Ras Al-Khaimah Medical and Health Sciences

University of Ras AL-Khaimah

College of Dental Sciences
(RAKCODS)

[OSTEOPOROSIS IN
POSTMENOPAUSAL WOMEN]

Done By: Rahma Omar

Supervised By: Dr.Hala Zakaria

Dept Oral Radiology, Diagnosis & Oral Medicine

Research Project - DRP 511/522

 Abstract
Purpose
The purpose of this review of the literature was to evaluate the different modalities of diagnosis
of Osteoporosis such as, radiographs, biochemical bone markers investigations. As well as
assessing the Correlation of osteoporosis with both local and systemic diseases.

Methodology
The study was a retrospective cross sectional, literature review, comparative study involving
postmenopausal women ranging from age 45- 65 years old. With the use of electronic (pubmed)
and hand searching methods (journals and books) who’s titles included the terms; digital
panoramic radiographs, dental cone beam computed tomography, biochemical bone markers,
local and systemic diseases, such as periodontitis, bisphosphonate-related osteonecrosis of the
jaw ,myasthenia gravis, type-II diabetes mellitus,, and their association with osteoporosis were
all included. The reported data included baseline characteristics of the study population (age, co-
morbidities, history of fractures, Body Mass Density , Body Mass Index, height and weight),
clinical features of osteoporosis (mandibular, femoral and lumbar vertebrae bone loss)

Results

Fractures induced by Osteoporosis in postmenopausal women could be detected in its early

stages , by well-trained dentists on radiomorphometric indices, and prevented, though further
referral to a physician would be necessary .

Conclusion
Age >or =45 years, female sex, and patients under corticosteroid treatments were the most
common characteristics of those who developed osteoporosis. Dentists usage of a computer
software program with digitally produced panoramic dental radiographs supplemented by a few
clinical questions, can detect who are at early, high risk of developing osteoporosis, therefore,
facilitating onward referral to medical colleagues.

KEYWORDS: Osteoporosis, postmenopausal women, co-morbidities, panoramic radiographs,

DEXA, Tooth loss.

Osteoporosis in postmenopausal women Page 1

Thesis objectives:

1. Learn examples on how to review panoramic radiographs to screen for early detection of
systemic diseases, and their limitation in detecting osteoporosis.

2. Learn dental radiographs limitations in detecting osteoporosis.

3. Learn the associated diseases with osteoporosis.

4. Learn other means in diagnosis of osteoporosis.

Osteoporosis in postmenopausal women Page 2

Table of contents

Abstract 1
Tables and Figures figure I 6

Table I 7
Table II 7

Table III 7
Figure II 11

Figure III 13
Table IV 16

Figure IV 18

Figure V 20
Figure VI 21

Table V 23

Thesis
Table VIObjectives 24 2
Introduction 4
Thesis Body 5
Conclusion 28
Results 29
Recommendations 29
Acknowledgment 30
References 31

Osteoporosis in postmenopausal women Page 3

Introduction

Osteoporosis is one of the most prevalent conditions associated with aging and is thus a major
public health problem. It is characterized by compromised bone strength, is frequently not
detected until a fracture occurs and is considered to be a silent disease that entails significant
social and economic burdens.

Osteoporosis risk factors include smoking, alcohol consumption, physical inactivity, genetics,
low calcium intake, drug therapy with glucocorticoids, antiepileptic and anticoagulant drugs and
diseases which affect bone metabolism.

It is known that after the age of thirty five the bone mass density (BMD) of men and women
gradually decreases with increasing age. Women tend to lose BMD more rapidly than men,
especially after the menopause as reported by( verheij JG, 2009). As a result osteoporosis is three
times more common among women than men.

The rate of bone loss has been reported to vary from 0.5 to 1% per year. Osteoporosis is defined
as a “skeletal disorder characterized by low bone mass and micro architectural deterioration of
bone tissue leading to enhanced bone fragility, with consequent increase in fracture risk.
Osteoporosis is usually diagnosed by BMD measurements, expressed as a T- score.

According to World Health Organization (WHO) criteria, BMD values are divided into
following clinical guidelines: normal (T –score > -1.0), osteopenia (T-score between -1.0 and
-2.5), and osteoporosis (T-score < -2.5).

Osteoporotic fractures are associated with substantial morbidity and high mortality risk involving
spine, hip, forearm and proximal humerus and among them hip fractures incur the greatest
morbidity and mortality, and give rise to the highest direct costs for health services.

When talking about the oral signs in a patient with osteoporosis, we are talking about the number
of teeth present (N), mandibular cortical width, alveolar bone resorption, and the morphologic
classification of the inferior cortex on panoramic radiograph. The number of teeth present was
highly related to the probability of thoracic spine fracture and was used to derive the probability

Osteoporosis in postmenopausal women Page 4

equation for the presence of thoracic spine fracture: probability value = 1/ (1 + e-z), Z = 18.68-
0.29 age -0.27N.

A probability it value higher than 0.5 suggests the possibility of thoracic spine fracture. It was
concluded that this equation could serve as a simple and useful tool for dentists to assess the
possibility of latent osteoporosis reported by( Tagudhi A, 1995).

In a study reported mandibular body to be the most appropriate site for any planned assessment
of validity of mandibular measurements as a predictor of general bone mass. Various studies
have reported that decreased BMD affects the morphometric, densitometric and architectural
properties of mandibular bone.

Although bone densitometry is accepted as the gold standard in diagnosis of osteoporosis and a
large number of methods for assessment of bone loss have been proposed (dual photon
absorptiometry (DPA), dual energy X-ray absorptiometry (DXA), single photon absorptiometry
(SPA), quantitative computed tomography (QCT), one of the simplest method in the dental
evaluation of mandibular bone loss is dental panoramic radiograph.

Our first aim of this literature review was to draw a comparison between the previously done
studies and the methods which have been used to diagnose osteoporosis as a disease. Therefore,

“What is the dentist's role in early prediction of patients at high risk of

osteoporosis?”

Evidence against using Dental radiographs to screen for osteoporosis:

 (Leila khojastehpour.s,2013), conducted a study to compare the mandibular bone density

between postmenopausal women with normal skeletal bone mass density (BMD) and
those with low skeletal BMD using digital panoramic radiographs.

