Diagnostic efficacy of alveolar bone loss of the mandible for identifying postmenopausal women with femoral osteoporosis

Radiomorphometric indices of the mandible as indicators of decreased bone mineral density and osteoporosis - meta-analysis and systematic review

This review aims to evaluate the accuracy of various mandibular radiomorphometric indices in comparison with DEXA BMD measurements in the diagnosis of osteopenia and osteoporosis based on a meta-analysis of the sensitivity and specificity of the indices. PRISMA statement was followed. The materials for analysis were collected in August 2023 by searching three databases: PubMed Central, Web of Science, and Scopus. The selection of studies consisted of three selection stages, and 64 articles were finally obtained. Quality assessment was performed with the QUADAS-2 tool, and the general methodological quality of retrieved studies was low. Statistical analysis was performed based on 2 × 2 tables and estimated sensitivity and specificity were obtained using SROC curves. The most used indices were MCI, MCW and PMI. The best results in detecting reduced BMD obtained for MCW ≤ 3 mm, estimated sensitivity and specificity were 0.712 (95% CI, 0.477-0.870) and 0.804 (95% CI, 0.589-0.921), respectively. The most prone to the risk of bias is the MCI due to the examiner's subjectivism. Radiomorphometric indices of the mandible can be useful as a screening tool to identify patients with low BMD, but should not be used as a diagnostic method. Further research needs to focus on analysing the ability of the indices to detect osteoporosis and also in combination the indices with clinical parameters.

Panoramic Indices: An Aid to Early Detection of Patients with Low Bone Mineral Density

Objective An early identification of patients who are at an obvious increased risk of osteoporosis and subsequent high risk of pathological bone fractures is important to prevent morbidity and its subsequent impact on the quality of life of the affected patients. Dental professionals have a chance of identifying such cases in their very initial stages through routinely prescribed dental radiographs. The aim of this study was to assess the influence of gender and age on different parameters of alveolar bone loss using orthopantomograph (OPG) as an aid to identify patients with low bone mineral density (BMD).

Materials and Methods This study included eighty subjects in whom after taking OPGs, mandibular cortical index (MCI), mandibular cortical width (MCW), and panoramic mandibular index were assessed, while the results obtained were subjected to statistical analysis. One-way analysis of variance followed by Tukey's test was used to compare the means, while p-value less than 0.05 was considered statistically significant.

Results The findings of this study revealed a significant association between MCI and age for females, with C2 and C3 categories being more common with advancing age. Also, a significant difference could be seen in relation to gender (p-value = 0.0315) for MCW with a concomitant decrease in the values of MCW in females over 60 years of age.

Conclusion Panoramic radiographic measurements could provide valuable information and help in screening patients with low BMD.

Osteoporosis and periodontal diseases - An update on their association and mechanistic links

Periodontitis and osteoporosis are prevalent inflammation-associated skeletal disorders that pose significant public health challenges to our aging population. Both periodontitis and osteoporosis are bone disorders closely associated with inflammation and aging. There has been consistent intrigue on whether a systemic skeletal disease such as osteoporosis will amplify the alveolar bone loss in periodontitis. A survey of the literature published in the past 25 years indicates that systemic low bone mineral density (BMD) is associated with alveolar bone loss, while recent evidence also suggests a correlation between clinical attachment loss and other parameters of periodontitis. Inflammation and its influence on bone remodeling play critical roles in the pathogenesis of both osteoporosis and periodontitis and could serve as the central mechanistic link between these disorders. Enhanced cytokine production and elevated inflammatory response exacerbate osteoclastic bone resorption while inhibiting osteoblastic bone formation, resulting in a net bone loss. With aging, accumulation of oxidative stress and cellular senescence drive the progression of osteoporosis and exacerbation of periodontitis. Vitamin D deficiency and smoking are shared risk factors and may mediate the connection between osteoporosis and periodontitis, through increasing oxidative stress and impairing host response to inflammation. With the connection between systemic and localized bone loss in mind, routine dental exams and intraoral radiographs may serve as a low-cost screening tool for low systemic BMD and increased fracture risk. Conversely, patients with fracture risk beyond the intervention threshold are at greater risk for developing severe periodontitis and undergo tooth loss. Various Food and Drug Administration-approved therapies for osteoporosis have shown promising results for treating periodontitis. Understanding the molecular mechanisms underlying their connection sheds light on potential therapeutic strategies that may facilitate co-management of systemic and localized bone loss.

