Quality assurance in forensic odontology

Quality assurance or quality control is a term and concept coming from the industry. Here it is most important. All products must have a minimum quality and variation in size, for example, must be kept within certain strict limits. There must be a system to control this. May be not every single product is controlled, but spot tests must be taken. Measures must be taken to improve the quality if it is not good enough. This concept has been transferred to medicine, odontology, and consequently also to forensic odontology. These areas have in common with industry the production of that certain products. However, they are usually handmade and not produced in an industrial process. In addition, dentistry is a great deal of art and judgement and quality control of these factors may be difficult. In this paper, I will focus on forensic odontology. What are the problems? What can we do and cannot do? In addition, how can we assure the quality of the work, the assessment and conclusion, and the report? I have some personal opinions on that and I will give some suggestions. Quality assurance on an international level is difficult. Conditions and juridical systems are different in different countries. Especially forensic odontologists are different and have different opinions. This presentation will be relevant to the ongoing discussion and attempts at revising the IOFOS' guidelines for quality assurance.

ESPEN guidelines on nutrition in cancer patients

Cancers are among the leading causes of morbidity and mortality worldwide, and the number of new cases is expected to rise significantly over the next decades. At the same time, all types of cancer treatment, such as surgery, radiation therapy, and pharmacological therapies are improving in sophistication, precision and in the power to target specific characteristics of individual cancers. Thus, while many cancers may still not be cured they may be converted to chronic diseases. All of these treatments, however, are impeded or precluded by the frequent development of malnutrition and metabolic derangements in cancer patients, induced by the tumor or by its treatment. These evidence-based guidelines were developed to translate current best evidence and expert opinion into recommendations for multi-disciplinary teams responsible for identification, prevention, and treatment of reversible elements of malnutrition in adult cancer patients. The guidelines were commissioned and financially supported by ESPEN and by the European Partnership for Action Against Cancer (EPAAC), an EU level initiative. Members of the guideline group were selected by ESPEN to include a range of professions and fields of expertise. We searched for meta-analyses, systematic reviews and comparative studies based on clinical questions according to the PICO format. The evidence was evaluated and merged to develop clinical recommendations using the GRADE method. Due to the deficits in the available evidence, relevant still open questions were listed and should be addressed by future studies. Malnutrition and a loss of muscle mass are frequent in cancer patients and have a negative effect on clinical outcome. They may be driven by inadequate food intake, decreased physical activity and catabolic metabolic derangements. To screen for, prevent, assess in detail, monitor and treat malnutrition standard operating procedures, responsibilities and a quality control process should be established at each institution involved in treating cancer patients. All cancer patients should be screened regularly for the risk or the presence of malnutrition. In all patients - with the exception of end of life care - energy and substrate requirements should be met by offering in a step-wise manner nutritional interventions from counseling to parenteral nutrition. However, benefits and risks of nutritional interventions have to be balanced with special consideration in patients with advanced disease. Nutritional care should always be accompanied by exercise training. To counter malnutrition in patients with advanced cancer there are few pharmacological agents and pharmaconutrients with only limited effects. Cancer survivors should engage in regular physical activity and adopt a prudent diet.

Does chemotherapy improve health-related quality of life in advanced pancreatic cancer? A systematic review.

Chemotherapy is increasingly being used in advanced pancreatic cancer, but side-effects are common. The aim of this systematic review was to assess whether chemotherapy improves health-related quality of life (HRQoL), pain or cachexia. Thirty studies were reviewed. Four of 23 studies evaluating HRQoL, 7 of 24 studies evaluating pain and 0 of 8 studies evaluating cachexia found differences between treatment arms. Change in HRQoL from baseline was evaluated in 14 studies: five studies reported an improvement in at least one treatment arm; three a worsening and the remaining stable scores. Change in pain intensity from baseline was evaluated in eight studies, and improvement was observed in seven. Of the four studies reporting improved survival, three reported improved HRQoL or pain. In conclusion, chemotherapy can stabilize HRQoL and improve pain control. Effects on cachexia are hard to elucidate. Improved survival does not come at the expense of HRQoL or pain control.

