Rashan­da Mc Ken­na

Med­ical pro­tag­o­nist, Dr Kevin Moze, is set to make a huge con­tri­bu­tion to the den­tal in­dus­try in T&T. Moze is the first den­tal and max­illo­fa­cial ra­di­ol­o­gist of Trinida­di­an ori­gin, and his ex­per­tise is crit­i­cal for fill­ing the gaps with­in the health­care sys­tem.

As a den­tist, he treats with the di­ag­no­sis of oro-fa­cial dis­ease and the ear­ly de­tec­tion of le­sions. As a ra­di­ol­o­gist, he de­ci­phers the na­ture of cer­tain le­sions and con­di­tions, dis­cerns whether they may be be­nign or ma­lig­nant tu­mours, de­vel­op­men­tal or in­flam­ma­to­ry odon­to­genic and non odon­to­genic, and in­ter­prets frac­tures of the oro­fa­cial re­gion.

Moze is al­so a lec­tur­er in oral ra­di­ol­o­gy at the Uni­ver­si­ty of the West In­dies' (UWI) School of Den­tistry (SoD). He forms part of a den­tal age as­sess­ment group in Trinidad and To­ba­go and he al­so works in con­junc­tion with the Den­tal Age Re­search Lon­don In­for­ma­tion Group (DAR­LInG).

In his ca­pac­i­ty as re­searcher, Moze was re­cent­ly pub­lished in the In­ter­na­tion­al Jour­nal of Foren­sic and Le­gal Med­i­cine. This lat­est re­search sought to as­sess and doc­u­ment the mean ages of at­tain­ment for the var­i­ous tooth de­vel­op­men­tal stages (TDS) in eth­nic spe­cif­ic Afro-Trinida­di­an chil­dren, ado­les­cents and emerg­ing adults of known chrono­log­i­cal age. These mean ages of at­tain­ment for the var­i­ous TDS have been or­gan­ised to de­vel­op a ref­er­ence da­ta set par­ti­tioned by eth­nic­i­ty and gen­der.

This is the first time a data­base was de­vel­oped to sci­en­tif­i­cal­ly es­ti­mate the chrono­log­i­cal age of liv­ing or de­ceased Afro-Trinida­di­an sub­jects, with a high de­gree of ac­cu­ra­cy. Moze ex­plained: "I want­ed to sen­si­tise T&T to the lo­cal re­search I am con­duct­ing." It is a col­lab­o­ra­tive ef­fort with DAR­LInG at King's Col­lege School of Med­i­cine and Den­tistry in Lon­don, and UWI, SoD.

DAATT DAR­LInG project

Build­ing on Moze's re­cent pub­li­ca­tion, he seeks to as­sign ages to chil­dren of un­known date of birth in this coun­try, specif­i­cal­ly those chil­dren and ado­les­cents who have been un­sci­en­tif­i­cal­ly as­signed an age by the State. He said: "This will be done by tak­ing an X-ray of the child's den­ti­tion, called a den­tal panoram­ic ra­di­ograph (DPR)." He in­di­cat­ed there are three ma­jor is­sues that re­quire na­tion­al dis­cus­sion:

• The ac­cu­ra­cy of den­tal age as­sess­ment (DAA) and the age as­signed to the in­di­vid­ual

• The medico-le­gal ex­po­sure of sub­jects to ion­is­ing ra­di­a­tion (X-rays) for the pur­pos­es of de­ter­min­ing age and not for the cus­tom­ary pur­pose of health rea­sons

• The ben­e­fits to be de­rived by both the in­di­vid­ual and the so­ci­ety as a whole from as­sign­ing an age to an in­di­vid­ual

Moze ex­plained: "I would like this re­search to be­gin at the root, and this in­volves a na­tion­al par­tic­i­pa­tion so we can all crit­i­cal­ly analyse and scru­ti­nise all of the rel­e­vant is­sues per­tain­ing to the DAATT DAR­LInG project in-depth."