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115 healthy non-smoker postmenopausal Iranian women at the age of 40-70 years were recruited
for a cross-sectional study. Corticosteroid therapy, alcoholism and systemic diseases that would
affect bone metabolism such as hyperpara-thyroidism, hypoparathyroidism, Paget’s disease,
thyrotoxicosis, malabsorption, liver diseases and cancers with bone metastasis were considered
as exclusion criteria,.An oral digital panoramic radiograph was prepared for each participant
using Digora PCT Sorodex equipments and Promax panoramic X-ray unit.

The interval between Dual-energy X-ray absorptiometry (DXA) examination and taking
radiographs was not longer than 2 weeks. An area with approximately 4×4 mm dimension just
near the distal edge of the right mental foramen in the digital panoramic radiograph was selected
and diagnostic for windows (DfW) was calculated and reported maximum, minimum and mean
density. For evaluation of obtained data of mandibular bone density between normal and
osteoporotic/osteopenic groups, femoral bone mass density (FBMD) and spinal bone mass
density (SBMD) values were considered both separately and together.

Figure I: Analyzing a digital panoramic radiograph using Diogra software

Osteoporosis in postmenopausal women Page 6

 Table I: Comparison of mandibular bone density in normal and osteoporotic

Table II: Comparison of mandibular bone density in normal and osteoporotic

(SBMD and FBMD T-score ≤ -2.5) groups

Table III: Comparison of mandibular bone density in normal and osteoporotic (FBMD T-
score ≤ -2.5) groups

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This study was carried out to see if there was any relation between mandibular density
measurement in panoramic radiograph and BMD. The difference however, was found only in
maximum mandibular bone density value between the control and osteoporotic group.

In addition, this difference was limited to the subjects who were osteoporotic in the femoral
region alone or in combination with the spinal region (FBMD T-Score ≤ -2.5 or both FBMD and
SBMD T-Score ≤ -2.5).

In this study they had hypothesized that FBMD is more related to mandibular bone density than
SBMD. It could be supported by this fact that there are some studies in which the investigators
only assessed the association of femoral osteoporosis with various panoramic radiographic
findings in postmenopausal women as reported by Amorim MA, 2007, IshiiK, 2007.

The results of this study showed that reduced skeletal bone mass is not totally related with
mandibular density measurement with (diagnostic for windows) DfW software in panoramic
radiographs. This could be related to the age of the study group.

(Watson et al ,1995) investigated whether osteoporotic postmenopausal women show a decrease

in mandibular cortical bone height, as measured by the PMI index, when compared with non-
osteoporotic postmenopausal women.

72 Caucasian females (33 cases/39 controls), age range 54-71, were selected through records and
screening via a dual-energy x-ray absorptiometry scan (LUNAR-DEXA). ANOVA analysis
indicated no differences in the mean PMI between case and control groups (0.37 ± 0.15 and 0.38
± 0.13, respectively; p = 0.69.

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Evidence supporting Dental radiographs to screen for osteoporosis:

 (Jayashree A.Mudda ,2010) conducted a study to assess mandibular bone changes in pre
and postmenopausal women with chronic generalized periodontitis using different
radiomorphometric indices, mandibular cortical index (MCI), mental index (MI), and
panoramic mandibular index (PMI) in Indian population.

60 female patients, who had received a dental panoramic radiograph (DPR) as a part of their
dental treatment, were selected randomly from the Department of Periodontology. All
panoramic images were made using the panoramic machine (Trophy Radiologie, Type OPX/105,
France) at 110kv and 100mA utilizing Kodak film.

Following indices were measured on DPRs:

MCI: This is a classification of the appearance of the lower border cortex of the mandible distal
to the mental foramina, as viewed on panoramic radiographs as described by
( Klemetti E.k.S,1994) On a three-point scale

C1: The endosteal margin of the cortex is even and sharp on both sides.

C2: The endosteal margin shows semilunar defects (lacunar resorption) or seems to form
endosteal cortical residues (one to three layers) on one or both sides.

C3: The cortical layer forms heavy endosteal residues and is clearly porous.

Panoramic mandibular index (PMI): Ratio of the mandibular cortical thickness measured on the
line perpendicular to the bottom of the mandible, at the middle of the mental foramen, by the
distance between the inferior mandibular cortex and the bottom of the mandible defined by
(Benson BW,1991) (normal value:≥0.3).

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Mental index (MI): Mandibular cortical thickness measured on the line perpendicular to the
bottom of the mandible at the center of the mental foramen (normal value≥3.1 mm) (10).

This study did not find any association between periodontal status and MCI appearance. These
results are consistent with the results of other studies conducted by (Markkanen H,1981), which
suggest that osteoporotic changes after menopause are not essential factors in causing
periodontal bone loss.

But may influence the speed of bone loss as raised by (Ward VJ,Manson JD,1973) , the MCI
appearance was related to the menopausal status of the patients suggesting that onset of
menopause leads to changes in mandibular cortical morphology. C1 was most common in
premenopausal group. Individuals with C3 appearance was seen in post-menopausal group only
after the age of 54 years and an age related increase in number of patients with C3 appearance
was also observed, thus reflecting age related changes.

Concurrently, the present study is in agreement with the results of (Knezovic-Zlataric D ,2002)
reflecting age related changes. MI showed a negative relation with age but PMI was positively
correlated. Post-M group was sub-divided into two groups based on age and a negative
correlation was seen with age after the age of 60 years.

 (Bhatnagar S, 2013) whether panoramic radiograph, can detect early osseous changes
(normal, mildly or severely eroded) of the mandibular inferior cortex and measure the
mandibular cortical width (CW) in post-menopausal women and correlate it with the
bone mass density (BMD).
A panoramic radiograph has been taken to assess cortical shape and measure the
mandibular cortical width and ultrasound bone sonometer at the mid-shaft tibia region to
measure BMD.
They concluded that the degree of mandibular cortical shape erosion was found to
significantly correlate with BMD and diagnostic efficacy of the panoramic radiograph in
detecting osseous changes in post-menopausal women with low BMD was shown to have
96% specificity and 60% sensitivity with mandibular cortical shape and 58% specificity
and 73% sensitivity with mandibular CW measurement.