Validation of the Consensus-Definition for Cancer Cachexia and evaluation of a classification model--a study based on data from an international multicentre project (EPCRC-CSA).

BACKGROUND: Weight loss limits cancer therapy, quality of life and survival. Common diagnostic criteria and a framework for a classification system for cancer cachexia were recently agreed upon by international consensus. Specific assessment domains (stores, intake, catabolism and function) were proposed. The aim of this study is to validate this diagnostic criteria (two groups: model 1) and examine a four-group (model 2) classification system regarding these domains as well as survival. PATIENTS AND METHODS: Data from an international patient sample with advanced cancer (N = 1070) were analysed. In model 1, the diagnostic criteria for cancer cachexia [weight loss/body mass index (BMI)] were used. Model 2 classified patients into four groups 0-III, according to weight loss/BMI as a framework for cachexia stages. The cachexia domains, survival and sociodemographic/medical variables were compared across models. RESULTS: Eight hundred and sixty-one patients were included. Model 1 consisted of 399 cachectic and 462 non-cachectic patients. Cachectic patients had significantly higher levels of inflammation, lower nutritional intake and performance status and shorter survival. In model 2, differences were not consistent; appetite loss did not differ between group III and IV, and performance status not between group 0 and I. Survival was shorter in group II and III compared with other groups. By adding other cachexia domains to the model, survival differences were demonstrated. CONCLUSION: The diagnostic criteria based on weight loss and BMI distinguish between cachectic and non-cachectic patients concerning all domains (intake, catabolism and function) and is associated with survival. In order to guide cachexia treatment a four-group classification model needs additional domains to discriminate between cachexia stages.

Genetic basis of interindividual susceptibility to cancer cachexia: selection of potential candidate gene polymorphisms for association studies.

Cancer cachexia is a complex and multifactorial disease. Evolving definitions highlight the fact that a diverse range of biological processes contribute to cancer cachexia. Part of the variation in who will and who will not develop cancer cachexia may be genetically determined. As new definitions, classifications and biological targets continue to evolve, there is a need for reappraisal of the literature for future candidate association studies. This review summarizes genes identified or implicated as well as putative candidate genes contributing to cachexia, identified through diverse technology platforms and model systems to further guide association studies. A systematic search covering 1986-2012 was performed for potential candidate genes / genetic polymorphisms relating to cancer cachexia. All candidate genes were reviewed for functional polymorphisms or clinically significant polymorphisms associated with cachexia using the OMIM and GeneRIF databases. Pathway analysis software was used to reveal possible network associations between genes. Functionality of SNPs/genes was explored based on published literature, algorithms for detecting putative deleterious SNPs and interrogating the database for expression of quantitative trait loci (eQTLs). A total of 154 genes associated with cancer cachexia were identified and explored for functional polymorphisms. Of these 154 genes, 119 had a combined total of 281 polymorphisms with functional and/or clinical significance in terms of cachexia associated with them. Of these, 80 polymorphisms (in 51 genes) were replicated in more than one study with 24 polymorphisms found to influence two or more hallmarks of cachexia (i.e., inflammation, loss of fat mass and/or lean mass and reduced survival). Selection of candidate genes and polymorphisms is a key element of multigene study design. The present study provides a contemporary basis to select genes and/or polymorphisms for further association studies in cancer cachexia, and to develop their potential as susceptibility biomarkers of cachexia.

Human papillomavirus subtypes in oral lesions compared to healthy oral mucosa.

BACKGROUND: Human papillomaviruses (HPV) are involved in the etiology of cervix cancer, but it is still unclear whether they play a role in related oral lesions. OBJECTIVES: The presence of HPV in oral leukoplakia biopsies (n=50) and oral squamous carcinoma biopsies (n=50) was compared to normal oral mucosa swabs (n=50) for the purpose of indicating a possible etiological role for the virus. STUDY DESIGN: DNA was extracted from tissue biopsies and from mucosa swabs of control samples. Nested PCR was performed with primers targeting conserved sequences within the capsid gene L1. PCR products were sequenced to identify the HPV genotype. RESULT: The results reveal a profile of low-risk HPV genotypes in oral leukoplakia similar to that in healthy controls, while HPV was less frequently observed in oral squamous carcinoma. CONCLUSIONS: HPV does not seem to represent an important causal factor for the development of oral leukoplakia or oral squamous carcinoma.

