Probity of Dental Radiographs for Age Estimation
Legal Status of Radiographs taken for a non-therapeutic / non-diagnostic purpose.
The legal status of exposing subjects to ionising radiation is occasionally cited by critics of DAE as a justification for abandoning the technique. The legislation as it relates to DAE has been explored and summarised in a article by Dr Philip Marsden, Forensic Odontologist, London, UK. This note quotes almost verbatim from that article.
The issue of dental age estimation of the living is an uncommon procedure in Forensic Odontology practice compared to identification of the dead, or the analysis of bite marks. The request for such an assessment most frequently comes in in relation to asylum seekers where the age stated is questioned. The maturity of such individuals usually means that age estimation can only be based on dental development. The great majority of disputed ages occurs in young people who look like adults but who claim to be under 18 years old. Thus the age estimation can only be carried out by using the development of the third molar. This requires that at least one radiographic exposure.
It is a common misconception that radiographs can only be taken for therapeutic reasons. This is not so. There is legislation that relates to the exposure of radiographs for non-therapeutic reasons.
There are two significant pieces of legislation. These are:S.I. No 1059 [Health and Safety, “The Ionising Radiation (Medical Exposure)Regulations 2000”] (IRMER) and as amended 2006. http://www.legislation gov.uk/uksi/2000/1059/contents.made and S.I. NO 1769, [Health and Safety, Environmental Protection, “The Justification of Practices Involving Ionising Radiation regulations 2004”] as updated http://www.decc.gov.uk/assets/deccwhat%20we%20do/uk%20energy%20Supply/energy%20mix/nuclear/radioactivity/justification-gyidance.pdf
It is true essential that the consent of the individual IS required in ALL cases and subjects are entitled to refuse consent for a radiograph to be taken. If consent is given, as happens in almost all cases, and assuming the individual (or accompanying carer) is competent to give consent, then the existing legislation already provides for the taking of radiographs as part of a medico-legal procedure. This is defined in IRMER in 2(1) as “a procedure performed for insurance or legal purposes without a medical indication”. In 3.(e) it is confirmed that IRMER regulations apply to “the exposure of individuals as part of medico-legal procedures.” The notes on good practice for IRMER 2000 are at http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/ dh_064707.pdf This provides the following explanation: 5.6 ” medico-legal procedure” 5.6.1 This category of exposure will include those required for legal purpose of any kind. e.g. those required in connection with legal proceedings or those required prior to emigration. As with all cases, 7.(7). applies “the need to keep doses arising from the medico-legal exposure as low as reasonably practicable”. In 6.(1). (a) it confirms that the exposure ” … has been justified by the practitioner as showing a sufficient net benefit giving appropriate weight to matters set out in Para 2. (see above for relevant section of para 2). Section 6. (3) states ” In considering the weight to be given to matters referred to in Para 2, the practitioner justifying any exposure pursuant to Para 1a shall pay special attention to –
a) Exposures on medic0 legal grounds;
b) exposure that has no direct health benefit for the individuals undergoing the exposure; Sufficient net benefit not only applies to the individuals but also; 6.(2). (b) … Benefits to Society … … ” This aspect is reiterated in the “The Justification of Practices Involving Ionising Radiation regulations 2004.” where section 2 of the forward reads: “European Union Council Directive 96/29/Euratom (known as the Basic Safety Standards Directive) lays down the basic safety standards for the protection of the health of workers and the general public against from ionising radiation. The Directive requires Member States to ensure that all new classes or types of practice resulting in exposure to ionising radiation are justified, in advance of being first adopted or first approved, by the economic social or other benefits in relation to the health detriment they may cause.
In addition, existing classes or types of practice may be reviewed as to justification whenever new and important evidence about their efficacy or consequences is aquired.” The issue of justification is carried in section 7. “No practice (activity) involving exposure to radiation should be adopted unless it produces at lest sufficient benefit to the exposed individuals or to society to offset the radiation detriment it causes … .. ” In section10: “the process of justifying classes or types of practice and reviewing existing practices involves consideration not only of technical factors associated with the practice and its radiological detriment, but also of wider social an economic issues … …” The taking of non-therapeutic radiographs for medico-legal reasons is an existing ‘justified’ procedure and is listed in Annexe 3 under Classes of types of practice existing prior (to) May 2000 at section 24. “Medico-legal procedures – Use of ionising radiation in radiography, fluoroscopy, interventional radiography, computed tomography and in vivo nuclear medicine”. A dentist making the decision to expose the individual for age assessment purposes will be able to reason that net benefits potentially may be had by either the individual (if the conclusion is that the subject is the age s/he claims to be and therefore will receive the most appropriate level of support ) or to society should the conclusion be that, on the balance of probabilities, the individual is likely to be older than s/he has claimed, and most commonly above the 18 year threshold. A decision of this nature means that limited resources could be directed to where they are legitimately needed and is therefore a net benefit to society. This means that whatever the outcome, there is a net benefit.
The radiographic assessment of age disputed asylum seekers is standard practice in many countries and thus could not be viewed as an unusual practice bearing in mind that DAE is the most reliable age estimation technique. The taking of radiographs where there is no therapeutic benefit to the individual is permitted under existing legislation.
This note is based very closely on a short article by Dr Phil Marsden fist published in the BAFO newsletter in 2010