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 These are similar to the findings of the studies conducted by( Taguchi A S.M. ,2003).
(Delvin H ,2002) reported that if dental panoramic radiograph was used as the basis of
identifying women with spinal osteopenia or osteoporosis, the finding of any mandibular
cortical erosion correctly identified a case of low BMD 80% of the time and a normal
finding on the panoramic radiograph correctly identified normal spine BMD 60% of the
time.

Figure II: Correlation between BMD and mandibular cortical shape

 (Bodade PR ,2013) conducted a study to establish the role of dental practitioners in

identifying patients at risk of osteoporosis from panoramic radiographs. He evaluated 32
randomly selected postmenopausal women with no known secondary cause of bone loss.

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 A panoramic radiograph of each patient was taken and quantitative (Mental index (MI),
Antegonion index (AI), Gonion index (GI),and qualitative (Mandibular cortical index
(MCI)) radiomorphometric indices were determined. Bone mineral densities of the
mandible and lumbar vertebrae were measured by dual energy x-ray absorptiometry.

Using WHO criteria, patients were divided into normal, osteopoenic and osteoporotic
categories. The relationship of qualitative and quantitative indices with bone mineral
densities of the mandible and lumbar area was analyzed statistically.

A significant positive correlation of mandibular bone mass density (MBMD) was found with the
BMD of lumbar vertebrae. Of the 32 patients, the numbers of patients classified into groups C1,
C2 and C3 were 10, 12 and 10, respectively. A strong positive correlation was observed between
all quantitative indices and bone mineral densities of lumbar vertebrae although they weren’t
useful because of their poor reproducibility.

 (Imad Barngkgei ,2014) conducted a study evaluate the use of dental cone-beam
computed tomography (CBCT) in the diagnosis of osteoporosis among menopausal and
postmenopausal women by using only a CBCT viewer program. 38 menopausal and
postmenopausal women who underwent dual-energy X-ray absorptiometry (DXA)
examination for hip and lumbar vertebrae were scanned using CBCT.

Slices from the body of the mandible as well as the ramus were selected and some
CBCT-derived variables, such as radiographic density (RD) as gray values, were
calculated as gray values. Pearson's correlation, one-way analysis of variance (ANOVA),
and accuracy (sensitivity and specificity) evaluation based on linear and logistic
regression were performed to choose the variable that best correlated with the lumbar and
femoral neck T-scores.

the study resulted that the RD of the whole bone area of the mandible was the variable
that best correlated with and predicted both the femoral neck and the lumbar vertebrae T-
scores; further, Pearson's correlation coefficients were 0.5/0.6 (p value= 0.037/0.009).

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 The sensitivity, specificity, and accuracy based on the logistic regression were 50%,
88.9%, and 78.4%, respectively, for the femoral neck, and 46.2%, 91.3%, and 75%,
respectively, for the lumbar vertebrae thus Lumbar vertebrae and femoral neck
osteoporosis can be predicted with high accuracy from the RD value of the body of the
mandible by using a CBCT viewer program.

Figure III: The angulation adjustment procedure of the CBCT images is seen. Coronal (A)
and axial (B) slices before angulation adjustment.

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Our second aim was to know the osteoporosis related diseases and their impact on bone mass
therefore,

“What is the significance of the associated diseases with osteoporosis?”

 (Shingo konno ,2015) investigated the association between glucocorticoid-induced

osteoporosis and myasthenia gravis (MG) using a cross-sectional survey in Japan, they
studied 363 patients with MG (female 68%; mean age, 57 ± 16 years) who were followed
at six Japanese centers between April and July 2012, mineral density at the lumbar spine
(L2-L4) and femoral neck was measured using a dual-energy X-ray absorptiometry
system.

Levels of serum pyridinoline cross-linked amino-terminal telopeptide of type I collagen

(NTx) and bone isoform of alkaline phosphatase (BAP) levels were also measured.
Results were as follows of 363 MG patients, 283 (78%) had been treated with
prednisolone at a dose of ≥ 5 mg/day for three months or more.

Glucocorticoid-induced osteoporosis was evaluated based on the development of fracture

after MG onset. Symptomatic fractures were developed in 19 (5%) patients of the 283
MG patients. Although a history of spine, arms, hips, or wrists fractures was seen in only
1 (1%) of the 80 MG patients without glucocorticoid treatment, 18 (6%) of 283 MG
patients treated with glucocorticoids had one or more such fractures.

They measured the bone mineral density at the lumbar spine and femoral neck. The
femoral neck T score of the patients with fractures was significantly lower than that in the
patients without fractures. The lumbar spine T score also showed a similar tendency.

With regard to the bone markers, there were no differences of serum BAP levels between
two groups. Serum NTx levels were significantly higher in the MG patients with fractures
than in those without fractures.

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 It was concluded that osteoporotic fractures made the quality of life of MG patients
significantly worse, and the duration of glucocorticoid therapy, but not the dose of
prednisolone, was associated with development of osteoporotic fractures in MG patients,
therefore neurologists have to consider shortening the duration of glucocorticoids
treatment for MG.

 (Nada M Alselami ,2015) evaluated the impact of type-II diabetes mellitus on

biochemical markers of bone turnover in obese postmenopausal Saudi women. This work
was a trail to set up measurements for some bone turnover markers in both obese
postmenopausal female with type-II diabetes mellitus and normal subject.

The present study included total of 65 T2-DM obese postmenopausal Saudi women, (36
uncontrolled, 29 controlled), and 20 healthy volunteer (control group). The following
serum biochemical parameters were evaluated [fasting blood glucose (FBG), total
calcium (Ca), phosphorus (Pi), parathyroid hormone (PTH), 1,25-(OH)2 Vitamin D3,
osteocalcin (OC), procollagen (PICP) and cathepsin k (Cath K)].