Diagnostic Validity of Orthopantomogram Compared to Dual Energy X-ray Absorptiometry Scan in Detecting Osteoporosis

Introduction Osteoporosis is one of the most common and rampant metabolic bone disorders among the geriatric, particularly affecting postmenopausal women. Even though resorption tends to occur more rapidly in bones with a higher proportion of trabecular bone (e.g., vertebrae, pelvis, calcaneus), bones with significant cortical bone content also do undergo resorption, for example, mandible. The dental manifestations that may indicate low-bone density include loose teeth, receding gums, and ill-fitting or loose dentures.

Objective To validate the efficacy of orthopantomograms (OPGs) in recognizing bone mineral density (BMD) changes of the mandible using mandibular cortical index (MCI) and substantiate the same with dual energy X-ray absorptiometry (DEXA) scan on femoral neck and spine.

Materials and Methods This cross-sectional study comprised 60 geriatric patients of both genders. All the patients were subjected to panoramic radiographs wherever clinically indicated. The visual analysis was done based on the radiographic appearance of the mandibular cortical border and results were compared with DEXA scan reports, followed by an analysis of three grades of MCI and BMD statistically.

Results In our study, out of 40 patients in C2 and C3 subgroups, 67% and 20% were normal, respectively. The incidence of osteopenia was 33% in the C2 group and 70% in the C3 group, whereas Osteoporosis was present only among 10% of the population in the C3 group. The difference between the groups are statistically significant (p = 0.01). These findings imply that a progressive link exists between BMD and deteriorating cortical morphology.

Conclusion The purpose of this study is that dentists will be able to refer patients to physicians of suspected low BMD, based on incidental findings on panoramic radiographs for further examination. There is a statistically significant correlation present between DEXA and MCI, so the latter can also be used for screening BMD changes.

Osteoporotic alterations in a group of different ethnicity Brazilian postmenopausal women: An observational study

OBJECTIVES

To compare peripheral bone mineral density alterations among Brazilian postmenopausal women from three ethnic groups considering age and body mass index influence; to correlate their bone mineral density with the mandibular cortical index (MCI); and to evaluate the influence of age, body mass index and ethnicity in the MCI using risk factor analysis.

BACKGROUND

Osteoporosis risk is known to have ethical influences. However, little is known about the differences in ethnicity in radiomorphometric indices.

MATERIALS AND METHODS

A total of 150 postmenopausal women with different ethnicities (Caucasian, Asian and Afro-descendant) who underwent peripheral dual X-ray absorptiometry and panoramic examination were included. Bone mineral density and MCI were assessed. Adjusted odds ratio analyses were performed on bone density and MCI considering the effect of age, ethnicity and body mass index. The correlations between the MCI and the dual X-ray absorptiometry results were made.

RESULTS

Old age, low body mass index and non-Afro-descendant were associated with low bone density. Compared with Afro-descendants, Asians and Caucasians have higher chances of having decreased bone mass. For the MCI, statistical analysis showed that age is the only variable associated with osteoporotic alterations in the mandible. Furthermore, an inverse correlation was found between the MCI and the T-scores.

CONCLUSION

Bone density is higher in Brazilian Afro-descendant women than in Caucasians and Asians. Patient's age is associated with bone density and the MCI. The mandibular cortical index is inversely correlated with the peripheral densitometry results within the study ethnic population.

Association between number of teeth present and mandibular cortical erosion in Japanese men and women aged 40 years and older: A cross-sectional study