Is there a genetic cause for cancer cachexia? - a clinical validation study in 1797 patients.

BACKGROUND: Cachexia has major impact on cancer patients' morbidity and mortality. Future development of cachexia treatment needs methods for early identification of patients at risk. The aim of the study was to validate nine single-nucleotide polymorphisms (SNPs) previously associated with cachexia, and to explore 182 other candidate SNPs with the potential to be involved in the pathophysiology. METHOD: A total of 1797 cancer patients, classified as either having severe cachexia, mild cachexia or no cachexia, were genotyped. RESULTS: After allowing for multiple testing, there was no statistically significant association between any of the SNPs analysed and the cachexia groups. However, consistent with prior reports, two SNPs from the acylpeptide hydrolase (APEH) gene showed suggestive statistical significance (P=0.02; OR, 0.78). CONCLUSION: This study failed to detect any significant association between any of the SNPs analysed and cachexia; although two SNPs from the APEH gene had a trend towards significance. The APEH gene encodes the enzyme APEH, postulated to be important in the endpoint of the ubiquitin system and thus the breakdown of proteins into free amino acids. In cachexia, there is an extensive breakdown of muscle proteins and an increase in the production of acute phase proteins in the liver.

Recurrent conventional cemento-ossifying fibroma of the mandible.

Cemento-ossifying fibromas are slow growing, benign lesions. Recurrence is considered rare. A mandibular periapical radiolucent lesion in a 30-year-old female was diagnosed histologically as a cemento-ossifying fibroma and excised. A recurrence was found 2 years and 6 months postoperatively. CT demonstrated that the recurrent lesion was larger than indicated by conventional radiography.

[Crohn disease of the oral cavity, illustrated by some cases]. / Crohns sykdom i munnhulen, belyst med noen kasuistikker.

BACKGROUND: We have several times experienced that Crohn's disease has not been diagnosed until several years after the start of oral symptoms. This article presents some patients with oral manifestations of Crohn's disease, as a contribution to more awareness of this possibility. MATERIAL AND METHODS: Clinical and histological data from four patients are presented. RESULTS: All patients had granulomatous inflammation of the oral mucosa. In three patients, the disease started in the mouth. The diagnosis of intestinal Crohn's disease was made from some months up to seven years later. In one patient, no granuloma was found in the intestinal tract, but the patient had intestinal symptoms. Two patients experienced disappointments in their contacts with the local health care system, with considerable delay in diagnosis. INTERPRETATION: We interpret these cases as evidence that a greater awareness of the possibility of Crohn's disease in the oral cavity may lead to a quicker diagnosis, earlier correct treatment, and less patient worry caused by uncertainty.

Comparison of bitemarks left in foodstuffs with models of the suspects' dentitions as a means of identifying a perpetrator.

In a recent court case, a comparison was made between an impression of marks left in cheese at a murder scene and a set of study models of one of the suspects. The court was reluctant to accept the validity of the pattern-associated comparison that was used in the identification. This study compared marks made in cheese, butter and cooked potato with study models taken from volunteers. Pattern-associated comparison was the method used. Eighty pair-wise comparisons were made by two odontologists. The examiners correctly identified all the true matches from among the eighty comparisons as well as selecting the dental models for which there were no corresponding silicone impressions. In the absence of identifiable fingerprints or DNA samples, the method can be employed for matching left in foodstuffs to the dentitions of suspects.

Hot isostatic pressing-processed hydroxyapatite-coated titanium implants: light microscopic and scanning electron microscopy investigations.