Ac­cu­ra­cy of DAA

There is a con­sen­sus that bi­o­log­i­cal hu­man growth pat­terns are ge­net­i­cal­ly in­tri­cate. Well-de­fined gauges of phys­i­o­log­i­cal ma­tu­ri­ty pro­vide a more re­li­able as­sess­ment of age rather than the "holis­tic ap­proach", which is flawed as put for­ward by Moze. He sug­gest­ed an ap­proach that is quan­tifi­able and al­most ex­act in age as­sess­ment.

Ac­cord­ing to Moze and DAR­LInG, the tech­nique is one of the most ac­cu­rate meth­ods for es­ti­mat­ing the age of an un­known per­son. DAA is cur­rent­ly used in some coun­tries as part of their asy­lum pol­i­cy. "DAR­LInG has re­cent­ly made a con­tri­bu­tion to a dis­cus­sion pa­per by in­vi­ta­tion of the Aus­tralian Hu­man Rights Com­mis­sion.

Aus­tralia is fac­ing an is­sue with in­di­vid­u­als seek­ing asy­lum from In­done­sia with no birth records. If they are un­der 18, the Aus­tralian State will pro­vide for them. If they are over 18, they are re­turned to In­done­sia. When is­sues like these arise, we must have a high­ly ac­cu­rate method of as­sess­ing the in­di­vid­ual's age," said Moze.

He point­ed out: "What we as­sess is den­tal ma­tu­ri­ty and what we have recog­nised in pre­vi­ous stud­ies pre­sent­ed abroad is that Afro-Trinida­di­ans will get to a giv­en stage of den­tal de­vel­op­ment ap­prox­i­mate­ly 1-1.9 years ear­li­er than an In­do-Trinida­di­an per­son; there­fore, I can­not use my Afro-Trinida­di­an data­base to as­sess the age of an In­do-Trinida­di­an per­son, be­cause I am go­ing to be off by al­most two years."

The data­base of ages of at­tain­ment for the var­i­ous TDS is eth­nic spe­cif­ic. Moze ad­vo­cat­ed: "The teeth do not lie. De­vel­op­ment of teeth is rel­a­tive­ly un­in­flu­enced by meta­bol­ic and en­docrine dis­eases; rel­a­tive­ly un­in­flu­enced by nu­tri­tion­al dis­eases; its rate of de­vel­op­ment is eth­nic spe­cif­ic; and high­ly cor­re­lat­ed with bi­o­log­i­cal ma­tu­ri­ty."

The medico-le­gal con­text

Moze posits that: "X-ray ex­po­sure of pa­tients us­ing DPR, as the imag­ing modal­i­ty for mat­ters re­lat­ed to the di­ag­no­sis of oro-fa­cial dis­ease, has set a cri­te­ria. Each X-ray tak­en in med­i­cine and den­tistry must be jus­ti­fied on the ba­sis that the pa­tient stands to ben­e­fit from the ex­po­sure." Medico-le­gal ex­po­sures must take in­to ac­count:

• An ap­praisal of the po­ten­tial ben­e­fits and detri­ments to both the ex­posed in­di­vid­ual and so­ci­ety

• Are the ex­posed in­di­vid­u­als dis­ad­van­taged by the po­ten­tial con­se­quences of the ex­po­sure?

• In­formed con­sent

• An ap­pro­pri­ate­ness for ra­di­at­ing cit­i­zens of T&T for the pur­pos­es of age as­sess­ment.

Not on­ly is an in­put from mem­bers of the ra­di­a­tion pro­tec­tion and sci­en­tif­ic com­mu­ni­ty re­quired, but a con­ver­sa­tion and in­put from the broad­est pos­si­ble so­cial base of T&T is al­so nec­es­sary, if the DAATT DAR­LInG project is to go fur­ther.

Dosime­try

Moze fur­ther ex­plained: "To put the dose from this imag­ing modal­i­ty in­to per­spec­tive, the den­tal panoram­ic X-ray unit will de­liv­er a dose of ap­prox­i­mate­ly three to six mi­crosiev­erts of ra­di­a­tion to the sub­ject." With a bit of hu­mour, he said that a ba­nana has ra­dioac­tive potas­si­um and will de­liv­er a dose of ten mi­crosiev­erts and the ra­di­a­tion from a six-hour flight from LA to NYC is 400 mi­crosiev­erts.

