|Year : 2016 | Volume
| Issue : 3 | Page : 274-280
Risk factors, quality of life, and oral implications of osteoporosis in postmenopausal women
Ravleen Nagi1, Yashoda Devi Bhoomareddy Kantraj2, Rakesh Nagaraju1, Sujatha S Reddy1
1 Department of Oral Medicine and Radiology, New Horizon Dental College and Research Institute, Bilaspur, Chhattisgarh, India
2 Department of Oral Medicine and Radiology, Faculty of Dental Sciences, Mathikere Sampige Ramaiah University of Applied Sciences, Bengaluru, Karnataka, India
|Date of Submission||22-Nov-2015|
|Date of Acceptance||06-Dec-2016|
|Date of Web Publication||13-Dec-2016|
Dr. Ravleen Nagi
Department of Oral Medicine and Radiology, New Horizon Dental College and Research Institute, Sakri, Bilaspur, Chhattisgarh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Osteoporosis is a systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture. Low bone mineral density (BMD), age, and low body mass index have been found to be major risk factors for osteoporosis. Postmenopausal women with low BMD had thinner mandibular cortex at the mental foramen region and more alveolar bone loss when compared to normal participants, and they are more susceptible to femoral neck fractures. Osteoporotic patients show various oral manifestations; more tooth loss, periodontitis, and decrease in alveolar crestal height. This review will focus on the relationship between osteoporosis and oral conditions such as periodontitis, tooth loss, and oral bone loss.
Keywords: Management, menopause, oral health, osteoporosis, panoramic radiography
|How to cite this article:|
Nagi R, Kantraj YD, Nagaraju R, Reddy SS. Risk factors, quality of life, and oral implications of osteoporosis in postmenopausal women. J Indian Acad Oral Med Radiol 2016;28:274-80
|How to cite this URL:|
Nagi R, Kantraj YD, Nagaraju R, Reddy SS. Risk factors, quality of life, and oral implications of osteoporosis in postmenopausal women. J Indian Acad Oral Med Radiol [serial online] 2016 [cited 2020 Jul 14];28:274-80. Available from: http://www.jiaomr.in/text.asp?2016/28/3/274/195663
| Introduction|| |
Osteoporosis is a systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue with consequent increase in fracture risk., It is also called as the silent disease, because with no symptoms bone resorption continues for a long time until the fracture occurs. The World Health Organization (WHO) has proposed bone mineral density (BMD) measurements to establish the diagnosis of osteoporosis. Women tend to lose BMD more rapidly than men, especially after menopause. Consequently, osteoporosis is three times more common among women than men.,
However, BMD testing for all postmenopausal women is not practical. Most of the elderly often visit dental clinic for the treatment of dental caries and periodontal disease. Hence, the panoramic radiographs have an important role in identifying postmenopausal women with undetected osteoporosis.,,,, This review will discuss the various risk factors and diagnostic tools in the early detection of osteoporosis, as well as highlight the oral implications of osteoporosis such as oral bone loss, tooth loss, and periodontitis, establishing the role of dentists in the early detection of osteoporosis.
| Risk Factors for Osteoporosis|| |
Several risk factors been proposed by the National Osteoporosis Foundation related to osteoporotic fractures in white postmenopausal women such as (1) personal history of fractures, low body weight, current smoking status, impaired vision, estrogen deficiency at an early age (younger than 45 years), poor health, recent falls, low dietary calcium intake, low physical activity, and alcohol intake more than 2 drinks per day; (2) systemic conditions associated with osteoporosis include chronic obstructive pulmonary disease, gastrectomy, diabetes mellitus, hyperparathyroidism, hypogonadism, multiple myeloma, and coeliac disease; (3) medications that are associated with reduced bone mass in adults include oral glucocorticoids (>3 months), anticonvulsants, gonadotropin-releasing hormone agonists, excessive thyroxin doses, and lithium., Osteoporosis is also influenced by the body mass index (BMI) of the women. The WHO classified BMI as follows: Normal weight 18.5 > BMI <25, overweight 25 > BMI <30, and obese BMI >30. Studies have reported that people with a BMI of 20–25 kg/m 2 have a higher rate of bone loss than those who are heavier.,,
| Nutrition|| |
With regards to nutritional approaches to bone metabolism, calcium and vitamin D have a beneficial effects. Calcium is required for the deposition of bone mineral throughout life and is the major non-hormone replacement therapy (HRT) intervention used in osteoporosis. The National Osteoporosis Society (NOS) accepts reference nutrient intake (RNI) of calcium of 700 mg/day for general population, however, higher intakes are required for osteoporotic females. Therefore, dietary calcium supplementation is essential to improve bone density. It has been postulated that, although the role of dietary calcium in the attainment of peak bone mass has been controversial, calcium supplements (0.5–2 g daily) can reduce the rate of bone loss at or after the menopause. The effects are less complete than those of estrogens, particularly at the time of menopause when losses are rapid, but bone loss can be halved, at least in cortical bone. There are reports that indicate that calcium supplementation alone or together with vitamin D slows the loss of bone calcium in elderly individuals and reduces the risk of hip fractures.
