Forensic Science International: Synergy 9 (2024) 100484

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Forensic Science International: Synergy

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Reliability of a forensic odontology method for age-at-death estimation in

adults: A Mexican case study
Roberto Scendoni a, *, 1 , Israel Soriano Vázquez b, 1 , Isabella Lima Arrais Ribeiro c ,
Stefano De Luca d , Galina V. Zolotenkova e , Serena Viva f , Akiko Kumagai g , Roberto Cameriere h
a
Department of Law, Institute of Legal Medicine (AgEstimation Project), University of Macerata, Macerata, Italy
b
Extraordinary Mechanism for Human Identification (MEIF) – United Nations Population Fund (UNFPA), Mexico
c
Postgraduate Program in Dentistry, Federal University of Paraíba, Campus I, João Pessoa, PB, 58051900, Brazil
d
Área de Identificación Forense, Unidad de Derechos Humanos, Servicio Médico Legal, Santiago de Chile, Chile
e
Department of Forensic Medicine, First Moscow State Medical University (Sechenov University), Moscow, Russia
f
Department of Cultural Heritage, University of Salento, Lecce, Italy
g
Division of Forensic Odontology and Disaster Oral Medicine, Department of Forensic Science, Iwate Medical University, Iwate, Japan
h
Department of Medicine and Health Sciences, University of Molise, Campobasso, Italy

A R T I C L E I N F O A B S T R A C T

Keywords: This study aimed to evaluate the reliability of an age estimation method based on the pulp⁄tooth area ratio by
Age estimation assessing intra- and inter-examiner agreement across five observers at different intervals. Using the same X-ray
Pulp/tooth area device and technical parameters, 96 digital periapical X-ray images of upper and lower canines were obtained
Observer agreement
from 28 deceased people in Central America, whose age at death ranged from 19 to 49 years. Excellent and good
Forensic odontology
Human identification
agreement of results were achieved, and there were no statistically significant differences. The R2 value for upper
Missing people teeth (54.0%) was higher than the R2 value for lower teeth (45.7%). The highest intraclass correlation coefficient
value was 0.995 (0.993–0.997) and the lowest 0.798 (0.545–0.895). Inter-examiner agreement was high with
values of 0.975 (0.965–0.983) and 0.927 (0.879–0.955). This method is adequate for assessing age in missing
and unidentified people, including victims of mass disasters.

1. Introduction The Scientific Working Group for Forensic Anthropology

(SWGANTH) states that the final age estimate is a matter of expert
Age-at-death estimation in adults remains challenging due to the judgment by synthesizing all available information. Factors to be
uncertainty involved in method selection and the challenge of making considered are: appropriateness of the reference data, skill in using one
an optimal decision for a court of law, especially in criminal cases and method over another, condition of the remains, applicability of statis­
mass disaster scenarios, where the skeletal remains are often com­ tical models, etc. [3]. In addition, the Organization of Scientific Area
mingled and incomplete [1]. Committees for Forensic Science (OSAC), which strives to strengthen
The particular value of estimating age at death in forensic contexts forensic standards, has published approved standards for age-at-death
has already been highlighted in several scientific publications [2]. estimation [4]. The aim of these forensic standards is to provide the
However, forensic estimation of age at death faces issues of time and best available up-to-date information and guidance for estimating age
cost. An added complication is that it must often be performed on small based on human dentition. They include guidelines on obtaining
body parts. One of the major aims of forensic experts is to achieve an forensic dental data and selecting the most appropriate recommended
accurate, non-destructive method of age-at-death estimation, with an methodology to establish accurate assessments of chronological age in
acceptable margin of error, to ensure accurate reporting to law humans. They are intended for practitioners performing dental age as­
enforcement, and to narrow the list of missing persons for presumptive sessments and for individuals, groups, or agencies that make use of the
identification. results. Age-at-death estimation assists in the identification of missing

* Corresponding author. Via Don Minzoni, 9, 62100, Macerata, Italy.

