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Over the borderline

      We often talk about borderline patients in orthodontics; for example, patients who do not have a full Class II or Class III malocclusion. I would like to discuss a different meaning of borderline that also has relevance for orthodontics. The borderline I am concerned with relates to the humanitarian crisis at the southwestern border of the United States. An unprecedented number of people, including many unaccompanied minors, are fleeing countries in Latin America and seeking asylum due to dangerous conditions in their homelands. In the first 6 months of 2021, more than 78,000 unaccompanied migrant children arrived at the border.
      • Department of Homeland Security
      U.S. Customs and border patrol.
      What does this have to do with orthodontics you may be wondering?
      When unaccompanied children arrive at the border without any documentation, the government needs to determine whether they are under or over the age of 18. This legal threshold is critical because it determines where the person is housed by the Office of Refugee Resettlement (ORR)—minors (less than 18 years) are housed in youth shelters and given protections including medical care and education; anyone deemed to be over 18 years is placed in adult detention facilities (ie, jails) operated by Immigration and Custom Enforcement (ICE) where the conditions are often harsh.
      For individuals who do not have any age documentation, dental radiographs are being employed as a method of chronologic age assessment. I first learned of this practice in an article by Kapadia et al
      • Kapadia F.
      • Stevens J.
      • Silver D.
      Dental radiographs for age estimation in US asylum seekers: methodological, ethical, and health issues.
      in the American Journal of Public Health in December 2020. Not only was I completely unaware that this was going on, but I was appalled at the misapplication of this methodology; as orthodontists, we are taught that dental age is not a reliable indicator of chronologic age. Since that time, I have learned more about this contentious practice of age determination as well as the many related issues that surround its use.
      Orthodontists are well-versed in the various methods of dental age assessment in order to appropriately diagnose and choose the most effective treatment plan based on a patient's status and growth pattern. Not only do we rely on panoramic radiographs to assess dental age, but we assess skeletal age by use of the cephalometric radiographs to look at cervical vertebral maturation and hand-wrist radiographs to assess ossification of the epiphyseal plates and the sesamoid processes.
      • Buschang P.H.
      • Roldan S.I.
      • Tadlock L.P.
      Guidelines for assessing the growth and development of orthodontic patients.
      • Baccetti T.
      • Franchi L.
      • McNamara J.A.
      The cervical vertebral maturation (CVM) method for the assessment of optimal treatment timing in dentofacial orthopedics.
      • Fishman L.S.
      Radiographic evaluation of skeletal maturation. A clinically oriented method based on hand-wrist films.
      These radiographic tools are never used alone to make an age determination—other physiological markers such as height, weight, and secondary sexual characteristics are used to assess an individual's growth. We do this because we know and understand that the correlation between dental age and chronologic age is poor at best.
      The use of radiographs to estimate dental age has its basis in the classic article by Demirjian, published almost 50 years ago.
      • Demirjian A.
      • Goldstein H.
      • Tanner J.M.
      A new system of dental age assessment.
      In that article he and his colleagues describe a method of dental age determination based on 7 teeth (central incisor to second molar) on the left side of the mandible. His reference population were French Canadian children ages 2-20 years old. Eight stages, A through H, were described based on the closure of the root apices. This provided a ‘dental maturity score,’ which was then translated into a ‘dental age.’ He presciently cautioned that “… the conversion to dental age, or the location of the centiles for maturity at different ages, depends on the population considered.” Demirjian's technique was never intended to estimate chronologic age—only whether a given child was dentally delayed or advanced.
      • Liversidge H.M.
      The assessment and interpretation of Demirjian, Goldstein and Tanner’s dental maturity.
      Demirjian's methodology for dental age determination has been modified to include third molars, the tooth that is the last to fully form in the mouth, in order to determine chronologic age for adolescents and young adults.
      • Lewis J.M.
      • Senn D.R.
      Dental age estimation utilizing third molar development: a review of principles, methods, and population studies used in the United States.
      As described by Mincer et al in 1993, the reason to develop stages of third molar root development to assess chronologic age were because “there are very few alternative methods during the interval between the middle teens and early 20s.”
      • Mincer H.H.
      • Harris E.F.
      • Berryman H.E.
      The A.B.F.O. study of third molar development and its use as an estimator of chronological age.
      Aside from the third molar being the most variable tooth in the mouth, there are other issues associated with the use of third molars for age determination. Of primary importance is the use of an adequate population-specific reference group to that of the individual in question.
      • Sauer P.J.
      • Nicholson A.
      • Neubauer D.
      Advocacy and Ethics Group of the European Academy of Paediatrics. Age determination in asylum seekers: physicians should not be implicated.
      There is however no reliable reference population for children coming from Latin America. Furthermore, it is acknowledged that many factors, including an individual's ethnicity, sex, environment, and nutrition may influence tooth development.
      • Liversidge H.M.
      • Buckberry J.
      • Marquez-Grant N.
      Age estimation.
      In forensic cases, age determination methodology is used for legal purposes to ascertain if an individual without any identification is above or below 18 years. A recent systematic review of the use of third molars for age determination in forensic cases concluded that the true positive rate (sensitivity) was 51% and diagnostic accuracy 71%, highlighting the need for complementary estimation methods.
      • Haglund M.
      • Mörnstad H.
      A systematic review and meta-analysis of the fully formed wisdom tooth as a radiological marker of adulthood.
      Despite the fact that the Trafficking Victims Protection Reauthorization Act (TVPRA) of 2008 requires age assessment methods to use “multiple forms of evidence” before making a determination, and despite the known methodological flaws with using third molars as a method of age determination, the ORR often relies on the dental radiograph as their sole means of age determination.
      • Kapadia F.
      • Stevens J.
      • Silver D.
      Dental radiographs for age estimation in US asylum seekers: methodological, ethical, and health issues.
      Many questions remain and answers are not readily found. Although there is some scattered information on blogs about who is performing these dental age assessments, it is unclear where the radiographs are being taken, what kind and quality of radiographs are being taken, who is performing the age determination, and what the process is (if there is one) for the adjudication of these films. How are the examiners trained and calibrated, or are they?
      In addition, although the focus of this commentary has been on the misuse of this radiographic method of age determination, it is important to note that there are other equally significant legal and ethical aspects that are highly problematic. Since the ORR has custodial authority over unaccompanied minors, they are not obligated to obtain informed consent or assent for the dental radiographs. Furthermore, the use of dental radiographs for nontherapeutic purposes alone raises significant public health and ethical concerns, for example, is the patient informed, and what steps are taken should dental or osseous disease be found on a radiograph?
      Many prominent European organizations have already denounced these age determination practices based on the known scientific uncertainty and ethical concerns.
      • Sauer P.J.
      • Nicholson A.
      • Neubauer D.
      Advocacy and Ethics Group of the European Academy of Paediatrics. Age determination in asylum seekers: physicians should not be implicated.
      I write this commentary in order to inform the orthodontic community of this practice and call upon our professional leaders to uphold our highest professional standards. I don't pretend that this is an easy problem, nor one that I have the answers for. What I do know however is that we must uphold evidence-based and ethical practice and call out those who do not respect those principles. In my opinion, that borderline is not subject to dispute.