Vitamin D is important because it facilitates intestinal calcium absorption and new bone formation. Inability to synthesize adequate amounts of 1,25-Dihydroxyvitamin D [1,25(OH)2 D] may play a role in decreased calcium absorption from the intestines causing increased osteoclast production, and hence mobilizing calcium from the bone. Vitamin D is made in the skin, however, aging is accompanied by a decrease in skin composition and thickness that affects vitamin D production. Low serum 25–hydroxyvitamin D [25(OH) D] concentration is often noted in the elderly, particularly those with hip fracture are frequently associated with high serum parathormone (PTH) concentrations, thus activating osteoclast production and accelerating bone loss leading to fracture risk. Low dose vitamin D supplements in elderly people improves vitamin D status, suppresses parathyroid hormone function, and reduces bone loss. Vitamin D taken with calcium reduces PTH and markers of bone resorption, hence reducing the fracture rates in postmenopausal women. These nutrients must be recommended in the dosages applicable for the age of the patient. The recommended dosage of calcium is 1500 mg/day (>65 years) and 600 to 800 IU of vitamin D per day.
| Menopause and Oral Health|| |
Menopause can lead to oral health problems that physicians ought to keep in mind. In menopause, estrogen levels decline rapidly, which can lead to systemic bone loss. According to Heaney, the decrease in skeletal bone mass within the first 5 years of the menopause is mainly induced by estrogen deficiency, whereas that occurring after more than 5 years is due to immobilization and calcium and vitamin D deficiency. Studies have shown that the rate of bone loss in postmenopausal women predicts tooth loss—for every 1% per year decrease in whole-body BMD, the risk of tooth loss increases more than four times.,
| Diagnosis of Osteoporosis|| |
Hip fracture is the most serious complication of osteoporosis and the most disabling type of fracture., Therefore, BMD testing for all postmenopausal women may be preferable to reduce the rate of osteoporotic fractures and its future complications. At present, various techniques of bone densitometry have been applied to detect low BMD to predict fracture risk and to monitor the response to therapy. These techniques should be selected based on the clinical purpose and skeletal sites for evaluation [Table 1].
|Table 1: Various diagnostic tools in the early diagnosis of osteoporosis|
Click here to view
Self-assessment tools such as Osteoporosis Self-Assessment Tool (OSTA), Osteoporosis Index of Risk (OSIRIS), Simple Calculated Osteoporosis Risk Estimation (SCORE), and Osteoporosis Risk Assessment Instrument (ORAI) have been utilized in identifying postmenopausal women with low skeletal BMD; their sensitivity has been reported to be 90% or more, although their specificity is low., Furthermore, these tools have limited application in a large segment of postmenopausal women, and selection cut-off point varies among different populations.
Biochemical markers of bone turnover
Biochemical markers of bone turnover are useful indicators to assess bone microarchitectural deterioration. These markers include serum-based assays for bone alkaline phosphatase (ALP), osteocalcin (bone formation markers) and urine-based assays for free and peptide-bound pyridinium crosslinks of type I collagen (bone resorption markers). Studies have shown that ALP and bone resorption markers and urinary hydroxyproline excretion were significantly increased in postmenopausal women.
Quantitative ultrasound (QUS) methods have been used for the assessment of the skeletal status in osteoporosis and provide information about not only bone density but also the microarchitecture and elastic properties of bone. The QUS statuses of bone status have been shown to be related to fracture risk, independent of BMD. However, calcaneal QUS thresholds for the diagnosis or treatment have not as yet been defined; moreover, precision of QUS devices has been reported to be poor. Hence, they are not recommended in patient follow-up for osteoporosis. In addition, there are several unresolved techniques and cross calibration between the various QUS devices.