The results were Serum OC levels were significantly decreased in diabetic obese
postmenopausal group compared to their respective healthy group. There was significant
elevation in 1, 25(OH) 2 Vitamin D3, Ca and Pi levels in diabetic obese postmenopausal
patients group compared to the healthy group.

it also showed that the bone resorptive marker cathepsin k studied in this study project,
showed highly significant increase (239.89 pmol/L) in uncontrolled patients with type-Π
diabetic compared with controlled diabetic subgroup (204.76 pmol/L) and healthy control
women (109.85 pmol/L, which indicates that bone resorption markers in postmenopausal
Saudi women with type-Π diabetes mellitus whether controlled or uncontrolled are very
high, which leads to high risk of fracture.

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 Tabl
e IV:Mean values ± SD of biochemical markers of bone turnover including bone formation
markers (osteocalcin and procollagen type-α carboxy terminal propeptide) and bone resorption
marker (cathepsin k) in the studied groups.

 (Pinherio MM1 ,2015) estimated the prevalence and analyzed the risk factors associated
to osteoporosis and low-trauma fracture in women, total of 4,332 women older than
40 were included, data and information about lifestyle habits, previous fracture, medical
history, food intake and physical activity were obtained.

Low-trauma fracture was defined as that resulting from a fall from standing height or less
in individuals 50 years or older. The results revealed that the prevalence of osteoporosis
and osteoporotic fractures was 33% and 11.5%, respectively.

The main risk factors associated with low bone mass were age, time since menopause
previous fracture and current smoking. BMI, regular physical activity and hormone
replacement therapy had a protective effect on bone mass.

Risk factors significantly associated with osteoporotic fractures were age, time since
menopause, familial history of hip fracture .and low BMD. Advanced age, menopause,
low-trauma fracture and current smoking are major risk factors associated with low BMD
and osteoporotic fracture. Therefore, clinical use of these parameters to
identify women at higher risk for fractures might be a reasonable strategy to improve the
management of osteoporosis.

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  Considering the fact that there is currently little known about the risk of developing
bisphosphonate-related osteonecrosis of the jaw (BRONJ). (Carmen Vidal-Real ,2015)
undertook a study to determine the prevalence of ONJ in patients who have undergone
intravenous bisphosphonate therapy as well as identifying the risk factors; it included 194
patients treated with IV bisphosphonates.

They concluded that prevalence of ONJ was 12.9 %. The most remarkable complication
was pain, which was reported by 80% of patients. The average age of the patients
undergoing bisphosphonate therapy was 68.91 years. Most of non-diabetic patients did
not develop ONJ .During bisphosphonate therapy, 3.1% of patients underwent extractions
in the same percentage in the maxilla and in the mandible; all of which, except for one
patient, developed ONJ.

In regards to the periodontal state, 94.3% of patients without periodontal problems did
not develop ONJ .Almost 50% of the necrosis were located unifocally on the mandible.
The number of affected patients and the aggressiveness of the disease increased
significantly three years after starting treatment.

They also concluded that the development of surgical procedures in patients undergoing
bisphosphonate therapy, bad periodontal health, and uncontrolled diabetic patients are all
risk factors of (BRONJ).

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 figureIV: Different degrees of ONJ.A) Degree I. B and C) Degree II. D) Degree III

 (Kim KC ,2010) has done a study to evaluate the associations between obesity or
metabolic syndrome and bone mineral density (BMD) or vertebral fracture. A total of 907
postmenopausal healthy female subjects, aged 60-79 years. BMD, vetebral fracture, bone
markers, and body composition including body weight, body mass index (BMI),
percentage body fat, and waist circumference were measure.

Osteoporosis in postmenopausal women Page 18

 Among the 907 participants, 44 (5%) individuals had a normal BMD, 350 (38%) had
osteopenia, and 513 (56%) had osteoporosis. It was revealed that both body weight (p<
0.001) and percentage body fat (p < 0.0001) were significantly and positively related to
lumbar Bone Mass Density (BMD).

However, waist circumference was negatively related to the lumbar and all femur site BMD,
The serum glucose level was positively correlated to Bone Mass Density( BMD), Serum high
density lipoprotein cholesterol (HDLC) was only related to femoral trochanter BMD (p =
0.0366).

Serum TG and systolic blood pressure (BP) were not related to BMD at any site. The average
body weights and BMIs of the two groups were not significantly different. However, the
percentage body fat and waist circumference were much higher in the fracture group than the
non-fracture group.

It was concluded in this study that body weight is positively related with BMD and a
protective factor for vertebral fractures, whereas percentage body fat and waist circumference
are negatively related to BMD and a risk factor for vertebral fractures. These results are
consistent with those of previous studies reported by (Lan –Juan Zhao ,2007) and (Hsu YH ,
2006) in the Chinese population , components of metabolic syndrome were related to BMD
and vertebral fracture.

Osteoporosis in postmenopausal women Page 19

  (Snophia Suresh ,2010) assessed the relationship between bone mineral density and
periodontitis in premenopausal and postmenopausal women.20 women between the ages
of 45-55 years were selected. 10 premenopausal women with healthy periodontium
constituted the control group and 10 postmenopausal women with ≥2mm of clinical
attachment loss in >30% of sites constituted the study group.

All patients were assessed for plaque index, probing depth and clinical attachment loss.
Radiographs (six IOPA and two posterior bitewing) were taken and assessed for
interproximal alveolar bone loss. \

The patients were scanned to assess the bone mineral density of lumbar spine (L2) and
femur using DEXA.The results were as follows: The bone mineral densities of lumbar
spine (L2) and femur were significantly lower in the study group than the control group.
Osteopenia of the lumbar spine and femur was observed in 60% whereas osteoporosis of
lumbar spine was observed in 30% of cases in the study group.

Figure V: This graph shows Mean clinical periodontal parameters in control and
study group.

Osteoporosis in postmenopausal women Page 20

 F
igure VI: This graph shows the Mean bone mineral densities in control and study group.

They concluded that occurrence of osteopenia and osteoporosis of the lumbar spine (L2) and
femur in postmenopausal women with periodontitis suggests that there is association between
bone mineral density and periodontitis. (Tezal M ,2002) stated that the severity and extent
of alveolar bone loss in postmenopausal women may be an indirect risk indicator for
systemic bone loss.

 (Sultan N ,2011) investigated the possible association between osteoporosis and

periodontal disease among postmenopausal women residing in India. A complete
periodontal examination including plaque index (PI), gingival index (GI), clinical
attachment loss (CAL) measurement was performed on 80
dentate postmenopausal women (age≥50 yrs) with generalized chronic periodontitis.