Mandibular cortical erosion detected on dental panoramic radiographs is associated with increased risk of osteoporosis in older adults. Additionally, many reports have demonstrated an association between decreased number of teeth present and osteoporosis. However, whether mandibular cortical erosion is associated with a decreased number of teeth remains unclear. The purpose of this study, therefore, was to clarify the association between mandibular cortical erosion and number of teeth present in Japanese men and women aged 40 years and older. Among patients who visited our university hospital and underwent dental panoramic radiography for the diagnosis of dental diseases, 839 patients (293 men and 546 women) aged 40–89 years (mean [SD], 63.7 [10.6] years) participated in this study. Multiple regression analysis revealed that mildly to moderately eroded cortex (p = 0.007) and severe eroded cortex (p < 0.001) were significantly associated with a decreased number of teeth present. Analysis of covariance adjusted for covariates revealed a significant association between mandibular cortical erosion category and number of teeth present (p < 0.001). Subjects with a severely eroded cortex had significantly fewer teeth present than those with a normal cortex (mean [SE], 20.7 [0.5] vs. 23.4 [0.3], p < 0.001) or mildly to moderately eroded cortex (22.2 [0.4], p = 0.04). Subjects with a mildly to moderately eroded cortex had significantly fewer teeth present than those with a normal cortex (p = 0.033). Our results suggest the significant association between mandibular cortical erosion and number of teeth present in Japanese men and women aged 40 years and older.

IDIOS: An innovative index for evaluating dental imaging-based osteoporosis screening indices

Purpose

The goal of this study was to develop a new index as an objective reference for evaluating current and newly developed indices used for osteoporosis screening based on dental images. Its name; IDIOS, stands for Index of Dental-imaging Indices of Osteoporosis Screening.

Materials and Methods

A comprehensive PubMed search was conducted to retrieve studies on dental imaging-based indices for osteoporosis screening. The results of the eligible studies, along with other relevant criteria, were used to develop IDIOS, which has scores ranging from 0 (0%) to 15 (100%). The indices presented in the studies we included were then evaluated using IDIOS.

Results

The 104 studies that were included utilized 24, 4, and 9 indices derived from panoramic, periapical, and computed tomographic/cone-beam computed tomographic techniques, respectively. The IDIOS scores for these indices ranged from 0 (0%) to 11.75 (78.32%).

Conclusion

IDIOS is a valuable reference index that facilitates the evaluation of other dental imaging-based osteoporosis screening indices. Furthermore, IDIOS can be utilized to evaluate the accuracy of newly developed indices.

Utilization of computer-aided detection system in diagnosing unilateral maxillary sinusitis on panoramic radiographs

OBJECTIVES

It is unclear whether computer-aided detection (CAD) systems for panoramic radiography can help inexperienced dentists to diagnose maxillary sinusitis. The aim of this study was to clarify whether a CAD system for panoramic radiography can contribute to improved diagnostic performance for maxillary sinusitis by inexperienced dentists.

METHODS

The panoramic radiographs of 49 patients with maxillary sinusitis and 49 patients with healthy sinuses were evaluated in this study. The diagnostic performance of the CAD system was determined. 12 inexperienced dentists and 4 expert oral and maxillofacial radiologists observed the total of 98 panoramic radiographs and judged the presence or absence of maxillary sinusitis, under conditions with and without the support of the CAD system. The receiver operating characteristic curves of the two groups were compared.

RESULTS

The CAD system provided sensitivity of 77.6%, specificity of 69.4% and accuracy of 73.5%. The diagnostic performance of the inexperienced dentists increased with the support of the CAD system. When the inexperienced dentists diagnosed maxillary sinusitis with CAD support, the area under the curve (AUC) was significantly higher than that without CAD support. When the focus was only on panoramic radiographs in which CAD support led to a correct diagnosis, the AUC of the inexperienced dentists increased to an equivalent level to that of the experienced radiologists.

CONCLUSIONS

The CAD system supported the inexperienced dentists in diagnosing maxillary sinusitis on the panoramic radiographs. If the accuracy of the CAD system can be increased, the benefits of CAD support will be further enhanced.

Panoramic measures for oral bone mass in detecting osteoporosis: a systematic review and meta-analysis