Dual energy X-ray absorptiometry
Dual energy X-ray absorptiometry (DXA) is effective in tracking the effects of treatment for osteoporosis and to assess an individual's risk for developing fractures. The risk of fracture is affected by age, body weight, history of prior fracture, family history of osteoporotic fractures, and lifestyle issues such as cigarette smoking and excessive alcohol consumption.,, DXA results are reported as T-scores and Z-scores. The T-scores are comparisons of the patients BMD with a young populations peak reference value, whereas Z-scores are comparison of the patients BMD with a population's age-matched reference value, allowing a comparison with the patients peer group.
According to the WHO, BMD values are divided into the following diagnostic guidelines: Normal: T-score > −1.0, Osteopenia: T-score between − 1.0 and − 2.5, and Osteoporosis: T-score <−2.5. Although osteoporosis is defined as a T-score of <−2.5, pharmacologic treatment should be considered for women with a T-score < −2.0 regardless of any osteoporosis risk factor. DXA is considered as a reference standard examination for BMD assessment and the best predictor of fracture risk., At present, DXA is widely accepted as the gold standard method of clinical BMD measurement, and it has also been applied to measure BMD in the jaws.
Fractal analysis is a mathematical technique that can aid in the quantification of complex structures. This technique has been evaluated with varying degrees of success in different imaging modalities such as plain film radiography, mammography, computed tomography, and magnetic resonance imaging.,, Bone is designed to resist gravitational and mechanical forces, and thus, has an internal structure that is highly oriented (anisotropic). Various investigators have evaluated this anisotropic structure of trabecular bone on dental radiographs by using different fractal dimension (FD) methods to discriminate individuals with and without osteoporosis. In some osteoporotic patients, decrease in FD was noticed, whereas in others increase in FD was observed.
BMD testing for all postmenopausal women by DXA is considered one of the immediate actions to conquer osteoporotic fractures. However, in areas where DXA facility is not available, BMD testing of postmenopausal females would be not possible. Moreover, DXA is expensive and has a limited availability for routine use in population screening. Postmenopausal women have many opportunities to visit dental clinics for oral health care or treatment. Therefore, it would be very beneficial in postmenopausal women with undetected low BMD if dentists could identify early radiographic features of osteoporosis on panoramic radiographs and refer them to medical professionals for BMD testing prior to the incidence of osteoporotic fractures.
It has been suggested by the authors that there may be a relationship between mandibular bone loss and osteoporosis of the remaining skeleton., Several panoramic radiographic measurements, also known as panoramic radiomorphometric indices such as mandibular cortical index (MCI), mandibular cortical width (MCW) or mental index (MI), and panoramic mandibular index (PMI), have been used by the dentists to assess the risk of undetected osteoporosis. Results suggested that the thickness of mandibular cortical bone is decreased in osteoporotic patients and inferior border of the mandible was more porous than the controls.
Mandibular cortical index
In 1994, Klemetti et al. devised the MCI as a classification of the appearance of the lower border of mandibular cortex distally from the mental foramen, as viewed on panoramic radiographs. This is a three-point index assessed as: C1 – the endosteal margin of the cortex was even and sharp on both sides; C2 – the endosteal margin showed semilunar defects (lacunar resorption) or appeared to form endosteal cortical residues (one to three layers) on one or both sides; C3 – the cortical layer formed heavy endosteal cortical residues and was clearly porous. MCI has been proposed as a method for identifying patients with poor bone quality in the primary dental care setting in various studies.