Hot isostatic pressing (HIP) was used in a new procedure to produce hydroxyapatite (HA) coatings on a commercially pure titanium (cpTi) substrate for osseous implantation. Eighteen HIP-processed HA-coated implants were placed in the inferior border of the mandibles in 2 Labrador retriever dogs and left submerged for 3 months. As control specimens, 12 sandblasted cpTi implants were placed in the same mandibles and, to compare the bone reaction, 2 additional plasma-sprayed HA-coated implants (Integral) were placed. Tissue reactions at the bony interfaces of the implants were studied in ground sections with the implants in situ, using ordinary, fluorescent, and polarized light microscopy and scanning electron microscopy (SEM). The HIP-processed HA coatings displayed an increased density in light microscopy and SEM as compared to plasma-sprayed coatings. Direct bone-implant contact was found in all 3 types of surfaces. However, the production of new bone was far more abundant for the HA-coated implants than for sandblasted cpTi implants. The presence of bone-forming and bone-resorbing cells indicated active bone remodeling in the interface area at 3 months after implant placement. The present results support the view that epitaxial bone growth may occur from the HA-coated implant surface. It was concluded that the increased density of the present HIP-processed HA material does not reduce the bioactive properties of the coatings.

Glandular odontogenic cyst (sialo-odontogenic cyst): report of two cases and literature review of 45 previously reported cases.

The clinical, radiological, histopathological and immunohistochemical (cytokeratin) features of two cases of glandular odontogenic cyst (GOC) are presented and discussed in a review of 45 cases of GOC hitherto reported. Of cases with available information, 34 occurred in the mandible and 6 in the maxilla; the male:female ratio was 19:28, and the mean age was 46.7 years in males and 50.0 years in females. Six cysts recurred once after 2-8 years (mean 2 years 8 months) and 2 (5.3%) recurred twice after 2 and 5 years and after 3 and 5 years, respectively, giving a rate of recurrence of 21%. The identification of osteodentin in one of the present cases and the co-expression of cytokeratins (CK) 13, 19 and 8 strongly support the concept of odontogenic differentiation in the GOC. Careful surgical removal of the lesion succeeded by a 5-year follow-up period is recommended.

Methods of measuring morphological parameters in dental radiographs. Comparison between image analysis and manual measurements.

Measurements of age-related changes in dental tissues are often used when estimating the age of an individual. With the new technology now available, the methods of measurement might be standardized and reproducible. The purpose of the present study was to compare the reliability of manual and computer-assisted measurements of morphological parameters in dental radiographs. Manual measurements were made conventionally using a pair of vernier callipers and a stereomicroscope with a measuring eyepiece. An image analysis software program was employed for the computer assisted measurements. Lengths and widths of tooth and pulp were measured both manually and with computer assistance on periapical radiographs from 40 patients, six teeth in each patient. Statistical analyses showed no significant intra- or inter-observer differences for the manual measurements. Statistically significant intra- and inter-observer differences were, however, found between the manual and computer-assisted measurements. The results implied that, despite advanced technology, conventional methods may be better suited for measuring linear morphological parameters in dental tissue.

Technical note: regression analysis in adult age estimation.

Accurate estimation of human adult age has always been a problem for anthropologists, archaeologists and forensic scientists. The main factor contributing to the difficulties is the high variability of physiological age indicators. However, confounding this variability in many age estimation applications is a systematic tendency for age estimates, regardless of physiological indicator employed, to assign ages which are too high for young individuals, and too low for older individuals. This paper shows that at least part of this error is the inevitable consequence of the statistical procedures used to extract an estimate of age from age indicators, and that the magnitude of the error is inversely related to how well an age indicator is correlated with age. The use of classical calibration over inverse calibration is recommended for age estimation.

A hierarchical system for the coding of dental information in reports and computer-assisted identifications.

Dental coding systems have hitherto been developed mainly to record treatment. The present hierarchical system was specially designed for computer aided dental identification and has been tested for 15 years in the Norwegian register of missing persons. It is in addition well suited for rapid and exact reporting of dental findings in identification cases. The system has also been proposed for adoption by Interpol.

Evaluation of preparation, staining and microscopic techniques for counting incremental lines in cementum of human teeth.