Osteoporosis in postmenopausal women Page 21

 Mean alveolar bone loss (ABL) was measured from full mouth intraoral periapical
radiographs, by recording the distance from cementoenamel junction (CEJ) and the most
coronal portion of alveolar crest at mesial and distal aspect of all teeth. Systemic bone
loss was determined from hand-wrist radiograph of the patient through Digital X-Ray
Radiogrammetry.

Statistical analysis was done to assess the relationships between periodontal variables and
bone mineral density (BMD) after adjusting for age, years since menopause, body mass
index (BMI), smoking, number of remaining teeth, PI and GI.

Results were: Age of the patient, years since menopause and BMI showed significant
correlation with BMD. CAL and ABL showed mildly negative and statistically non-
significant correlation with the BMD. Of all the variables studied, only smoking and BMI
were strong predictors of BMD.

They concluded that Skeletal BMD is related to interproximal ABL and CAL, though not
to a statistically significant level; implicating postmenopausal osteopenia as a risk
indicator for periodontal disease.

Our third aim was to investigate whether biochemical bone markers examination can be
used in early detection of patients who are at risk of osteoporosis, therefore,

Can only biochemical bone markers be used in early detection of low bone mass?

 [ CITATION Ind07 \l 1033 ] studied a group 150 pre- and postmenopausal women.

Osteoporosis in postmenopausal women Page 22

The study group consisted of 75 Premenopausal women in the age group of 25-45 years and 75
Postmenopausal women in the age group of 46-65 years. Bone formation markers (Total
Calcium, Ionised calcium, Phosphorus, Alkaline phosphatase), and bone resorption markers
(Urinary Hydroxyproline) were analyzed in pre and postmenopausal women.

All the participants were nonsmokers, nonalcoholic and ambulatory. The women were neither
pregnant nor on oral contraceptive pills. None of the postmenopausal women had suffered any
fracture in the previous 1 year nor were they on Hormone replacement therapy or any other
medication that might affect bone turnover.

Based on time since menopause, 75 postmenopausal women were categorized into 2 groups. 22
women were in their early postmenopausal period (<5years) and remaining 53 women were in
their late postmenopausal period (>5years). Among 75 postmenopausal women, 27 were having
Diabetes mellitus. Height, Weight and Body mass index (BMI)of all the participants were
noted.3 ml of random blood sample was collected in a plain bulb from each participant.

Serum was separated immediately by centrifuging at 3000rpm for 10 min and analysed for Total
calcium, Ionised Calcium, Phosphorus, Total protein, Albumin and Alkaline phosphatase.
Random sample of urine was collected at the same time in a clean plastic bulb and analysed for
Hydroxyproline and Creatinine immediately.

It was noted that there was a significant decrease in Serum Total Calcium and Ionised Calcium in
postmenopausal women .Similarly it was observed that Serum ALP levels and Urinary excretion
of Hydroxyproline were significantly increased in postmenopausal women compared to
premenopausal women (TABLE V).

TABLE V: ‘’Comparison of markers of bone turnover in pre- and post-Menopausal women (values
expressed as mean ± SD)’’

Osteoporosis in postmenopausal women Page 23

 Ionised calcium levels were significantly less in early postmenopausal women compared
to late premenopausal women .It was also observed that Serum ALP levels and Urinary
excretion of Hydroxyproline were more in Early postmenopausal women compared to
late postmenopausal women, but they were not significant (TABLE VI).

Table VI: Comparison of markers of bone turnover in Early (5 yrs) post-menopausal period and late
postmenopausal women.

BMI was significantly high in postmenopausal women; in comparison to premenopausal

women Literature says that a low BMI is one of the risk factors for increased bone turnover.
In this study they concluded Biochemical parameters can give an idea as to the rates of bone
formation and resorption.

 [ CITATION Moh14 \l 1033 ] has done a study to determine the relationship

between bone markers, BMD and osteoporotic fracture. It included 65 women who were
referred for measure of BMD during the period between May and August 2010.

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  Each patient had a dosage of serum bone formation markers: osteocalcin (OC) and N-
terminal propeptide of type I collagen (P1NP) and bone resorption markers: serum and
urinary C-terminal telopeptide of type I collagen (β-CTX or CrossLaps) as well as
parathyroid hormone and calcium, the majority (83%) were menopausal women.

The study results were: Osteoporosis was found in 52%, osteopenia 26% and normal
BMD 22% of cases. An increase in bone turnover markers was correlated with
menopause, low body mass index and osteoporosis. They concluded that
bone turnover markers increase in menopausal women and in case of low BMD.
However, their contribution in the diagnosis of osteoporosis is low. They are rather an
interest in the prediction of fracture risk.

The fourth aim was to assess the correlation between tooth loss and osteoporosis, therefore,

Is there an association between tooth loss and low Bone Mass Density?

 [ CITATION Sla11 \l 1033 ] did a study to determine the relation between tooth loss and
general body bone mineral density in postmenopausal female who needed prosthetic
treatment.

There were included 79 women in this study (age from 49-81 years) with partial tooth
loss. For all patients bone mineral density measurements for lumbar spine and both
femoral necks by dual energy X-ray absorptiometry were performed.

Patients were divided into 3 groups: normal bone density (T-score ≥-1.0), osteopenia (T-
score from -1.0 till -2.5) and osteoporosis (T-score ≤-2.5). Dental investigation was
performed to detect existing teeth.

Osteoporosis in postmenopausal women Page 25

 It was found that the number of teeth in different bone mineral density groups is almost
similar. There are no statistically significant differences between groups according the
number of the all teeth present and according the number of teeth in maxilla and
mandible.

There is no significant correlation between the number of the teeth and DEXA readings,
except there is weak correlation between the number of maxillary posterior teeth and
bone mineral density in femoral neck, these results suggest that there  is no correlation
between number of the teeth and general bone mineral density.

 [ CITATION Pau11 \l 1033 ] evaluated oral health in postmenopausal women and verified
w hether there is a correlation between tooth loss according to index of decayed, missing,
filled teeth (DMFT) and bone mineral density (BMD), it was conducted with 100 women.