Panoramic mandibular index
Panoramic mandibular index (PMI) has also been used as a radiomorphometric tool for assessing osteoporosis status by different researchers.,, In 1991, Benson et al. first proposed it as a radiomorphometric index of adult cortical bone mass. It is the thickness of the mandibular cortex to the distance between the inferior margin of the mental foramen and inferior mandibular cortex [Figure 1]. Recent studies in literature on PMI values have been performed mostly on women. On average, the results of these literature revealed that PMI values varied between 0.31–0.38 for postmenopausal women, and these values which decreased with increasing age were smaller in whites than black individuals.,
|Figure 1: Measurement of mental index (a) and panoramic mandibular index (a/b)|
Click here to view
Antegonial and gonial index
Antegonial Index (AI) is the measurement of the cortical width in the region anterior to the gonion at a point identified by extending a best fit line along the anterior border from the ascending ramus down to the lower border of the mandible [Figure 2]. Gonial index (GI) is assessed by tracing a line tangent to the lower border of the mandible and another line tangent to the posterior border of the ramus on each side. The intersection of these lines forms the mandibular angle. Studies on AI measurement have shown that the change in measurement is inversely proportional to age, and that values are smaller in edentulous individuals than in dentate and denture-wearing individuals as well as in females than in males. It was also suggested that the decrease in cortical bone thickness in the gonial region, particularly among women, might be associated with osteoporosis., Studies have also been carried out in which authors have not considered them as a reliable screening tool to predict skeletal osteoporosis.
Mental index or MCW at the mental foramen region
MI on panoramic radiographs is the measurement of the MCW at the mental foramen region [Figure 1] to predict early osteoporosis, however, the cut-off threshold of the MI at which patients should be referred to bone densitometry is not yet clear. In 2002, Horner et al. suggested that patients with the thinnest mandibular cortices (<3 mm) should be referred for further investigations because these patients have a high fracture risk. Similar results have been reported by Taguchi et al.
| Oral Implications of Osteoporosis|| |
Osteoporotic females usually have lesser number and thinner trabecular plates, and the anterior maxilla have large amount of trabecular bone and the relatively low cortical bone thickness than non-osteoporotic individuals. Studies have found that the density of maxillary alveolar process bone is significantly related to the density of the mandibular alveolar process, lumbar spine, coxa, and radius in healthy women, and that maxillary alveolar process bone density declines with age., In temporomandibular dysfunction (TMD), bony changes and bone resorption occur in both the condyle and temporal components of the temporomandibular joint and may range from mild decreases in cortical bone to severe destruction of the condyle and temporal components. It has been reported that the habits and conditions that provoke development of general bone loss in the skeleton may disturb the functional harmony of the masticatory system, and thus may increase the possibility for TMDs.,
Studies have demonstrated correlation between osteoporosis and periodontitis. Similar to osteoporosis, periodontitis is a silent disease, not causing symptoms until late in the disease process when mobile teeth, abscesses, and tooth loss may occur. A history of previous bone loss, age, smoking, systemic disease, and certain medications (such as chronic corticosteroid treatment) are common risk factors for both periodontitis and osteoporosis., Kribbs reported that postmenopausal women with osteoporosis had decreased mandibular bone density, thinned cortex at the gonion, and more tooth loss than healthy postmenopausal women. Studies have indicated that estrogen status may influence alveolar bone density changes. A subsequent 2-year study by the authors demonstrated that estrogen deficiency was associated with alveolar bone crestal height and density loss in postmenopausal women with a history of periodontitis.,
| Management of Postmenopausal Osteoporosis|| |
Studies have shown that HRT promotes an increase in BMD that parallels the hormone dosage received., It also promotes oral health by inhibiting gingival inflammation, periodontitis, and consequent loss of teeth. This probably occurs because estrogen supplementation inhibits pro inflammatory cytokines (interleukin-1 (IL-1), tumor necrosis factor–alpha and IL-6 from mononuclear cells, T-cell mediated inflammation, and bone marrow production of leukocytes. IL-6 was found to be a causal factor because it has osteoclastogenic properties. Estrogen inhibits IL-6 and the drop in estrogen levels after menopause may be a factor for elevated IL-6 concentrations in aging females. It has been argued that the effect of estrogens is reversed shortly after treatment is stopped, such that fractures in later life are not prevented. Non-HRT interventions are approved for osteoporosis in many countries, and in numerous instances have been shown to have favorable effects on fracture rates. These include the agents known to affect bone metabolism, calcium, calcitonins, and bisphosphonates. They are used in the treatment of established osteoporosis with fractures for prevention; the long-term effects of calcitonins on bone mass are uncertain. The effects of bisphosphonates are known to persist for many months after the treatment is stopped. These interventions have been shown to reduce the frequency of hip fractures but their undisciplined use is expensive; however, they are more acceptable in later life with fewer side effects than HRT.
| Conclusion|| |
Osteoporosis, a silently progressing metabolic bone disease, is widely prevalent in India; it is very difficult to treat the fracture once it has occurred, and therefore, it is important to identify the percussive signs of fracture. The relationship between systemic osteoporosis and oral health is of significant interest to a large number of researchers and clinicians and requires further research. In addition, dentists could screen patients with unrecognized osteoporosis using information already available in the dental office.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Lenchik L, Sartoris DJ. Current concepts in osteoporosis. Am J Roentgenol 1997;168:905-11.