E-mail address: [email protected] (R. Scendoni).
1
These authors contributed equally to the drafting of the manuscript, sharing the first authorship.

https://doi.org/10.1016/j.fsisyn.2024.100484
Received 14 April 2024; Received in revised form 10 June 2024; Accepted 18 June 2024
Available online 26 June 2024
2589-871X/© 2024 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
R. Scendoni et al. Forensic Science International: Synergy 9 (2024) 100484

and unidentified individuals by narrowing search parameters. However, Table 1

dental age assessment is based on large populations of identifiable Sample distribution according to the circumstances of victims (fully identified),
human groups and involves an associated level of uncertainty, which analyzed teeth, and nationality.
needs to be quantified in the application of the method. Deceased Analyzed teeth Nationality
In a mass disaster involving a huge number of fatalities, it is neces­ Illegal burials 18 66 Mexico
sary not only to handle the bodies with respect, but also to identify them Migrants 10 30 Central America
so that families can find out what happened to their missing relatives Total 28 96
and bury them quickly (a death certificate is needed in this case). Un­
identified human remains should be deposited in registered places and
properly identified, in accordance with regulations and protocols, such Table 2
as the Minnesota Protocol [5], so that the protection of human remains Sample quantity of analyzed upper and lower
can be guaranteed until their identification. canines.
Today, Mexico faces a series of challenges in forensic practice: the so- Quantity
called “War on Drugs” has resulted in multitude deaths and missing
Upper canines 49
people as well as hundreds of illegal graves throughout the country and Lower canines 47
thousands of people internally displaced [6,7]. In addition, hundreds of Total 96
thousands of Mexicans try to cross the Mexico–United States border
annually and hundreds of these individuals die in the attempt [8].
Finally, due to its particular geographic position, surrounded by several Table 3
volcanoes (including Popocatepetl Volcano, one of the most active Distribution of cases according to the presence of canine.
stratovolcanoes in Mexico [9]), the country has been struck by several
Quantity
large earthquakes [10] and remains under constant risk of a mass
disaster [11]. Deceased people with upper right canine 25
Deceased people with upper left canine 24
Although Mexican authorities have the duty to locate and identify Deceased people with lower left canine 23
victims, Mexico lacks an official protocol to regulate the systematic Deceased people with lower right canine 24
protection of bodies [12]. In addition, while much has been published Total 96
worldwide on the most common methodologies for assessing a biolog­
ical profile [13], publications from Mexico are limited [12].
Since forensic personnel have to search for matching ante-mortem data
Dental age estimation methods are based on biological changes over
within a specific age range from a missing persons list, the most precise
time that include growth and wear. The various approaches based on the
age estimation technique should be selected in order to reduce estima­
formation and development of teeth involve the use of conventional
tion times and subjectivity. However, while different researchers express
radiographs, CT scans, or MRIs. Dental age estimation techniques are
concerns about inter- and intra-observer error [21–23], few report on
considered highly reliable in children and therefore useful in cases
the extent to which these types of error affect the accuracy or repro­
where it is important to distinguish between minor/major age. Over the
ducibility of the method being used, especially when it comes to the
years, methods have also been refined in adult subjects, resulting in
Mexican context.
reduced evaluation errors.
The main aim of this study, then, is to determine the intra- and inter-
As indicated in Solheim [14], secondary dentine apposition in a
observer agreement between five forensic experts in blind trials in order
tooth has a relatively high correlation with chronological age in adults
to assess whether reliability (intra-observer error) and reproducibility
and can be calculated using radiographic techniques. According to the
(inter-observer error) can significantly reduce errors in estimating the
last few works on this issue [15], once dental development is complete,
age of human remains, which would lead to more reliable personal
rapid secondary dentine deposition is observed in the lower canine until
identification. This can be achieved when several experts are available
the 25–30 years age group. In middle age, secondary dentine deposition
to work together as a team applying the same method.
slows down and is consistent. In the 6th decade of life, rapid dentine
formation is once again observed.
2. Material and methods
In the last two decades, several studies have been published on age
estimation using quantitative measurements of these morphological
2.1. Sample
changes on X-ray images of teeth [16]. Cameriere et al. [17], who
developed a method for assessing age based on pulp/tooth area ratio,
The sample consisted of 96 X-ray images of teeth from 28 subjects
found that canines showed the highest correlation with chronological
(26 males and 2 females): 18 deceased people of Mexican origin
age when compared with other types of teeth (e.g., incisors or
(recovered from illegal burials) and 10 deceased migrants from Central
premolars).
America (7 from Guatemala and 3 from the Dominican Republic) who
In such analyses, permanent canines are selected because they have
had been killed in car crash accidents (Table 1). All of the teeth collected
long roots and distinct pulp margins and can therefore be easily
were upper and lower healthy unaltered canines with fully formed roots
measured in both panoramic and periapical X-rays [18]. In addition,
(Tables 2 and 3), and all subjects were aged between 19 and 49 years at
they are single rooted and have the largest pulp areas among the mon­
death. Each tooth had been extracted from the dental socket without
oradicular anterior teeth [19]. Furthermore, canines are more resistant
damage, and all 96 X-ray images were analyzed by multidisciplinary
and survive longer than any other teeth regardless of age, unaffected by
the most common taphonomic and diagenetic changes (e.g., thermal
alterations) [20]. The resistance of this particular tooth against most Table 4
environmental alterations makes it a useful indicator for assessing age at Age and sex distribution of the sample.
death and for identifying victims of mass disasters. This last task is an
Sex Age groups Total
intensive and demanding mission involving specialists from various
disciplines. 19–29 30–39 40–49