"Does this mean that we are go­ing to stop eat­ing ba­nanas and stop us­ing air trav­el?" He as­sured that it is high­ly un­like­ly that a can­cer will be in­duced from the ra­di­a­tion at this low dose and that the sub­ject be­ing ra­di­at­ed will die from the ex­po­sure.

Chil­dren who are off the radar

"The is­sue of the risk ver­sus ben­e­fit ra­tio must arise when us­ing ra­di­a­tion," said Moze. His pre­lim­i­nary and un­sci­en­tif­ic en­quiries re­vealed that there are about 1,000 chil­dren of un­known ages ex­ist­ing in this coun­try. He said: "These chil­dren ef­fec­tive­ly have no iden­ti­ty. They are off the radar. These chil­dren can­not get a na­tion­al iden­ti­fi­ca­tion card, a dri­ver's li­cense, a job or ac­cess to health care."

Moze said: "This re­search would help to de­fine peo­ple legal­ly, so­cial­ly and de­mo­graph­i­cal­ly. It would al­so af­ford them in­ter­ac­tion with med­ical care, school­ing, in­ter­ac­tions with­in peer groups, com­men­su­rate with their bi­o­log­i­cal ma­tu­ri­ty." In the crim­i­nal con­text, there are far-reach­ing con­se­quences for both State and in­di­vid­ual when ju­ve­niles have been wrong­ly as­signed ages and are charged for a crime.

"The cur­rent method in use in Trinidad and To­ba­go in terms of age as­sess­ment is based sole­ly on phe­no­typ­i­cal ap­pear­ance as I am re­li­ably in­formed. This means that a 14-year-old, de­pend­ing on the stage of phys­i­cal ma­tu­ri­ty and phe­no­typ­i­cal ap­pear­ance, can be eas­i­ly as­signed an age of 18. This is too big a gap com­ing from a le­gal and med­ical stand­point," ar­gued Moze.

"In­ter­est­ing­ly, the Scot­tish de­part­ment of Foren­sic Sci­ence, through the British As­so­ci­a­tion of Foren­sic Odon­tol­ogy and DAR­LInG, asked for ac­cess to my data­base re­cent­ly." "They said that an Afro-Caribbean male of un­known age was charged for a crime in Scot­land. The age as­sess­ment was in dis­pute since the par­ents had not reg­is­tered the child's birth. They thought he could have been be­tween 16 and 18 years old.

"In or­der to be cer­tain of age they sent a DPR of the sub­ject and he was as­signed an age of 10.91 years. This marked the first time that this Afro-Trinida­di­an da­ta set had been for­mal­ly used in a court of law." Re­view­er com­ments from The Jour­nal of Foren­sic and Le­gal Med­i­cine stat­ed:

"Moze's pa­per has a large amount of da­ta from both the UK Cau­casian and Afro-Trinida­di­an Ref­er­ence Da­ta Set. The use of the Val­i­da­tion Study Group to test the re­li­a­bil­i­ty of the Ref­er­ence Da­ta Set is a rel­a­tive­ly new ap­proach for which the au­thors must be com­mend­ed.

A gen­er­al short­com­ing of many Den­tal Age re­ports is the lack of in­de­pen­dent test­ing of the Ref­er­ence Da­ta Set. The Weight­ed Av­er­ages Method us­ing the Math­e­mat­i­cal Tech­niques of Meta-Analy­sis ap­pears to have much to com­mend it. This pa­per pro­vides a mod­el for the com­par­i­son of den­tal ma­tu­ri­ty da­ta from sub­jects of dif­fer­ent eth­nic groups, as it en­ables ap­pro­pri­ate com­par­isons at the Tooth De­vel­op­ment Stage lev­el, and the out­put vari­able of Den­tal Age.

Per­haps one of the great­est strengths of this is the use of Chrono­log­i­cal Age as the Gold Stan­dard for com­par­ing the Den­tal Age. This work shows clear­ly the need to have the da­ta par­ti­tioned by gen­der as well as eth­nic­i­ty." Dr Moze has in­vit­ed the pub­lic to par­tic­i­pate with con­tri­bu­tions, ques­tions or in­sights to his fol­low-up re­search at daatt.project@gmail.com.