      References

        • Department of Homeland Security
        U.S. Customs and border patrol.
        (Available at:)
        • Kapadia F.
        • Stevens J.
        • Silver D.
        Dental radiographs for age estimation in US asylum seekers: methodological, ethical, and health issues.
        Am J Public Health. 2020; 110: 1786-1789
        • Buschang P.H.
        • Roldan S.I.
        • Tadlock L.P.
        Guidelines for assessing the growth and development of orthodontic patients.
        Semin Orthod. 2017; 23: 321-335
        • Baccetti T.
        • Franchi L.
        • McNamara J.A.
        The cervical vertebral maturation (CVM) method for the assessment of optimal treatment timing in dentofacial orthopedics.
        Semin Orthod. 2005; 11: 119-129
        • Fishman L.S.
        Radiographic evaluation of skeletal maturation. A clinically oriented method based on hand-wrist films.
        Angle Orthod. 1982; 52: 88-112
        • Demirjian A.
        • Goldstein H.
        • Tanner J.M.
        A new system of dental age assessment.
        Hum Biol. 1973; 45: 211-227
        • Liversidge H.M.
        The assessment and interpretation of Demirjian, Goldstein and Tanner’s dental maturity.
        Ann Hum Biol. 2012; 39: 412-431
        • Lewis J.M.
        • Senn D.R.
        Dental age estimation utilizing third molar development: a review of principles, methods, and population studies used in the United States.
        Forensic Sci Int. 2010; 201: 79-83
        • Mincer H.H.
        • Harris E.F.
        • Berryman H.E.
        The A.B.F.O. study of third molar development and its use as an estimator of chronological age.
        J Forensic Sci. 1993; 38: 379-390
        • Sauer P.J.
        • Nicholson A.
        • Neubauer D.
        Advocacy and Ethics Group of the European Academy of Paediatrics. Age determination in asylum seekers: physicians should not be implicated.
        Eur J Pediatr. 2016; 175: 299-303
        • Liversidge H.M.
        • Buckberry J.
        • Marquez-Grant N.
        Age estimation.
        Ann Hum Biol. 2015; 42: 299-301
        • Haglund M.
        • Mörnstad H.
        A systematic review and meta-analysis of the fully formed wisdom tooth as a radiological marker of adulthood.
        Int J Legal Med. 2019; 133: 231-239