Although new protocols have been developed to make the identifi­ Male 16 5 5 26
cation process faster and more accurate [4], each mass fatality incident Female 2 – – 2
Total 18 5 5 28
results in new challenges for identification teams of well-trained experts.

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R. Scendoni et al. Forensic Science International: Synergy 9 (2024) 100484

Fig. 1. A digital system was used for periapical radiography. X-ray from extracted upper right canine (a); pulp and tooth outlines are well defined (b).

Fig. 2. Digital image of a periapical X-ray from an extracted lower left canine (a); measurement of pulp area (b); measurement of tooth area (c). The polygon
selection tool in ImageJ® software (National Institute of Health, Bethesda, Maryland, USA) was used [24].

post-mortem analysis units between 2020 and 2021. Each tooth was placed in a vertical position no more than 5 cm from the
Chronological age and country of origin/birth place were confirmed digital receptor and exposed using the paralleling technique. The
when the person was fully identified by one or more scientific methods equipment was operated at 50 kV and 8 mA with an exposure time of
for human identification. Age was calculated by subtracting date of birth 0.500 ms, and the two-digit notation system proposed by the FDI World
from the date the subject went missing or died. Table 4 shows the dis­ Dental Federation (French: Fédération Dentaire Internationale) was
tribution of the sample by age (categorized into groups: 19–29, 30–39, adopted. The exclusion criteria were: visible third molar open apices,
and 40–49 years) and sex. teeth with prosthetic restorations, any sign of endodontic treatment, and
Digital periapical X-ray images were obtained in line with routine visible alterations such as wear or extensive cavities.
dental post-mortem analysis using Kodak Carestream RVG 5200 digital The five observers were of four different nationalities (Italian,
sensors and the Aribex Nomad Pro Dentalportable X-ray system (Fig. 1). Russian, Japanese, and Mexican) and each had over five years’

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R. Scendoni et al. Forensic Science International: Synergy 9 (2024) 100484

