|Year : 2015 | Volume
| Issue : 4 | Page : 539-543
Evaluation of the relationship of mandibular cortical index and panoramic mandibular index with bone mineral density using panoramic radiography in postmenopausal women: A short study
Gargi Saran, Neeta Misra, Deepak Umapathy, Shivakumar Ganiga Channaiah, Priya Singh, Saurabh Srivatava
Department of Oral Medicine and Radiology, Babu Banarasi Das College of Dental Sciences, Lucknow, Uttar Pradesh, India
|Date of Submission||08-May-2015|
|Date of Acceptance||19-May-2016|
|Date of Web Publication||19-Aug-2016|
Dr. Gargi Saran
Department of Oral Medicine and Radiology, Babu Banarasi Das College of Dental Sciences, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: The problems associated with age-related skeletal osteopenia have received attention since the human skeleton undergoes a continuous physiologic decrease in bone mass with advancing age. Bone status at various sites can be assessed using dual-energy X-ray absorptiometry (DXA) or quantitative computed tomography. It would be useful to answer whether radiographic changes in the mandible indicate skeletal osteopenia. Aims and Objectives: The aim and objective of the study was to examine the mandibular cortical index (MCI) and panoramic mandibular index (PMI) on panoramic radiograph and to establish a relationship between the two indices (MCI and PMI) with the bone mineral density (BMD) in postmenopausal women. Materials and Methods: The study consisted of 15 postmenopausal women within the age group of 45-75 years. BMD was performed by DXA and measured at the lumbar spine and femoral neck and values were recorded. Panoramic radiographs of the same women were obtained for measuring MCI and PMI. There were two groups taken as C1 and C2 for determination of MCI and PMI. Results: The Pearson correlation analysis revealed a significant correlation between age and T-score (r = −0.59, P < 0.05), i.e., as age increased the T-score decreased. Comparing the T-score of two MCI groups, t-test revealed MCI was 69.1% lower in C2 as compared to C1. The value of P < 0.001 and t-test revealed significantly different and lowered (32.4%) inferior cortex level in C2 as compared to C1 (t = 4.76, P < 0.001). Conclusion: Results suggest that in this study panoramic radiography could be a reliable tool in screening for BMD.
Keywords: Bone mineral density, osteoporosis, panoramic, postmenopausal women
|How to cite this article:|
Saran G, Misra N, Umapathy D, Channaiah SG, Singh P, Srivatava S. Evaluation of the relationship of mandibular cortical index and panoramic mandibular index with bone mineral density using panoramic radiography in postmenopausal women: A short study. J Indian Acad Oral Med Radiol 2015;27:539-43
|How to cite this URL:|
Saran G, Misra N, Umapathy D, Channaiah SG, Singh P, Srivatava S. Evaluation of the relationship of mandibular cortical index and panoramic mandibular index with bone mineral density using panoramic radiography in postmenopausal women: A short study. J Indian Acad Oral Med Radiol [serial online] 2015 [cited 2021 Nov 30];27:539-43. Available from: https://www.jiaomr.in/text.asp?2015/27/4/539/188749
| Introduction|| |
The problems associated with age-related skeletal osteopenia have received much attention since the human skeleton undergoes a continuous physiologic decrease in bone mass with advancing age. Bone status at various sites can be assessed using dual-energy X-ray absorptiometry (DXA), quantitative ultrasound, or quantitative computed tomography.  Osteoporosis is a silent, progressive, complex, chronic, and symptomless disease that affects bones of the adults regardless of gender.  Women after menopause are more affected. It is estimated that 33.33% of women and 12.5% of men over 50 years of age are most commonly affected.  The mandible and maxilla can be affected by systemic diseases as well as local bone diseases which can result in total loss of teeth. Currently, DXA is widely accepted as the "gold standard" method of clinical bone mineral measurement in the lumbar spine and the femoral neck because of its high precision and high accuracy.  Dental panoramic radiography is a useful imaging technique by which the dentist can evaluate the whole dentition as well as the jaw bones and is widely used for routine examinations. Clinicians have started to focus on some mandibular panoramic indices such as mandibular cortical index (MCI), mandibular cortical thickness, and panoramic mandibular index (PMI) for the identification of elderly individuals who should undergo bone mineral density (BMD) assessment.
Women lose more mineralized bone than men, especially after menopause when bone loss accelerates and can result in fractures which are often the first symptoms of osteoporosis. Osteoporosis, the most common metabolic bone disease, is characterized by low bone mass, microarchitectural weakening leading to bone fragility and an increase in fracture risk. The earliest suggestion of an association between osteoporosis and oral bone loss was made in 1960.  A number of investigators have stated that the progressive loss of alveolar bone may be a manifestation of osteoporosis. ,, Some authors concluded that panoramic dental radiographs should not be used to assess the patient's status regarding osteoporosis, and some stated that it could be reliable in screening for osteoporosis. ,
| Aims and Objectives|| |
The aim of this study was to examine the MCI and PMI on a panoramic radiograph. The objective of the study was to establish a relationship between the MCI and PMI on panoramic radiograph and compare it with BMD in postmenopausal women.
| Materials and Methods|| |
The study consisted of 15 postmenopausal women within the age group of 45-75 years. BMD was performed by DXA as measured at the lumbar spine and femoral neck with (DEXA scan). Panoramic radiographs of the same women were obtained by Carestream (Kodak) Machine 9000 3D (Carestream HealthCare Inc. 150 Verona Street Rochestar, NY. USA), for measuring MCI and PMI at 70 kVp with 13 mAs. The patients were classified as normal, osteopenic, and osteoporotic based on the BMD data of total body at anteroposterior (AP) spine and femoral neck. Patients who were taking hormone replacement therapy and who were previously taking treatment for osteoporosis were not enrolled in the study. The ethical clearance was obtained from the institutional ethical committee.
