aim of this study is to collect and compare the liability-insurance-period and the CMC trial-period. MATERIALS AND METHODS: Data were derived from the management claims database of the Health Directorate of the Careggi Hospital in Florence between 2006 and 2012. Two main periods are considered for the comparison of data: 2006-2007-2008 during the insurance management and 2010-2011-2012 during the CMC trial. RESULTS: During the insurance management period, the total expenditure was equal to the €14,846,334.44 paid in the 3-year period. The total expenditure during the CMC trial 3-years period was equal to €7.076.370,75. Under the CMC management, we observed a marked decrease in the recourse to legal action in the face of a substantial maintenance of the number of claims opened for each year. The CMC trial showed a greater speed in setting claims for damages. DISCUSSION AND CONCLUSIONS: Under CMC management, a greater and more diligent efficiency is matched by a lower economic outlay. The use of the direct management of damage compensation may be an important tool for risk management, thus guaranteeing the recourse to targeted and appropriate interventions.

Skeletal age estimation for forensic purposes: A comparison of GP, TW2 and TW3 methods on an Italian sample.

BACKGROUND: Paediatricians, radiologists, anthropologists and medico-legal specialists are often called as experts in order to provide age estimation (AE) for forensic purposes. The literature recommends performing the X-rays of the left hand and wrist (HW-XR) for skeletal age estimation. The method most frequently employed is the Greulich and Pyle (GP) method. In addition, the so-called bone-specific techniques are also applied including the method of Tanner Whitehouse (TW) in the latest versions TW2 and TW3. AIM: To compare skeletal age and chronological age in a large sample of children and adolescents using GP, TW2 and TW3 methods in order to establish which of these is the most reliable for forensic purposes. MATERIAL AND METHODS: The sample consisted of 307 HW-XRs of Italian children or adolescents, 145 females and 162 males aged between 6 and 20 years. The radiographies were scored according to the GP, TW2RUS and TW3RUS methods by one investigator. The results' reliability was assessed using intraclass correlation coefficient. Wilcoxon signed-rank test and Student t-test were performed to search for significant differences between skeletal and chronological ages. RESULTS: The distributions of the differences between estimated and chronological age, by means of boxplots, show how median differences for TW3 and GP methods are generally very close to 0. Hypothesis tests' results were obtained, with respect to the sex, both for the entire group of individuals and people grouped by age. Results show no significant differences among estimated and chronological age for TW3 and, to a lesser extent, GP. The TW2 proved to be the worst of the three methods. CONCLUSIONS: Our results support the conclusion that the TW2 method is not reliable for AE for forensic purpose. The GP and TW3 methods have proved to be reliable in males. For females, the best method was found to be TW3. When performing forensic age estimation in subjects around 14 years of age, it could be advisable to use and associate the TW3 and GP methods.

Comparison of the applicability of four odontological methods for age estimation of the 14 years legal threshold in a sample of Italian adolescents.

The 14-years age threshold is especially important in Italy for criminal, civil and administrative laws. Several methods relying on dental calcification of the teeth, up to the second molar, are used for the evaluation of age in childhood. The objective of the research was to compare the inter-rater agreement and accuracy of four common methods for the dental age estimation - Demirjian (D), Willems (W), Cameriere (C) and Haavikko (H) - in a sample of Italian adolescents between 11 and 16 years. The sensitivity and specificity, and the different level of probability, according to the peculiarities of Italian criminal and civil law, were compared for the methods examined, considering the threshold of 14 years. The sample was composed of 501 digital OPGs of Italian children (257 females and 244 males), aged from 11 years and 0 days to 15 years and 364 days. The maturation stage of the teeth was evaluated according to D, W, H and C methods by three independent examiners. Mixed statistical models were applied to compare the accuracy and the errors of each method. The inter-rater agreement was high for the four methods and the intraclass correlation coefficients were all ≥ 0.81. Methods H and C showed a general tendency to underestimate the age in the considered sample while the methods D and W tended to overestimate the child's age. In females, D and W were more accurate than C, which is more accurate than H. In the males, W is the most accurate method even though it over-estimated age. Considering the 14-years threshold, the sensitivity of D and W methods is quite high (range 0.80; 0.95) and specificity is low (range 0.61; 0.86). The principal findings of the research are: the W and D methods are much more accurate than C and H, but they tend to overestimate the age. The C method largely underestimates the age (by ~1 year) for both genders and for all operators. H is unsuitable for dental age estimation in the Italian population, while W and D yielded high sensitivity but low specificity, thus producing high rates of false positive results. The choice of method to estimate if an Italian child has reached the 14-years legal threshold should mainly be chosen according to the different legal milieu (if civil or criminal) and the gender of the examined individual. The age assessment in criminal case must be prudently managed.

Dental identification by comparison of antemortem and postmortem dental radiographs: influence of operator qualifications and cognitive bias.

Dental forensic identifications based on comparison of antemortem and postmortem radiographs provide effective and reliable evidence. There are no standardized procedures for assessing similarities between different types of dental radiographs (e.g. orthopantomograms, bitewings, and periapical radiographs), and the operator's subjective judgment can considerably affect identification. The purpose of this study is to evaluate the potential influence of experts' qualifications, training, and cognitive bias on the accuracy of identification. Seventy-eight differently qualified and experienced experts underwent an identification test. The expert sample was composed of 10 specialists in emergency care (ER), 10 specialists in legal medicine (ML), 20 pregraduate dental students (STU), 12 dentists (DENT), 20 dentists educated in forensic odontology (DENT-TRA), and 6 experienced forensic odontologists (FOR). The simulated cases required participants to assess the possible matching of 42 postmortem intraoral radiographs with 16 antemortem panoramic radiographs. Accuracy and specificity for the different operator groups were as follows: ER, 0.76-0.70; ML, 0.76-0.88; STU, 0.89-0.82; DENT, 0.87-0.97; DENT-TRA, 0.88-0.92; and FOR, 0.97-1. As evidenced by high rates of accuracy and repeatability, the most experienced forensic odontologist consistently outperformed operators less or differently educated and trained, especially for difficult cases. In our sample, the dentists who received additional education in forensic odontology did not necessarily perform better than dentists who had not received this additional education. Some cognitive bias, mainly the so-called observer effect, emerged as a possible source of outcome variability among the operator groups.

Techniques of dental DNA extraction: Some operative experiences.

This study presents and discusses the possibility of multiple dental DNA extraction at different times using an endodontic technique. We chose a mixed sample of twenty teeth (decayed, filled, different kinds of teeth, etc.) and performed two different accesses to the pulp cavity to collect samples of dental tissue useful for DNA extraction. The Identifiler(®) and Minifiler(®) kits were used respectively for the first and second genetic analysis. The research's most relevant findings are the possibility of successfully repeating dental DNA extractions, and that a dental element can be considered as a DNA source that can be reused even after prolonged time elapses. The study's results document a simple and efficient methodology for dental identification based on the choice of dental elements, endodontic techniques and the use of the Minifiler(®) kit for genetic analysis.