Table 5 images were saved in high resolution JPEG digital format, and dental
Results obtained regarding intra- and inter-examiner agreement according to the age assessment for each tooth was performed according to the pulp⁄tooth
intraclass correlation coefficient (ICC). area ratio method [17]. To obtain the points of tooth and pulp outlines in
Agreement analysis Examiner/ ICC (CI95%) a
Classification order to evaluate tooth and pulp areas and area ratios, the ImageJ®
type Exam public domain image processing program (National Institute of Health,
Intra-examiner ST 0.953 Excellent Bethesda, Maryland, USA) was used [24] (Fig. 2).
agreement (0.925–0.970) The following morphological variables were recorded: TA = tooth
A 0.798 Good area; PA = pulp area; date of death/disappearance; date of birth; sex;
(0.545–0.895)
and nationality. Data were entered in a single Microsoft Excel©
SE 0.995 Excellent
(0.993–0.997) (Microsoft Corp., Redmond, WA, USA) file (used by all five observers).
I 0.882 Excellent However, only the first observer (the person who collected the data of
(0.811–0.926) the whole sample) knew chronological age; the other four observers
G 0.986 Excellent performed blind age-at-death estimations in order to test the intra- and
(0.975–0.992)
Inter-examiner 1st 0.975 Excellent
inter-observer reliability [17].
agreement (0.965–0.983) The first observer assessed age at death for each of the 96 canines
2nd 0.927 Excellent within 48 h of collecting the sample. The other four observers evaluated
(0.879–0.955) age at death one month later. Two months after the first results, the five
ICC = Intraclass correlation coefficient; CI95% = Confidence interval 95%. observers evaluated twelve random cases from the twenty-eight
a
According to Landis & Koch [25]. deceased people, and the third and final evaluations were made by all
five observers on the entire sample eight months after the first
experience in the field of forensic anthropology or odontology. All ob­ evaluations.
servers were skilled at performing the age estimation method based on Cameriere et al.’s [17] linear regression equation was applied for
the pulp⁄tooth area ratio. each tooth according to upper or lower canine as follows:
A single forensic odontologist collected all dental information; the Upper canine: Age = 99.937–532.775 * PA/TA.

Fig. 3. Results of the intra-class correlation coefficient (ICC) for the five examiners.

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R. Scendoni et al. Forensic Science International: Synergy 9 (2024) 100484

Fig. 4. Plot of the inter-class correlation coefficient (ICC) of both exams.

Lower canine: Age = 89.456–461.873 * PA/TA. way random method and absolute agreement was observed in the
same evaluator at two different times (intra-examiner agreement), and
between evaluators for each examination (inter-examiner agreement)
2.2. Statistical analysis
[25].
The intraclass correlation coefficient values for four of the five ob­
The analysis was performed using the Statistical Package for the
servers showed high agreement between observers, indicating that the
Social Sciences software (SPSS version 26.0, IBM Corporation, Armonk,
measurements were strong and reliable. In one evaluator only, agree­
New York, USA). Intra- and inter-observer agreement rates for the “age
ment between evaluations was moderate. However, the results from all
at death” variable were assessed with intraclass correlation coefficients
five observers indicated significant agreement on all measurements
using a two-way random method and expressed with 95% confidence.
(Figs. 3 and 4).
Thus, we evaluated absolute agreement between the 5 observers, as well
Upper right canines provided a higher determination coefficient and
as consistency of repeated measurements by the same observer at
lower mean prediction error compared to the lower right canines be­
different times. The observers’ age-at-death estimates were compared to
tween all five observers. Therefore, upper canines offered more accurate
chronological age by linear regression, which generated the determi­
age estimation with predictions closer to chronological age compared to
nation coefficient (R2), and error parameters were calculated. A signif­
the lower canines (Fig. 5).
icance level of 5% was adopted for the entire analysis (Table 5).
The distribution of the difference between chronological and esti­
mated age at death, according to observer and tooth evaluated for age-
3. Results at-death estimation, also combining two and three teeth, are reported in
Tables 6 and 7, respectively (Tables 6 and 7).
Both intra- and inter-observer agreement were considered satisfac­
tory, in view of the good and excellent correlation coefficients (Table 5). 4. Discussion
The results indicate that the method under study could be reproduced
with confidence both by the same operator at different times and by In contexts of missing and unidentified people, age-at-death esti­
different evaluators. mates are an integral part of establishing the individual characteristics
For the agreement analysis, the data were evaluated using the two-