The DMFT and its associations with lumbar and femoral BMD (T-score and g/cm2) were
assessed, the analysis of covariance (ANCOVA) revealed significant association between
bone mass in L2-L4 (below average) in g/cm2 and DMFT index (P = 0.0332), and for
women with bone mass below the average index DMFT was higher.

Association between bone mass in L2-L4 (below average, g/cm2) and extracted
component (P = 0.0483) was also significant because women with bone mass below the
average had a greater extracted component.

Considering the fact that most women reported limited schooling, because only 10% of
them had high school level or higher, the tooth loss may be related to low education and
poor oral hygiene.

Osteoporosis in postmenopausal women Page 26

  [ CITATION SAE98 \l 1033 ] Did a study on 1365
Caucasian women aged between 45 and 59 years, to evaluate whether tooth counts can
predict postmenopausal women who are at high risk of osteoporosis.

Bone mineral density (BMD) at the lumbar spine and proximal femur was measured by
dual energy x-ray absorptiometry (DXA).

A full physical examination was performed including a tooth count. Baseline tooth counts

ranged from 0 to 32 (median 26): 84 (6%) subjects were edentulous. When classified
according to the WHO criteria 445 (33%) of subjects were osteoporotic at one or more of
the skeletal sites analyzed; 694 (51%) were osteopenic, and 226 (16%) were normal.

Adjusting for confounding variables, there was no significant correlation

between tooth count and BMD at any skeletal site;

Based on these results they concluded there is no relationship between tooth count and

BMD in early postmenopausal women. Tooth counts therefore cannot be used to identify
individuals at risk of osteoporosis.

Osteoporosis in postmenopausal women Page 27

Conclusion

In all the studies which were reviewed, any treatment or systemic diseases which would affect
the bone metabolism were excluded. For dentists to diagnose patients with osteoporosis they
could use digital panoramic radiographs and dental cone beam computed tomography, which
resulted in 73% correctness in the identification of low Bone Mass Density.

The radiographic density of the later was found to be significantly related to the BMD of the hip
and lumbar vertebrae. On the other hand osteoporosis have been associated with some
local/systemic diseases, which either were present before the development of osteoporosis or it
developed as a complication of certain medications e.g. glucocorticoids, amongst those diseases
which co-occur with osteoporosis , periodontitis had an association.

postmenopausal osteoporosis isn't essential factor in causing periodontal bone loss but may
influence the speed of bone loss, in the contrary when there is alveolar bone loss it may be an
indirect risk factor of systemic bone loss .On the subject of the systemic co-morbidities , type II
diabetes mellitus (controlled & uncontrolled) ,Myasthenia Gravis, were all significantly correlate
therefore these patients should be carefully and regularly checked with DEXA (for low bone
mineral density ) or shorten the period /minimize the dosage of glucocorticoid treatment.

Biochemical bone markers can also be useful to improve the assessment of individual fracture
risk when bone mineral density (BMD) measurement by itself does not provide a clear answer.
The combined use of BMD measurement and bone markers is likely to improve the assessment
of the risk of fracture in patients with low bone mineral density, which showed high mean values
of these markers.

Fractures induced by osteoporosis can aggravate the quality of life of these patients thus, making
the daily physical activities hard to perform, hip fractures which is the most serious due to its
high morbidity and mortality can be prevented by early diagnosis and intervention.

Osteoporosis in postmenopausal women Page 28

Results

I was able to collect and read 40 articles which I have chosen 20 articles from them to include in
my literature review. According to those articles I have classified the ideas based on questions.
Therefore, while answering these questions in relation to previously done studies some were
supporting raised idea while the others were against it.

Dentist can play a very important role in the early diagnosis of osteoporosis and osteopenia, by
means of orthopantomograms (OPG) or periapical radiographs. There are methods that require
making measurements that are somewhat sophisticated (PMI, MI, PHOTODENSOMETRY, etc.)
and others in which a simple visual check (Klemetti, trabecular pattern)

In regard to tooth loss being an oral sign of osteoporosis, more longitudinal studies are needed to
prove that point.

Recommendations

1. Raise awareness of the Vitamin D deficiency in our countries.

2. Establish in each country, the local BMD reference.

3. Regular testing for patients who are at high risk of fractures ,mainly DXA.

4. When using vitamin D and calcium for treatment of osteoporosis, regular checkup pf renal
calcium level should be performed.

5. Health authorities should emphasize on the dentist's important role in detecting patient in
early/ high risk of osteoporosis and further referral to physicians.

6. Dentists should be trained on different radiomorphometric indices, in order to detect patient in

early risk of osteoporosis.

Osteoporosis in postmenopausal women Page 29

7.All patients who are undergoing bisphosphonates treatment , should be diagnosed and educated
in oral hygiene prior to surgical treatment, performing periodical maintenance, to detect possible
traumatisms and periodontal infection as soon as possible.

Acknowledgment

I would like to express my gratitude to my research supervisor Dr.Hala and to Dr.Juma for their
guidance and providing needed information in relation to my topic.

Osteoporosis in postmenopausal women Page 30

References

Amorim MA, T. L. (2007). Comparative study of axial and femoral bone mineral density and parameters
of mandibular bone quality in patients receiving dental implants. Osteoporos Int , 18 (4), 703-9.

Benson BW, P. T. (1991). Variations in adult cortical bone mass as measured by a panoramic mandibular
index. Oral Surg Oral Med Oral Pathol. , 71 (3), 349-56.

Bhatnagar S, K. V. (2013). Diagnostic efficacy of panoramic radiography in detection of osteoporosis in

post-menopausal women with low bone mineral density. J Clin Imaging Sci , 4 (4), 3:23.

Bodade PR, M. R. (2013). panoramic radiography for screening postmenopausal osteoporosis in India: a
pilot study. Oral Health Dent Manag , 12 (2), 65-72.

Carmen Vidal-Real, M. P.-S.-M.-P.-M.-R.-G. (2015). Osteonecrosis of the jaws in 194 patients who have
undergone intravenous bisphosphonate therapy in Spain. Med Oral Patol Oral Cir Buca , 20 (3), e267–
e272.