Dervis E. Oral implications of osteoporosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100:349-56.
World Health Organization. Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. Report of a WHO study group. World Health Organ Tech Rep Ser 1994;843:1-129.
Verheij JGC, Geraets WGM, Stelt PFV, Horner K, Lindh C, Nicopoulou-Karayianni K, et al
. Prediction of osteoporosis with dental radiographs and age. Dentomaxillofac Radiol 2009;38:431-7.
Jeffcoat MK, Lewis CE, Reddy MS, Wang CY, Redford M. Post-menopausal bone loss and its relationship to oral bone loss. Periodontol 2000 2000;23:94-102.
WHO Scientific Group on the Assessment of Osteoporosis at Primary health care level. Summary Meeting Report. Brussels, Belgium; May 2004. Available from: http://www.who.int/chp/topics/Osteoporosis.pdf
. [Last accessed on 2015 Nov 01].
Yasar F, Akgunlu F. The differences in panoramic mandibular indices and fractal dimension between patients with and without spinal osteoporosis. Dentomaxillofac Radiol 2006;35:1-9.
Cakur B, Dagistan S, Sahin A, Harorli A, Yilmaz AB. Reliability of mandibular cortical index and mandibular bone mineral density in the detection of osteoporotic women. Dentomaxillofac Radiol 2009;38:255-61.
Ishii K, Taguchi A, Nakamoto T, Ohtsuka T, Sutthiprapaporn P, Tsuda M, et al
. Diagnostic efficacy of alveolar bone loss of the mandible for identifying postmenopausal women with femoral osteoporosis. Dentomaxillofac Radiol 2007;36:28-33.
Taguchi A, Tanimoto K, Suei Y, Otani K. Oral signs as indicators of possible osteoporosis in elderly women. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;80:612-6.
Lewiecki EM, Kendler DL, Kiebzak GM, Schmeer P, Prince RL, El-Hajj Fuleihan G, et al
. Special report on the official positions of the international society for clinical densitometry. Osteoporos Int 2004;15:779-84.
White SC. Oral radiographic predictors of osteoporosis. Dentomaxillofac Radiol 2002;31:84-92.
World Health Organization, Obesity: Preventing and managing the global epidemic. WHO obesity technical report series 2000; no. 894. Geneva: Switzerland World Health Organization; 2000. Available from: http://whqlibdoc.who.int/trs/WHO_TRS_894.pdf
. [Last accessed on 2015 Nov 01].
Jacobs R, Ghyselen J, Koninckx P, Van Steenberghe D. Long term bone mass evaluation of mandible and lumbar spine in a group women receiving hormone replacement therapy. Eur J OralSci 1996;104:10-6.
Ravn P, Cizza G, Bjarnason NH, Thompson D, Daley M, Wasnich RD, et al
. Low body mass index is an important risk factor for low bone mass and increased bone loss in early postmenopausal women. Bone Miner Res 1999;14:1622-7.
Sugiura M, Nakamura M, Ogawa K, Ikoma Y, Ando F, Yano M. Bone mineral density in post-menopausal female subjects is associated with serum antioxidant carotenoids. Osteoporos Int 2008;19:211-9.
Bronner F. Calcium and osteoporosis. Am J Clin Nutr 1994;60:831-6.
Lindsley R, Cosman F. Osteoporosis. In: Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL, editors. Harrison's Principles of Internal Medicine. 16th
ed. Mc Graw Hill Companies Inc; 2005. p. 2268-73.
Mulligan R, Sobel S. Osteoporosis: Diagnostic testing, interpretation, and correlations with oral health-implications for dentistry. Dent Clin North Am 2005;49:463-84.
Buencamino MCA, Palomo L, Thacker HL. How menopause affects oral health, and what we can do about it. Clev Clin J Med 2009;76:467-75.
Heaney RP. Why does bone mass decreases with age and menopause? Abstract in the 4th
International Symposium on Osteoporosis and Consensus Development Conference. Hong Kong; 1993. p. 15.