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R. Scendoni et al. Forensic Science International: Synergy 9 (2024) 100484

Fig. 5. R2 values for upper and lower teeth.

of the deceased person. Therefore, the proper age estimation method dental) aimed at finding specific signs of identity; these teams also use
and criteria must be selected according to the age range. radiographic examination tools to estimate sex and age [30].
Mexico is undergoing a forensic crisis regarding human identifica­ In our experience, radiography has been widely used in post-mortem
tion. According to official numbers, over 52,000 unidentified bodies are age estimation for the purposes of victim identification. Limiting the
being held in forensic facilities waiting to be fully identified, but this analysis to forensic odontology, several techniques have been developed
number could be higher [26]. to estimate chronological age in both children and adults, using the
In 2019, the state of Mexico approved the agreement and creation of relationship between age and morphological changes in the structure of
the Extraordinary Forensic Identification Mechanism (MEIF) whose the teeth, particularly dimensional changes in the pulp area in relation
main purpose is to collaborate with the national authorities in the to the tooth area [31].
identification process of unidentified deceased people in the custody of Using a single tooth in age assessment can lead to errors in age
forensic institutions. Once identified by valid scientific methods for estimation as the tooth under analysis might be the most worn down or
human identification [27,28], the deceased must be handed over to their not present in the mouth. Age assessment in forensic contexts requires
family members under decent conditions respecting human dignity in access to as much of the sample as possible in order to perform indi­
accordance with international human rights standards [29]. vidual analysis and obtain independent results per tooth to express a
Mexico has constantly high rates of kidnappings, disappearances, unique result. At least two canines are needed to perform Cameriere’s
and other criminal violence that has resulted in the deaths of tens of age estimation method [32].
thousands of people in recent years [26]. Forensic anthropologists work In the context of age assessment for forensic purposes, the impor­
with teams of forensic specialists that may include forensic pathologists, tance of intra- and inter-observer reliability in the measurement of
forensic odontologists, radiologists, fingerprint examiners, molecular odontological parameters cannot be overstated [34]. Inter-observer
biologists, mortuary technicians, photographers, and others. reliability is defined as the agreement between two or more observers.
Mass disasters are situations in which a multitude of victims need to Sometimes different observers produce different results because they do
be identified, and X-ray imaging is often a vital tool for victim identi­ not use the measurement device in the same way [33]. Differences in
fication. It is important to establish a team to carry out external exam­ readings could also be due to small random changes in the morpho­
inations and autopsies, as well as instrumental examinations (especially logical variable itself during the measurement process. Intra-observer

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R. Scendoni et al. Forensic Science International: Synergy 9 (2024) 100484

Table 6
Distribution of the difference between chronological and estimated age at death, according to observer and tooth evaluated for age estimation.
Observer Tooth R2 Mean chronological age (SD) Mean estimated age (SD) Mean difference (SD) Median difference (IQR) Mean prediction error (SD)