Different quantitative and qualitative indices calculated on oral panoramic radiographs have been proposed as useful tools to screen for reduced skeletal bone mineral density (BMD). Our aim was to systematically review the literature on linear and qualitative panoramic measures and to assess the accuracy of these indices by performing a meta-analysis of their sensitivity and specificity. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement was followed. Fifty studies were included in the qualitative appraisal and 19 were considered for meta-analysis. The methodological quality of the retrieved studies, assessed with the QUADAS-2 tool, was on average low. Three indices were reported by most of the studies: mandibular cortical width, panoramic mandibular index, and the Klemetti index. Mandibular cortical width presented with a better accuracy in excluding osteopenia/osteoporosis (specificity), since patients with a cortical width more than 4 mm had a normal BMD in 90% of the cases. Almost all studies used a cutoff of 0.3 for the panoramic mandibular index, resulting in an estimated sensitivity and specificity in detecting reduced BMD, respectively, of 0.723 (SE 0.160; 95% confidence interval [CI], 0.352-0.926) and 0.733 (SE 0.066; 95% CI, 0.587-0.841). The presence of any kind of mandibular cortical erosion gave an estimated sensitivity and specificity in detecting reduced BMD, respectively, of 0.789 (SE 0.031; 95% CI, 0.721-0.843) and 0.562 (SE 0.047; 95% CI, 0.47-0.651) and a sensitivity and specificity in detecting osteoporosis, respectively, of 0.806 (SE 0.105; 95% CI, 0.528-0.9200) and 0.643 (SE 0.109; 95% CI, 0.417-0.820). The mandibular cortical width, panoramic mandibular index, and Klemetti index are overall useful tools that potentially could be used by dentists to screen for low BMD. Their limitations are mainly related to the experience/agreement between different operators and the different image quality and magnification of the panoramic radiographs.

Y, Rakesh N, Reddy SS, Santana N, Shetty N. Relationship between femur bone mineral density, body mass index and dental panoramic mandibular cortical width in diagnosis of elderly postmenopausal women with osteoporosis

OBJECTIVES

To measure and determine mandibular cortical width (MCW) on the panoramic radiographs, to evaluate the usefulness of the method in identifying postmenopausal women with low femoral bone mineral densities (f- BMD) and to correlate the radiographic findings on panoramic radiographs with the f-BMD assessed by dual X-ray absorptiometry (DXA) to predict the efficacy of the radiographic method in diagnosing osteoporosis.

MATERIALS AND METHODS

One hundred and twenty postmenopausal women (60 normal and 60 osteoporotic) in the age group of 50-75 y with f-BMD assessed by DXA had undergone panoramic radiographic examination. The patients were classified as normal (T-score ≥ -1.0) and osteoporotic (T-score ≤ -2.5). MCW on panoramic radiographs was measured bilaterally at the mental foramen region with a caliper and their mean was used as the exposure measure in the analysis.

RESULTS

Student t-test showed that mean f-BMD, BMI and MCW was found be less in osteoporotic patients as compared to normal group with a statistically significant p-value < 0.001. Pearson correlation coefficient test revealed that MCW correlated positively with f-BMD and showed a significant decrease with age of the patient.

CONCLUSION

Postmenopausal women with low f-BMD had thinner mandibular cortex at the mental foramen region when compared to normal subjects and are more susceptible to femoral neck fractures. Mandibular inferior cortical width at the mental foramen region could be used to identify postmenopausal women with low f- BMD. Hence, dental panoramic radiographs serve as a useful screening tool for early diagnosis of osteoporotic fractures.

Risk factors for periodontal disease

Risk factors play an important role in an individual's response to periodontal infection. Identification of these risk factors helps to target patients for prevention and treatment, with modification of risk factors critical to the control of periodontal disease. Shifts in our understanding of periodontal disease prevalence, and advances in scientific methodology and statistical analysis in the last few decades, have allowed identification of several major systemic risk factors for periodontal disease. The first change in our thinking was the understanding that periodontal disease is not universal, but that severe forms are found only in a portion of the adult population who show abnormal susceptibility. Analysis of risk factors and the ability to statistically adjust and stratify populations to eliminate the effects of confounding factors have allowed identification of independent risk factors. These independent but modifiable, risk factors for periodontal disease include lifestyle factors, such as smoking and alcohol consumption. They also include diseases and unhealthy conditions such as diabetes mellitus, obesity, metabolic syndrome, osteoporosis, and low dietary calcium and vitamin D. These risk factors are modifiable and their management is a major component of the contemporary care of many periodontal patients. Genetic factors also play a role in periodontal disease and allow one to target individuals for prevention and early detection. The role of genetic factors in aggressive periodontitis is clear. However, although genetic factors (i.e., specific genes) are strongly suspected to have an association with chronic adult periodontitis, there is as yet no clear evidence for this in the general population. It is important to pursue efforts to identify genetic factors associated with chronic periodontitis because such factors have potential in identifying patients who have a high susceptibility for development of this disease. Many of the systemic risk factors for periodontal disease, such as smoking, diabetes and obesity, and osteoporosis in postmenopausal women, are relatively common and can be expected to affect most patients with periodontal disease seen in clinics and dental practices. Hence, risk factor identification and management has become a key component of care for periodontal patients.

