Quality Assurance in Forensic Odonto-Stomatology
IOFOS is the only world wide forensic odontology organization and data collected from more than 40 national society members show that very few pre- and post-graduate programs are dedicated to forensic odontology and education in the subject is often tutor based.
Practice in some fields of forensic odontology (e.g. bitemark) is rather concentrated in few areas of the world, so that forensic odontologists living out of these areas can hardly achieve a robust qualification in these specific fields.
In dentistry as well as in forensic odontology the final products include a certain degree of individual assessment and the personal qualification of the odontologist can remarkably affect the expertise. Thus quality assurance in these fields is more difficult to define and to implement. If too rigid rules had set, the general cultural development and personal professional improvement could even be prevented.
Quality assurance implies the adoption of measures to ensure that the task is performed to at least a minimum standard. The goal is to improve the level of quality adopting the standards recommended by IOFOS.
The following chapters try to suggest the steps which must be performed during the caseworks and in the subsequent reports. Established protocols benefit both the forensic odontologists and the general dental practitioners who are involved in forensic casework only from time to time.
IOFOS bears a general responsibility for setting up standards and especially to avoid important differences from one country to another.
IOFOS and Quality Assurance: 2003- 2005
During 2003 the executive of IOFOS drafted working procedures for quality assurance at an international level.
IOFOS then called for an international workshop at Hafjell, Norway ( March 11-14 2004 ). About 30 participants from different corners of the world attended this meeting and contributed additional suggestions. It was soon apparent that practices varied considerably. It also became evident that what is good practice in one country, could be impossible to implement in another. The only way to solve these problems was to separate recommended steps in two types.
1. Steps which should be applied in all cases (required)
2. Steps which may be optional and applicable only in certain countries (recommended)
After the meeting, the suggested steps of quality assurance were edited into a more logic sequence, taking into accounts most of the suggestions from the meeting. These drafts were then distributed to all presidents of the IOFOS member associations for comments. Those were incorporated, and further improvements were made by the IOFOS executive Board.
IOFOS and Quality Assurance: 2016-2018
In 2016 the IOFOS Board promoted an updating process of the IOFOS recommendations on Quality assurance.
First, the IOFOS Board considered if other topics should have to be added and considered for recommendations or if the topic originally established be widened. The original topics were maintained and six subgroups were established to deal with the following six different topics: 1-Identification, single cases; 2- Identification after disasters; 3- Age estimation; 4- Tooth marks; 5- Dental injuries; 6- Forensic odontology report
The Subgroups worked separately but following the same approach that consisted of: 1- collection of relevant scientific publications; international or national guidelines, protocols or recommendations; 2- discussion; 3- elaboraton of the 1st draft of the updated recommendations. During the last part of the discussion the subgroup on bitemark stopped the activity since no agreement could be found. On the contrary the drafts of the recommendations # 1- # 3 and # 5- #6 were discussed during the pre-conference closed meeting, restricted to the members of the subgroups, held in Leuven, September 2017. A 2nd draft for each recommendation was elaborated and then presented to the IOFOS General Assembly that was held in Leuven as well. Comments were then received and implemented during the following months. The 3rd draft of the recommendations was then published in the IOFOS website and comments were asked to the national member societies. The received comments were collected and considered by the coordinator of each subgroup and the updated final version of the IOFOS recommendations was issued in August 2018.
Quality Assurance at three levels
The most basic level to ensure quality is to describe the various steps taken during an examination and evaluation. During the revision and updating of previous IOFOS recommendations (IOFOS, 2005) some steps forward were possible on an international level for the second and third level.
The second level would be to provide standards or recommendations about the specific methods to be used at each step. The methods can vary according to the reference populations (age estimation, e.g.) or national practices, thus international recommendations cannot catch all these variabilities. Therefore, with a few exceptions, no standards or recommendations are provided for the second level. Recommendations on specific methods could be more easily implemented on a national level and ought to be explored for national quality assurance efforts.
The third level, which is usually where the industry works, is to describe what a quality result is. An example may be the exact measurement of an item and the limits of variation accepted in its production. If we doubt that we will ever be able to implement this level sensu strictu in forensic odontology, some standards have been clearly dictated for results and conclusions.
The New Quality Assurance recommendations
The recommendations are divided according to the topics defined in 2005 and the same topics are maintained in the updated version in 2018. Recommendations on tooth marks have not updated yet since the bitemark analysis and evidence from bitemark have been highly questioned in some countries. Different opinions of experts and national societies are under consideration at the moment towards a possible revision and update of IOFOS recommendations also on tooth marks. The General Assembly of IOFOS held in Leuven, September 2017, decided to maintain the former recommendations on bitemark until IOFOS will be able to issue a revised and updated version.
Some overlapping and differences – for example in “identification” and “identification after disasters” – have been avoided in the 2018 new version of recommendations. For instance, the conclusions of the ID procedures were modified and merged.
Given the huge variability of approaches at the international level or the differences of caseworks in these wide fields of forensic odontology, the IOFOS recommendations 2005 provided black steps and blue steps. This approach was maintained for the new and updated IOFOS recommendations 2018 with the only exception of age estimation. In this case a more flexible approach was adopted given the variability of methods adopted according to the different legal thresholds, the reference populations, the tolerable errors, etc. As explained in recommendation #6 (Report in Forensic Odontology) the black steps are generally intended as standards, which apply to all cases and shall not be omitted without an explanation.
Instead, the steps marked in blue are optional.
They are intended as recommendations and they can be omitted without any explanation.
We also hope that the IOFOS recommendations on Quality Assurance 2018 will be accepted by the member societies. Their members will then be requested to follow the IOFOS quality assurance recommendations in their daily activity. We also suggest the forensic odontologists to declare in their reports that the IOFOS recommendations for quality assurance have been followed.
Since quality assurance should never be static, its guidelines should be periodically reconsidered and – if possible – continuously updated according to the actual scientific advancements and practice improvements.
The IOFOS executive takes the commitment for further improvements and updating of the IOFOS recommendations for quality assurance in the future.
IOFOS Executive, December 2004
Tore Solheim (president), Sigrid Kvaal (vice-president and secretary), Leif Grusd (cashier), Wencke Stene-Johansen (editor)
IOFOS executives that worked on the guidelines updating project
2014-2017: Vilma Pinchi (President); Hrvoje Brkic (Vice-President); Francesco Pradella (Secretary); Patrick Thevissen (Editor of JFOS, Treasurer); Ruediger Lessig (Editor of IOFOS newsletter); Stefano Garatti (webmaster)
2017-2020: Hrvoje Brkic (President); Ruediger Lessig (Vice-President), Ricardo Henrique Alves da Silva (Secretary); Patrick Thevissen (Treasurer) Vilma Pinchi (JFOS Editor,); Marin Vodanovic(Editor of IOFOS newsletter) ; Stefano Garatti (webmaster)