1 All 75.1% 29.16 (8.35) 30.74 (7.77) − 1.57 (4.12) − 2.87 (4.80) 0.49 (0.31)
13 77.4% 29.76 (8.58) 31.04 (9.23) − 1.27 (4.32) − 1.72 (6.02) 0.49 (0.32)
23 52.6% 28.93 (8.22) 30.22 (10.38) − 1.28 (7.01) − 0.80 (8.65) 0.69 (0.63)
33 63.3% 28.75 (8.29) 31.35 (7,51) − 2.60 (4.97) − 3.31 (7.69) 0.61 (0.41)
43 37.4% 28.43 (7.89) 28.97 (7.00) − 0.53 (6.43) − 0.47 (7.29) 0.62 (0.58)
2 All 67.9% 29.16 (8.35) 28.54 (8.21) 0.62 (4.81) 0.58 (3.79) 0.43 (0.47)
13 72.7% 29.76 (8.58) 29.85 (8.53) − 0.08 (4.54) 0.79 (4.80) 0.42 (0.42)
23 66.6% 28.93 (8.22) 28.95 (8.84) − 0.01 (5.08) − 0.12 (4.32) 0.43 (0.51)
33 58.4% 28.75 (8.29) 28.89 (7.87) − 0.13 (5.41) − 0.37 (6.40) 0.50 (0.50)
43 38.3% 28.43 (7.89) 26.71 (7.78) 1.71 (6.65) 1.84 (5.24) 0.61 (0.67)
3 All 68.1% 29.16 (8.35) 30.46 (7.93) − 1.29 (4.73) − 0.45 (1.64) 0.32 (0.56)
13 69.5% 29.76 (8.58) 31.29 (8.90) − 1.52 (4.93) − 0.68 (2.83) 0.41 (0.54)
23 56.8% 28.93 (8.22) 30.28 (8.72) − 1.35 (5.81) − 0.63 (1.57) 0.43 (0.66)
33 69.7% 28.75 (8.29) 30.59 (7.42) − 1.84 (4.47) − 0.62 (2.96) 0.34 (0.54)
43 42.7% 28.43 (7.89) 29.71 (7.81) − 1.28 (6.36) − 0.76 (3.13) 0.49 (0.70)
4 All 66.6% 29.16 (8.35) 28.09 (8.71) 1.07 (5.08) 0.51 (3.79) 0.44 (0.52)
13 58.5% 29.76 (8.58) 28.65 (9.72) 1.11 (6.22) 2.22 (7.97) 0.65 (0.51)
23 56.2% 28.93 (8.22) 27.95 (10.74) 0.98 (6.95) 0.92 (3.90) 0.61 (0.70)
33 70.6% 28.75 (8.29) 28.44 (8.71) 0.30 (4.70) 1.09 (4.23) 0.44 (0.43)
43 58.3% 28.43 (7.89) 27.01 (8.06) 1.42 (5.35) 2.22 (5.60) 0.56 (0.46)
5 All 45.0% 29.16 (8.35) 35.64 (10.31) − 6.48 (7.61) − 7.02 (13.80) 1.05 (0.80)
13 38.8% 29.76 (8.58) 36.90 (11.24) − 7.13 (8.71) − 6.24 (11.53) 1.14 (0.96)
23 38.2% 28.93 (8.22) 35.56 (10.97) − 6.62 (8.52) − 7.01 (13.48) 1.15 (0.84)
33 37.8% 28.75 (8.29) 35.41 (9.87) − 6.65 (7.86) − 8.31 (11.92) 1.11 (0.79)
43 26.6% 28.43 (7.89) 33.80 (9.62) − 5.36 (8.48) − 5.78 (15.04) 1.03 (0.84)
All All 57.5% 29.16 (8.35) 30.69 (8.93) − 1.53 (5.97) − 0.66 (4.75) 0.55 (0.61)
13 56.7% 29.76 (8.58) 31.54 (9.84) − 1.78 (6.52) − 0.68 (6.18) 0.62 (0.64)
23 50.5% 28.93 (8.22) 30.59 (10.16) − 1.65 (7.16) − 0.30 (6.83) 0.66 (0.71)
33 54.0% 28.75 (8.29) 30.94 (8.55) − 2.18 (6.05) − 0.93 (7.55) 0.60 (0.60)
43 37.3% 28.43 (7.89) 29.24 (8.36) − 0.80 (7.09) − 0.29 (6.83) 0.66 (0.68)

R2 = Determination coefficient; SD: Standard deviation; IQR: Interquartile range. Linear regression. Significance level = 5%.