Can mandibular bone resorption predict hip fracture in elderly women? A systematic review of diagnostic test accuracy

OBJECTIVES

The aim of this systematic review was to determine the diagnostic accuracy of the mandibular cortical width measurements and porosity in detecting hip osteoporosis.

BACKGROUND

All of the included studies used measurements on panoramic radiographs.

MATERIALS AND METHODS

Studies were included if they compared the radiographic measurements (or index tests) with central dual energy X-ray absorptiometry (DXA) of the hip as the reference standard. A measure of diagnostic accuracy such as sensitivity and specificity or area under the receiver operating characteristic curve was also required for inclusion.

RESULTS

Seven studies were identified. Meta-analysis was not possible because of the heterogeneity of the studies. The studies all demonstrated moderate diagnostic accuracy.

CONCLUSION

If a patient with a thin or porous mandibular cortex is identified by a chance radiographic finding, additional clinical risk factors need to be considered and the patient referred for further investigation with DXA where necessary.

Panoramic radiomorphometry and vertebral fractures in Spanish postmenopausal women

OBJECTIVE

To evaluate the relationship between panoramic radiomorphometric indexes, and the presence of osteoporotic fractures in a Spanish postmenopausal women.

METHODS

A sample of 120 women (60 with fragility spine fractures and 60 healthy), aged 55-70 years, with fragility spine fractures, were included in this cross-sectional study that was conducted from 2008 to 2011. All the women were referred to undergo a radiological spine examination, spinal densitometry and a panoramic radiograph for assessing osteoporosis using 3 radiomorphometric indexes: Panoramic Mandibular Index (PMI), Mental Index (MI) and Mandibular Cortical Index (MCI). According to mandibular cortical shape, in MCI, three groups were defined: C3 (osteoporosis), C2 (osteopenia), C1 (health).

RESULTS

Significant differences were found between all the MCI groups due to their composition between fractures and non-fractures. C1 group (healthy) has less fractures women than C2 (Bonferroni p<0.001), C1 has less fractures than C3 (Bonferroni p<0.001) and finally, C2 has less fractures than C3 (Bonferroni p<0.006). PMI and MI values were significantly lower in cases than in controls (U Mann-Whitney p<0.001).

CONCLUSIONS

Panoramic radiomorphometrics mandibular indexes such as MCI, PMI, and MI, may be useful for identifying the population at higher risk for fracture. The relationship between panoramic index and osteoporosis remains unclear and further studies using fragility fracture as a real marker of osteoporosis are warranted to clarify the exact role and effect of one condition on the other and the corresponding clinical implications.

Osteoporosis, fragility fracture, and periodontal disease: a cross-sectional study in Spanish postmenopausal women

OBJECTIVE

Osteoporosis and periodontitis are common disorders that affect aging populations. It has been hypothesized that both conditions may be related. The aim of this study was to evaluate the relationship between osteoporosis and periodontitis using vertebral fragility fracture as a real marker of osteoporosis and periodontal clinical examination to define periodontitis.

METHODS

Six hundred thirty-four women aged 55 to 70 years, with fragility spine fractures, and living in the same healthcare region of Seville, Spain, were invited to take part in this cross-sectional study conducted from 2008 to 2010. All the women included in the study were referred to undergo spine radiological examination, spinal densitometry, and full-mouth periodontal assessment.

RESULTS

With the exception of number of teeth (19 in the fractured postmenopausal group and 23 in the control group; P < 0.007) and sites with a clinical attachment level lower than 7 mm (P < 0.048), there were no significant differences in clinical and periodontal parameters among women in the fractured postmenopausal group and the control group. In short, fractured postmenopausal women have lost more teeth with more advanced attachment loss (clinical attachment level >7 mm). None of the definitions of periodontitis used resulted in significant differences between groups.