Devlin H, H. K. (2002). Mandibular radiomorphometric indices in the diagnosis of reduced skeletal bone
mineral density. Osteoporos Int. , 13 (5), 373-8.

Hsu YH, V. S. (2006). Relation of body composition, fat mass, and serum lipids to osteoporotic fractures
and bone mineral density in Chinese men and women. Am J Clin Nutr. , 83 (1), 146-54.

Imad Barngkgei, c. a. (2014). Osteoporosis prediction from the mandible using cone-beam computed
tomography. Imaging Sci Dent. , 44 (4), 263–271.

Indumati V, P. V. (2007). Hospital based preliminary study on osteoporosis in postmenopausal women.

Indian J Clin Biochem. , 22 (2), 96-100.

Ishii K, T. A. (2007). Diagnostic efficacy of alveolar bone loss of the mandible for identifying
postmenopausal women with femoral osteoporosis. Dentomaxillofac Radiol. , 36 (1), 28-33.

Jayashree A. Mudda, M. B. (2010, apr-jun). A Radiographic comparison of mandibular bone quality in

pre- and post-menopausal women in Indian population. Retrieved august 13, 2015, from
www.pubmed.com: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3110466/

Jayashree A. Mudda, M. B. (2010). A Radiographic comparison of mandibular bone quality in pre- and
post-menopausal women in Indian population. J Indian Soc Periodontol , 14 (2), 121–125.

Osteoporosis in postmenopausal women Page 31

Kim KC, S. D. (2010). Relation between obesity and bone mineral density and vertebral fractures in
Korean postmenopausal women. Yonsei medical journal. , 51 (6), 857-63.

Klemetti E, K. S. (1993). Panoramic mandibular index and bone mineral densities in postmenopausal
women. Oral Surg Oral Med Oral Pathol , 75 (6), 774-9.

Klemetti E, K. S. (1994). Pantomography in assessment of the osteoporosis risk group. Scandinavian

journal of dental research , 102 (1), 68-72.

Knezović Zlatarić D, C. A.-O. (2002). Influence of age and gender on radiomorphometric indices of the
mandible in removable denture wearers. Collegium antropologicum , 26 (1), 259-66.

Lan-Juan Zhao, Y.-J. L.-Y.-W. (2007). Relationship of obesity with osteoporosis. the journal of clinical
endocrinology and metabolism , 92 (5), 1640–1646.

Leila Khojastehpour, ,. S. (2013). Comparison of the Mandibular Bone Densitometry Measurement

Between Normal, Osteopenic and Osteoporotic Postmenopausal Women. Journal of dentistry / Tehran
University of Medical Sciences , 10 (3), 203–209.

Leila Khojastehpour, S. M. (2013, may). Comparison of the Mandibular Bone Densitometry Measurement
Between Normal, Osteopenic and Osteoporotic Postmenopausal Women. Retrieved july 11, 2015, from
www.pubmed.com: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4264091/

Markkanen H, R. M. (1981). Alveolar bone loss in relation to periodontal treatment need, socioeconomic
status and dental health. Journal of periodontology , 52 (2), 99-103.

Mohamed Y, H. H. (2014). The role of biochemical markers of bone turnover in the diagnosis of
osteoporosis and predicting fracture risk. Tunis Med , 92 (5), 304-10.

Nada M Alselami, A. F.-G. (2015). Bone turnover biomarkers in obese postmenopausal Saudi women
with type-II diabetes mellitus. 90–96 , 15 (1).

Paulo Sergio Gomes Henriquesa, c. a. (2011). Association Between Tooth Loss and Bone Mineral Density
in Brazilian Postmenopausal Women. journal of clinical medicine research , 3 (3), 118–123.

Pinheiro MM, R. N. (2010). Risk factors for osteoporotic fractures and low bone density in pre and
postmenopausal women. Rev Saude Publica , 44 (3), 479-85.

SA Earnshaw, N. K. (1998). Tooth counts do not predict bone mineral density in early postmenopausal
Caucasian women. international journal of epidemiology , 27, 479-483.

Shingo Konno, S. S. (2015). Association between Glucocorticoid-Induced Osteoporosis and Myasthenia

Gravis: A Cross-Sectional Study. PLoS ONE , 10 (5).

Slaidina A, S. U. (2011). Postmenopausal osteoporosis and tooth loss. Stomatologija , 13 (3), 92-5.

Osteoporosis in postmenopausal women Page 32

Snophia Suresh, T. S. (2010). Periodontitis and bone mineral density among pre and post menopausal
women: A comparative study. Journal of indian society of periodontology , 14 (1), 30–34.

Sultan N, R. J. (2011). Association between periodontal disease and bone mineral density in
postmenopausal women: a cross sectional study. Med Oral Patol Oral Cir Bucal , 16 (3), e440-7.

Taguchi A, S. M. (2003). Relationship between dental panoramic radiographic findings and biochemical
markers of bone turnover. Journal of bone and mineral research , 18 (9), 1689-94.

Taguchi A, T. K. (1995). Oral signs as indicators of possible osteoporosis in elderly women. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod , 80 (5), 612-6.

Tezal M, W.-W. J. (2000). The relationship between bone mineral density and periodontitis in
postmenopausal women. Journal of periodontology , 71 (9), 1492-8.

Verheij JG, G. W.-K. (2009). Prediction of osteoporosis with dental radiographs and age. Dento maxillo
facial radiology , 38 (7), 431-7.

Watson EL, K. R. (1995). The measurement of mandibular cortical bone height in osteoporotic vs. non-
osteoporotic postmenopausal women. Spec Care Dentist , 15 (3), 124-8.

Amorim MA, T. L. (2007). Comparative study of axial and femoral bone mineral density and parameters
of mandibular bone quality in patients receiving dental implants. Osteoporos Int , 18 (4), 703-9.

Benson BW, P. T. (1991). Variations in adult cortical bone mass as measured by a panoramic mandibular
index. Oral Surg Oral Med Oral Pathol. , 71 (3), 349-56.

Bhatnagar S, K. V. (2013). Diagnostic efficacy of panoramic radiography in detection of osteoporosis in

post-menopausal women with low bone mineral density. J Clin Imaging Sci , 4 (4), 3:23.