Apposition of cementum occurs in phases resulting in two types of layers with different optical and staining properties that can be observed by light microscopy. Narrow, dark staining incremental lines are separated by wider bands of pale staining cementum. The distance from one line to the next represents a yearly increment deposit of cementum in many mammals, and counting these lines has been used routinely to estimate the age of the animals. Incremental lines in cementum have also been observed in sections of human teeth, and the object of the present investigation was to examine a number of methods for preparing and staining them for counting. Longitudinal and transverse sections, either ground or decalcified, were cut from formalin fixed human dental roots, paraffin embedded or frozen, and stained using several techniques. The cementum was investigated using conventional light, fluorescence, polarized light, confocal laser scanning, interference contrast, phase contrast, and scanning electron microscopy. Incremental lines in the cementum could be observed in ground sections and, following decalcification, in both frozen and paraffin embedded sections. Toluidine blue, cresyl violet, hematoxylin, or periodic acid Schiff (PAS) stained incremental lines allowing differentiation by conventional light microscopy. Contrast was best using fluorescence microscopy and excitation by green light since the stained cemental bands, but not the incremental lines, fluoresced after staining with cresyl violet, PAS or hematoxylin and eosin. The results with other microscopic techniques were unsatisfactory. Since incremental lines are not destroyed by acids and stain differently than the remaining cementum, it is likely that they possess an organic structure which differs from the cementum. Incremental lines in human dental cementum could be observed best using decalcified sections stained with cresyl violet excited by green light.

A Bayesian approach to adult human age estimation from dental observations by Johanson's age changes.

Much of the data which appears in the forensic and archaeological literature is ordinal or categorical. This is particularly true of the age related indicators presented by Gustafson in his method of human adult age estimation using the structural changes in human teeth. This technique is still being modified and elaborated. However, the statistical methods of regression analysis employed by Gustafson and others are not particularly appropriate to this type of data, but are still employed because alternatives have not yet been explored. This paper presents a novel approach based upon the application of Bayes' theorem to ordinal and categorical data, which overcomes many of the problems associated with regression analysis.

Bonding capacity in bone of HIP-processed HA-coated titanium: mechanical and histological investigations.

The main problems using plasma-sprayed hydroxyapatite (HA) as a coating material on metallic implants are its porosity, low fatigue strength, and weak adherence to the metallic substrate. To overcome these problems a new technique using hot isostatic pressing (HIP) has been developed for producing HA-coated titanium (Ti) implants. Specimens produced at a maximum temperature of 850 degrees C and a maximum pressure of 720 bar displayed a dense, glassy, 25-microns thick coating with small amounts of porosity and a mean surface roughness of 0.7 microns, as compared with 1.6 microns for sandblasted Ti. Twenty conical HA-coated (720 and 100 bar pressure) and 10 noncoated Ti implants were inserted through the cortex of the lower margin of the mandibles of sheep and allowed to heal for 60 days. Push-out tests for implants processed at 720 bar pressure showed substantially higher bone/implant bonding values than for sandblasted Ti implants. Histological studies indicated a direct contact and probably chemical bonding between bone tissue and the HA coatings. The area of contact was almost 3 times as large as for the Ti implants. The adherence of the 100-bar coating to the Ti surface was inferior to the 720-bar coating, as shown by the loosening of the coatings in several areas.

Incremental lines in human dental cementum in relation to age.

Counting incremental lines in dental cementum is an accepted method for estimating age in many wild mammals. In human teeth such countings have given variable results, and the aim of the present investigation was to find out if one incremental line is formed per year in human teeth as well. Canines and single-rooted premolars were demineralized, paraffin wax-embedded, sectioned and stained, and the sections were viewed in a fluorescence microscope. Non-fluorescent lines, seen against a fluorescent background, were either counted directly or their number calculated by counting only some of them and computing this on the total width of the cementum. The correlation coefficient between tooth age and the number of lines for the whole material was = 0.84 when counted and = 0.73 when calculated. This coefficient was stronger in mandibular second premolars but lower in teeth extracted because of dental diseases. The coefficient was only significant in teeth from individuals below the age of 50 yr. The regression formula with tooth age as dependent variable indicated that only incremental lines formed in about every other year stained sufficiently to be counted.