CONCLUSIONS

The relationship between periodontitis and osteoporosis remains unclear, and further studies considering fragility fracture as a real marker of osteoporosis are warranted to clarify the exact role and effect of one condition on the other and the corresponding clinical implications.

The facial skeleton in patients with osteoporosis: a field for disease signs and treatment complications

Osteoporosis affects all bones, including those of the facial skeleton. To date the facial bones have not drawn much attention due to the minimal probability of morbid fractures. Hearing and dentition loss due to osteoporosis has been reported. New research findings suggest that radiologic examination of the facial skeleton can be a cost-effective adjunct to complement the early diagnosis and the follow up of osteoporosis patients. Bone-mass preservation treatments have been associated with osteomyelitis of the jawbones, a condition commonly described as osteonecrosis of the jaws (ONJ). The facial skeleton, where alimentary tract mucosa attaches directly to periosteum and teeth which lie in their sockets of alveolar bone, is an area unique for the early detection of osteoporosis but also for the prevention of treatment-associated complications. We review facial bone involvement in patients with osteoporosis and we present data that make the multidisciplinary approach of these patients more appealing for both practitioners and dentists. With regard to ONJ, a tabular summary with currently available evidence is provided to facilitate multidisciplinary practice coordination for the treatment of patients receiving bisphosphonates.

Triage screening for osteoporosis in dental clinics using panoramic radiographs

Many patients with osteoporosis go undiagnosed because typically no symptoms are present before a fracture. Triage screening to refer patients to appropriate medical professionals for further investigation would be useful to address the increase in the incidence of osteoporotic fractures. Dental clinics may offer a new triage screening pathway because dentists frequently take radiographs of bones in the course of dental treatment. A major premise for such triage screening in dental clinics is that dentists can readily use a screening tool in their dental practice. For example, cortical width and shape of the mandible detected on panoramic radiographs may be appropriate indices for triaging individuals with osteoporosis. To date, several investigators have demonstrated significant associations between cortical indices on panoramic radiographs and bone mineral density of the skeleton generally, such as the spine and femur, biochemical markers of bone turnover and risk of osteoporotic fractures. Further, in two recent Japanese clinical trials, approximately 95% of women who were identified by trained dentists in their clinics using cortical shape findings did have osteopenia or osteoporosis. These findings support the possibility that dental clinics may offer a new triage platform to identify individuals with otherwise undetected osteoporosis.

Radiomorphometric indices and their relation to alveolar bone loss in completely edentulous Turkish patients: a retrospective study

STATEMENT OF PROBLEM

In edentulous patients, alveolar bone loss is a critical factor that affects denture retention, stability, and masticatory function. In addition to their use for the assessment of bone quality, panoramic radiomorphometric indices have been used to observe signs of bone resorption. Currently, there is no published data on the possible relationships between bone loss, radiomorphometric indices, and edentulism.

PURPOSE

The purpose of this study was to investigate the influence of age and gender on the mandibular cortical index, panoramic mandibular index, and mandibular cortical width, as well as alveolar bone loss and bone height, using panoramic radiographs of patients having been edentulous for more than 2 years.

MATERIAL AND METHODS

Panoramic radiographs of 94 edentulous patients (41.5% men and 58.5% women) were assessed. In addition to gender and age, the mandibular cortical index (normal cortex, mild or severe erosions on endosteal margin of the mandible), panoramic mandibular index, mandibular cortical width at the mental foramen region, alveolar bone loss, and bone heights of the premolar and molar regions of the mandible were recorded. Statistical comparisons were performed using chi-square, Mann-Whitney U, Kruskal-Wallis, and 2-way ANOVA tests (alpha=.05).

RESULTS

Mild erosions on the endosteal margin of the mandible were more frequently seen in age groups of <or=60, and severe erosions on the endosteal margin of the mandible were more frequently observed in age groups of >60 in women (P<.001). While the mean values of the mandibular cortical width were stable as age increased in men, the mean mandibular cortical width values decreased significantly with age in women (P<.01). The panoramic mandibular index, alveolar bone loss, and bone heights were not affected by age or gender.

CONCLUSIONS

Severe erosions on the endosteal margin of the mandible are seen more frequently in women over 60 years in age. While mean mandibular cortical width values are stable in men over 60 years, mean mandibular cortical width values decrease significantly in women of the same age group.