A combination of both medical examinations and non-medical methods were utilized in assessing age across the country. Admittedly, the decision to apply any method is dependent on the age and circumstances of each individual hence variation in the application of the methods is expected. The assessment of availed documents and psychosocial history were utilized in all the study facilities though devoid of any structured protocol of doing it. This is an important part of the physically-non-invasive method of assessing age which is deemed sufficient if it proofs one’s age beyond any reasonable doubt. To this end, expertise in psychology and social work is essential. Besides, patients who require age estimation could be experiencing psychologically traumatizing events and therefore require to be handled carefully and professionally without exerting undue stress. Therefore, this may be a challenge to the dentist who may not be adequately trained to apply such knowledge.16,23,24 Moreover, the European Asylum Support Office (2018) recommends that any method which is applied should be interpreted by experts who have been trained to apply that particular method. Thus, there is need to train the dentists in this regard while looking into future possibilities of incorporating the psychologists and social workers in age assessment.
The exclusive analysis of eruption patterns without imaging was utilized in some patients but dental growth charts used to derive the age were not commonly specified. There are recommendations that methods used to determine age should be specified, their accuracy and reliability should be noted and a margin of error provided in the age assessment report.25 This highlights the need to develop local guidelines on age assessment which would additionally help to absolve the clinicians when the age assessment is challenged in a court of law. The dental clinicians are likely to use familiar charts that were provided during dental training or any other that is easily accessible whether online or in print media. There is paucity of local publications on eruption patterns and the most popular local study is one published three (3) decades ago based on teeth of Kenyan Africans and Asians.26,27 Due to the secular trends of growth resulting from changing diet and other environmental factors, there is need for current data on eruption patterns in Kenya In addition; ethnicity has been found to play a role in the development of third molars.28–31
Interpretation of dental age through observation of eruption patterns should be done cautiously following a thorough dental examination since local or exogenous factors such as tooth crowding, early extraction, dental impaction and nutritional status have been found to either delay or hasten tooth eruption.32 Therefore, a reasonable margin of error should also be provided. Notably, most patients who sought age assessment services were above 16 years; hence, mostly the status of the eruption of the third molars would be utilized to determine age. Clinically missing third molars due to impaction, extraction or congenital anodontia may lead one to assess an individual as underage. This may cause future disputes with dire legal implications especially when the same individual is assessed after a few years and the age remains the same or when authentic evidence of age is reproduced later in the court of law. Therefore, a dental panoramic image is indicated as it’s also medically justified.33
Most patients had panoramic dental radiographs taken which played a role in determining the age through assessment of mineralization levels of developing tooth. A similar practice was utilized in 17 European countries; however, they were combined with hand and wrist x-rays to assess age of asylum seeking individuals.16 In this study, the dentists still utilized unspecified atlas methods to allocate age based on the level of tooth maturity. Nevertheless, tooth developmental charts/tables do not provide an age range while they are not gender specific. Newly developed age estimation methods utilise radiographs in calculating age through either utilization of tooth measurements or through staging of maturity levels and assigning a maturity score 4,5 Such mathematical methods are advantageous since they meet the criteria for age estimation methods as outlined by Ritz-Timme et al. 23 but they were not applied in the selected study centers. Therefore, further training is required on how to utilize such methods. In addition, the methods need to be validated in the Kenyan population since they have been developed using other populations. The validation of Willems method has been assessed in Kenya using a small study population and was found to be accurate, however, validation with a larger sample is still required.34
Despite having numerous radiographic age estimation methods, their credibility is still disputed since not all individuals grow at the same rate, hence, the methods may lead to over- or underestimation of age of some individuals leading to unfair judgment. 35 To this end, The International Society for Social Pediatrics and Child Health in Geneva and British Dental Association have discouraged their professionals from assessing age of asylum seekers. This is meant to protect the asylum seekers whose tooth maturity reference data is hardly documented. Further; the use of ionizing radiation for the absolute purpose of age assessment is still disputed in the United Kingdom. Nevertheless, some dental professionals support their utilization since they are associated with low ionizing radiation and are only utilized on individuals whose age is disputed. 36,37 Hence, the need for each country to evaluate their own practices and establish acceptable guidelines that will benefit those seeking age assessment services. It is recommended that the age of an individual should be determined using a reference population in which the person belongs and the most accurate method for a particular population should also be utilized. 7,14,38 Therefore, a local study on tooth eruption and developmental stages of mineralization is highly recommended. This ensures reduction of the racial and environmental influence, hence, improving accuracy and limiting the margin of error in the estimated age.
The study found that there was no utilization of any documented criteria of age assessment. Therefore, there is need to develop a national protocol so as to provide equality in provision of age assessment services and hence, avoid legal implications or violation of human rights. An online age assessment computer application is strongly recommended. Collaboration with international professional organizations or agencies that are highly experienced in age assessment is paramount. The results provide a general outlook of age assessment practices in Kenya but may not be generalized since they were based on selected hospitals. Recall and non response bias was noted where tooth maturity tables and charts referred to during age assessment were not specified. The personal and legal implication of the given age was not assessed and additional studies are recommended.