Bodade PR, M. R. (2013). panoramic radiography for screening postmenopausal osteoporosis in India: a
pilot study. Oral Health Dent Manag , 12 (2), 65-72.

Osteoporosis in postmenopausal women Page 33

Carmen Vidal-Real, M. P.-S.-M.-P.-M.-R.-G. (2015). Osteonecrosis of the jaws in 194 patients who have
undergone intravenous bisphosphonate therapy in Spain. Med Oral Patol Oral Cir Buca , 20 (3), e267–
e272.

Devlin H, H. K. (2002). Mandibular radiomorphometric indices in the diagnosis of reduced skeletal bone
mineral density. Osteoporos Int. , 13 (5), 373-8.

Hsu YH, V. S. (2006). Relation of body composition, fat mass, and serum lipids to osteoporotic fractures
and bone mineral density in Chinese men and women. Am J Clin Nutr. , 83 (1), 146-54.

Imad Barngkgei, c. a. (2014). Osteoporosis prediction from the mandible using cone-beam computed
tomography. Imaging Sci Dent. , 44 (4), 263–271.

Indumati V, P. V. (2007). Hospital based preliminary study on osteoporosis in postmenopausal women.

Indian J Clin Biochem. , 22 (2), 96-100.

Ishii K, T. A. (2007). Diagnostic efficacy of alveolar bone loss of the mandible for identifying
postmenopausal women with femoral osteoporosis. Dentomaxillofac Radiol. , 36 (1), 28-33.

Jayashree A. Mudda, M. B. (2010, apr-jun). A Radiographic comparison of mandibular bone quality in

pre- and post-menopausal women in Indian population. Retrieved august 13, 2015, from
www.pubmed.com: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3110466/

Jayashree A. Mudda, M. B. (2010). A Radiographic comparison of mandibular bone quality in pre- and
post-menopausal women in Indian population. J Indian Soc Periodontol , 14 (2), 121–125.

Kim KC, S. D. (2010). Relation between obesity and bone mineral density and vertebral fractures in
Korean postmenopausal women. Yonsei medical journal. , 51 (6), 857-63.

Klemetti E, K. S. (1993). Panoramic mandibular index and bone mineral densities in postmenopausal
women. Oral Surg Oral Med Oral Pathol , 75 (6), 774-9.

Klemetti E, K. S. (1994). Pantomography in assessment of the osteoporosis risk group. Scandinavian

journal of dental research , 102 (1), 68-72.

Knezović Zlatarić D, C. A.-O. (2002). Influence of age and gender on radiomorphometric indices of the
mandible in removable denture wearers. Collegium antropologicum , 26 (1), 259-66.

Lan-Juan Zhao, Y.-J. L.-Y.-W. (2007). Relationship of obesity with osteoporosis. the journal of clinical
endocrinology and metabolism , 92 (5), 1640–1646.

Leila Khojastehpour, ,. S. (2013). Comparison of the Mandibular Bone Densitometry Measurement

Between Normal, Osteopenic and Osteoporotic Postmenopausal Women. Journal of dentistry / Tehran
University of Medical Sciences , 10 (3), 203–209.

Osteoporosis in postmenopausal women Page 34

Leila Khojastehpour, S. M. (2013, may). Comparison of the Mandibular Bone Densitometry Measurement
Between Normal, Osteopenic and Osteoporotic Postmenopausal Women. Retrieved july 11, 2015, from
www.pubmed.com: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4264091/

Markkanen H, R. M. (1981). Alveolar bone loss in relation to periodontal treatment need, socioeconomic
status and dental health. Journal of periodontology , 52 (2), 99-103.

Mohamed Y, H. H. (2014). The role of biochemical markers of bone turnover in the diagnosis of
osteoporosis and predicting fracture risk. Tunis Med , 92 (5), 304-10.

Nada M Alselami, A. F.-G. (2015). Bone turnover biomarkers in obese postmenopausal Saudi women
with type-II diabetes mellitus. 90–96 , 15 (1).

Paulo Sergio Gomes Henriquesa, c. a. (2011). Association Between Tooth Loss and Bone Mineral Density
in Brazilian Postmenopausal Women. journal of clinical medicine research , 3 (3), 118–123.

Pinheiro MM, R. N. (2010). Risk factors for osteoporotic fractures and low bone density in pre and
postmenopausal women. Rev Saude Publica , 44 (3), 479-85.

SA Earnshaw, N. K. (1998). Tooth counts do not predict bone mineral density in early postmenopausal
Caucasian women. international journal of epidemiology , 27, 479-483.

Shingo Konno, S. S. (2015). Association between Glucocorticoid-Induced Osteoporosis and Myasthenia

Gravis: A Cross-Sectional Study. PLoS ONE , 10 (5).

Slaidina A, S. U. (2011). Postmenopausal osteoporosis and tooth loss. Stomatologija , 13 (3), 92-5.

Snophia Suresh, T. S. (2010). Periodontitis and bone mineral density among pre and post menopausal
women: A comparative study. Journal of indian society of periodontology , 14 (1), 30–34.

Sultan N, R. J. (2011). Association between periodontal disease and bone mineral density in
postmenopausal women: a cross sectional study. Med Oral Patol Oral Cir Bucal , 16 (3), e440-7.

Taguchi A, S. M. (2003). Relationship between dental panoramic radiographic findings and biochemical
markers of bone turnover. Journal of bone and mineral research , 18 (9), 1689-94.

Taguchi A, T. K. (1995). Oral signs as indicators of possible osteoporosis in elderly women. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod , 80 (5), 612-6.

Tezal M, W.-W. J. (2000). The relationship between bone mineral density and periodontitis in
postmenopausal women. Journal of periodontology , 71 (9), 1492-8.

Verheij JG, G. W.-K. (2009). Prediction of osteoporosis with dental radiographs and age. Dento maxillo
facial radiology , 38 (7), 431-7.

Watson EL, K. R. (1995). The measurement of mandibular cortical bone height in osteoporotic vs. non-
osteoporotic postmenopausal women. Spec Care Dentist , 15 (3), 124-8.

Osteoporosis in postmenopausal women Page 35

 1.

Osteoporosis in postmenopausal women Page 36