Klemetti E, Collin HL, Forss H, Markkanen H, Lassila V. Mineral status of skeletal and advanced periodontal disease. J Clin Periodontol 1994;21:184-8.
Taguchi A, Suei Y, Sanada M, Ohtsuka M, Nakamoto T, Sumida H, et al
. Validation of dental panoramic radiography measures for identifying postmenopausal women with spinal osteoporosis. Am J Roentgenol 2004;183:1755-60.
Friedlander AH. The physiology, medical management and oral implications of menopause. J Am Dent Assoc 2002;133:73-81.
Ito M, Nishida A, Kono J, Uetani MKM, Hayashi K. Which bone densitometry and which skeletal site are clinically useful for monitoring bone mass? Osteoporos Int 2003;14:959-64.
Corten FGA, Vant Hof MA, Buus WCAM, Hoppenbrouwers P, Kalk W, Corstens FHM. Measurement of mandibular density ex vivo
and in vivo
by dual energy X-ray absorptiometry. Arch Oral Biol 1993;38:215-9.
Lu CY, Chen DC, Cai YH, Wei SQ. Concordance of OSTA and lumbar spine BMD by DXA in identifying risk of osteoporosis. J Orthop Surg Res 2006;1:1-6
Taguchi A, Tsuda M, Ohtuska M, Kodama I, Sanada M, Nakamoto T, et al
. Use of dental panoramic radiographs in identifying younger postmenopausal women with osteoporosis. Osteoporos Int 2006;17:387-94.
Kress BC, Mizrahi IA, Armour KW, Marcus R, Emkey RD, Santora AC. Use of bone alkaline phosphatase to monitor alendronate therapy in individual postmenopausal osteoporotic women. Clin Chem J 1999;45:1009-17.
Indumati V, Patil VS, Jailkhani R. Hospital based preliminary study on osteoporosis in postmenopausal women. Indian J Clin Biochem 2007;22:96-100.
Shin MH, Kweon SS, Park KS, Heo H, Kim SJ, Nam HS, et al
. Quantitative ultrasound of the calcaneus in a Korean population: Reference data and relationship to bone mineral density determined by peripheral dual X-ray absorptiometry. J Korean Med Sci 2005;20:1011-6.
Engelke K, Adams JE, Armbrecht G, Augat P, Bogado CE, Bouxsein ML, et al
. Clinical use of quantitative computed tomography and peripheral quantitative computed tomography in the management of osteoporosis in adults: The 2007 ISCD official positions. J Clin Densitom 2008;11:123-62.
Civitelli R, Pilgram TK, Dotson M. Hormone/estrogen replacement therapy improves alveolar and postcranial bone density in postmenopausal women. Arch Intern Med 2002; 162:1409-15.
Leite AF, Figueiredo PTDS, Guia CM, Melo NS, Paula APD. Correlations between seven panoramic radiomorphometric indices and bone mineral density in postmenopausal women. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:449-56.
Horner K, Devlin H. The relationship between mandibular bone mineral density and panoramic radiographic measurements. J Dent 1998;26:337-43.
Caligiuri P, Giger ML, Favus M. Multifractal radiographic analysis of osteoporosis. Med Phys 1994;21:503-8.
Velanovich V. Fractal analysis of mammographic lesions: A feasibility study quantifying the difference between benign and malignant masses. Am J Med Sci 1996;311:211-4.
Link TM, Majumdar S, Lin JC, Newitt D, Augat P, Ouyang X, et al
. A comparative study of trabecular bone properties in the spine and femur using high resolution MRI and CT. J Bone Miner Res 1998;13:122-32.
Pothuaud L, Lespesailles E, Harba R, Jennane R, Royant V, Eynard E, et al
. Fractal analysis of trabecular bone texture on radiographs: Discriminant value in postmenopausal osteoporosis. Osteoporosis Int 1998;8:618-25.
Geraets WG, van der Stelt PF. Fractal properties of bone. Dentomaxillofac Radiol 2000;29:144-53.
Southard TE, Southard KA, Jakobsen JR, Hillis SL, Najim CA. Fractal dimension in radiographic analysis of alveolar process bone. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:569-76.
Ruttimann UE, Webber RL, Hazelrig JB. Fractal dimension from radiographs of peridental alveolar bone: A possible diagnostic indicator of osteoporosis. Oral Surg Oral Med Oral Pathol 1992;74:98-110.