Table 7
Distribution of the difference between chronological and estimated age at death, according to combinations of two and three teeth evaluated for age-at-death
estimation.
Teeth R2 Mean chronological age (SD) Mean estimated age (SD) Mean difference (SD) Median difference (IQR) Mean prediction error (SD)

13 and 23 54.0% 29.36 (8.26) 31.08 (9.99) − 1.72 (6.83) − 0.44 (6.61) 0.64 (0.68)
13 and 33 55.8% 29.28 (8.29) 31.25 (9.23) − 1.97 (6.29) − 0.86 (6.92) 0.61 (0.62)
13 and 43 48.6% 29.11 (8.12) 30.42 (9.20) − 1.30 (6.81) − 0.48 (6.63) 0.64 (0.66)
23 and 33 52.0% 28.84 (8.09) 30.76 (9.39) − 1.91 (6.64) − 0.68 (7.04) 0.63 (0.66)
23 and 43 44.7% 28.68 (7.91) 29.92 (9.31) − 1.23 (7.13) − 0.29 (7.03) 0.66 (0.69)
33 and 43 45.7% 28.59 (7.93) 30.07 (8.48) − 1.48 (6.63) − 0.68 (7.37) 0.63 (0.64)
13, 23 and 33 53.9% 29.16 (8.21) 31.03 (9.54) − 1.86 (6.59) − 0.68 (6.84) 0.63 (0.66)
13, 23 and 43 49.3% 29.05 (8.10) 30.47 (9.51) − 1.42 (6.92) − 0.39 (6.77) 0.65 (0.68)
13, 33 and 43 50.1% 29.00 (8.12) 30.58 (8.99) − 1.58 (6.58) − 0.68 (6.85) 0.63 (0.64)
23, 33 and 43 47.4% 28.70 (7.97) 30.25 (9.07) − 1.54 (6.80) − 0.62 (7.00) 0.64 (0.67)

R2 = Determination coefficient; SD: Standard deviation, IQR: Interquartile range. Linear regression. Significance level = 5%.

reliability, on the other hand, is defined as consistency of measurements by calculating the average of the measurements performed on multiple
by the same rater on two or more different occasions. Cohen’s K statistic dental elements collected from the corpse; the specific standard devia­
is commonly used for reliability assessments of categorical scales, while tion can be extrapolated from the same method. This certainly guaran­
intraclass correlation coefficient (ICC) or concordance correlation co­ tees greater ease of interpretation of the data, and the results can be
efficient (CCC) statistics are appropriate for continuous scales [35]. The explicitly reported to a judicial authority.
greater the difference between the results, the poorer the inter- and
intra-observer reliability of the survey [36].
4.1. Limitations
In this case study sample, the deceased subject more often had four
canines intact rather than just two. Since the linear regression equation
It is difficult to know which of the four permanent canines provides
model did not require any modification, the pulp⁄tooth area ratio
the best results in age-at-death estimation [34]. In comparison to third
method could be applied to the entire sample. In keeping with inter­
molars, canines are more susceptible to the effects of external factors
national forensic best practices, the method was validated by at least a
such as dental wear, severe or low trauma, and even food and chewing
second observer to confirm the results in age estimation [37].
frequently on one side. The forensic odontologist must be highly trained
A critical issue in the field of age estimation for forensic purposes is
to confidently and accurately mark the precise points of pulp and tooth
the interpretation of results. Combined anthropological methods are
outlines in order to calculate pulp and tooth areas followed by pulp/­
often used, but they give different results. Providing a court of law with a
tooth area ratios. At least two canines need to be evaluated for age
single result is not straightforward, given the risks of error involved in
assessment. For better results in pulp/tooth area ratios, dental X-rays
the application of different techniques. Our approach centers on a
should be obtained outside the tooth socket with digital sensors, along
consolidated forensic method for obtaining a single value which is given
with image enhancement tools for better visibility. Another limitation of

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R. Scendoni et al. Forensic Science International: Synergy 9 (2024) 100484

our study is the fact that the sample consisted predominantly of male [2] E. Baccino, A. Schmitt, Chapter 11 determination of adult age at death in the
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subjects. However, the sex variable was considered in the analyses, and
Anthropology and Medicine: Complementary Sciences from Recovery to Cause of
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