Lee K, Taguchi A, Ishii K, Suei Y, Fujita M, Nakamoto T, et al
. Visual assessment of the mandibular cortex on panoramic radiographs to identify postmenopausal women with low bone mineral densities. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100:226-31.
Taguchi A, Asano A, Ohtsuka M, Nakamoto T, Suei Y, Tsuda M. Observer performance in diagnosing osteoporosis by dental panoramic radiographs: Results from the osteoporosis screening project in dentistry (OSPD). Bone 2008;43:209-13.
Taguchi A, Ohtsuka M, Tsuda M, Nakamoto T, Kodama I, Inagaki K, et al
. Risk of vertebral osteoporosis in post-menopausal women with alterations of the mandible. Dentomaxillofac Radiol 2007;36:143-8.
Nah KS. Bone density relationship of mandible and cervical vertebrae in panoramic radiography. Korean J Oral Maxillofac Radiol 2000;30:259-63.
Jonasson G, Kiliandis S, Gunnarsson R. Cervical thickness of the mandibular alveolar process and skeletal bone mineral density. Acta Odontol Scand 1999;57:155-7.
Klemetti E, Kolmakov S, Kroger H. Pantomography in assessment of the osteoporosis risk group. Scand J Dent Res 1994;102:68-72.
Ledgerton D, Horner K, Devlin H, Worthington H. Radiomorphometric indices of the mandible in a British female population. Dentomaxillofac Radiol 1999;28:173-81.
Gulsahi A, Yuzugullu B, Imirzalioglu P, Genc Y. Assessment of panoramic radiomorphometric indices in Turkish patients of different age groups, gender and dental status. Dentomaxillofac Radiol 2008;37:288-92.
Benson BW, Prihoda TJ, Glass BJ. Variations in adult cortical bone mass as measured by a panoramic mandibular index. Oral Surg Oral Med Oral Pathol 1991;71:349-56.
Halling A, Persson GR, Berglund J, Johansson O, Renvert S. Comparison between the Kelmetti index and heel DXA BMD measurements in the diagnosis of reduced skeletal bone mineral density in the elderly. Osteoporos Int 2005;16:999-1003.
Dubravka K, Asja C. Comparison of mandibular bone density and radiomorphometric indices in wearers of complete or removable partial dentures. Oral Radiol 2005;21:259-66.
Knezovic Zlataric D, Celebic A, Lazic B, Baucic I, KomarD, Stepetic Ovcaricek J, et al
. Influence of age and gender on radiomorphometric indices of the mandible in removable denture wearers. Coll Antropol 2002;26:259-66.
Dutra V, Susin C, Pereira da Costa N, Bauer Veeck E, Bahlis A, da Rocha Correa Fernandes A. Measuring cortical thickness on panoramic radiographs: A validation study of the mental index. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:686-91.
Horner K, Devlin H, Harvey L. Detecting patients with low skeletal bone mass. J Dent 2002;30:171-5.
Southard KA, Southard TE, Schlechte JA, Meis PA. The relationship between the density of the alveolar processes and that of postcranial bone. J Dent Res 2000;79:964-9.
Southard TE, Southard KA, Lee A. Alveolar process fractal dimension and postcranial bone density. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91:486-91.
Klemetti E, Vainio P, Kroger H. Craniomandibular disorders and skeletal mineral status. Cranio 1995;13:89-92.
Gruber HE, Gregg J. Subchondral bone resorption in temporomandibular joint disorders. Cells Tissues Organs 2003;174:17-25.
Wactawski-Wende J. Periodontal diseases and osteoporosis: Association and mechanisms. Ann Periodontal 2001;6:197-208.
Kribbs PJ. Comparison of mandibular bone in normal and osteoporotic women. J Prosthet Dent 1990;63:218-22.
Payne JP, Zachs NR, Reinhardt RA, Nummikoski PV, Patil K. The association between estrogen status and alveolar bone density changes in postmenopausal women with a history of periodontitis. J Periodontal 1997;68:24-31.
Payne JP, Reinhardt RA, Nummikoski PV, Patil K. Longitudinal alveolar bone loss in postmenopausal osteoporotic/osteopenic women. Osteoporos Int 1999;10:34-40.
Friedlander AH. The physiology, medical management and oral implications of menopause. J Am Dent Assoc 2002;133:73-81.
[Figure 1], [Figure 2]