Measurement of mandibular cortical index and panoramic mandibular index
Three linear measurements were recorded [Figure 1]. (1) The total height of the mandibular body (the distance between the lower and upper borders of mandible) "H" (mm). (2) The height from the lower border of the mandible to the lower border of the mental foramen "h" (mm). (3) The height of the mandibular inferior cortex "IC" (mm).
PMI was calculated according to the method of Benson et al. as a ratio IC/h.  The MCI was grouped based on the appearance of the lower border of mandibular cortex distally from the mental foramen, as viewed on panoramic radiographs. C1 [Figure 2]: The endosteal margin of the cortex was even and sharp on both sides. C2 [Figure 3]: The endosteal margin showed semilunar defects (lacunar resorption) or seemed to form endosteal cortical residues (1-3 layers) on one or both sides. C3 [Figure 4]: The cortical layer formed heavy endosteal cortical residues and was clearly porous.  There were two groups taken as C1 and C2 for determination of MCI [Table 1] and [Table 2]. MCI and IC of PMI correlated with T-score [Table 3] and [Table 4].
| Results|| |
In this study, out of 15 postmenopausal women, 8 women were normal, 6 were osteopenic, and 1 was found to be osteoporotic based on the BMD scores obtained. Three correlations were made, which are as follows:
- Age correlated with T-score (BMD)
- MCI and IC of PMI correlated with T-score
- IC of PMI correlated with T-score.
The data was summarized as mean ± standard deviation. Groups were compared by independent Student's t-test. Pearson correlation analysis was done to assess association between the variables. A two-tailed (α = 2) correlation was obtained. P < 0.05 was considered statistically significant. Analyses were performed on SPSS software (Windows version 17.0 by IBM SPSS.Inc. 2009).
Age correlated with T-score (bone mineral density)
The correlation between age and T-score is summarized in Graph 1. The Pearson correlation analysis revealed a significant and negative (inverse) correlation between age and T-score (r = −0.59, P < 0.05), i.e., as the age increased, the T-score decreased.
Mandibular cortical index and inferior cortex of panoramic mandibular index correlated with T-score
The distribution of IC (mm) and T-score according to MCI (C1 and C2) is summarized in [Table 5] and also depicted in Graph 2. Comparing the mean IC levels of two MCI groups, t-test revealed significantly different and lowered (32.4%) IC level in C2 as compared to C1 (4.17 ± 0.52 vs. 2.82 ± 0.52, t = 4.76, P < 0.001). Similarly, comparing the T-score of two MCI groups, t-test revealed similar T-score between the two groups (−0.55 ± 1.31 vs. −1.78 ± 1.49, t = 1.64, P = 0.124) although it was 69.1% lower in C2 as compared to C1.
|Table 5: Distribution inferior cortex and T - score according to mandibular cortex index |
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Inferior cortex of panoramic mandibular index correlated with T-score
The correlation of T-score and IC is also summarized in Graph 3. The Pearson correlation analysis revealed an insignificant correlation between T-score and IC (r = 0.39, P > 0.05) although a positive correlation was seen.
| Discussion|| |
In this study, out of 15 postmenopausal women, 7 patients were found osteopenic and their BMD values when correlated with age were also decreasing; hence, it was concluded that with age all the bones of the body, including mandible, are affected due to progressing bone loss. Ledgerton et al. in 1999 found that there was a general downward trend with age until the sixth decade when values of BMD began to fall sharply compared to the mean values for the population.  Many investigators have suggested that thin, eroded mandibular IC detected on panoramic radiographs is an indicator for alterations in mandible and is useful in identifying postmenopausal women with undetected low BMD. Horner et al. in 1998 and Taguchi et al. in 2008 concluded that MCI was more dominant in determining BMD and panoramic radiography was superior to questionnaire-based screening for identifying women who are at high risk for fracture. , In this study, MCI and IC of PMI index was correlated with T-score and was found that while comparing the mean IC levels of two MCI groups, t-test revealed significantly different and lowered (32.4%) IC level in C2 as compared to C1 (4.17 ± 0.52 vs. 2.82 ± 0.52, t = 4.76, P < 0.001). Similarly, comparing the T-score of two MCI groups, t-test revealed similar T-scores between the two groups (−0.55 ± 1.31 vs. −1.78 ± 1.49, t = 1.64, P = 0.124) although it was 69.1% lower in C2 as compared to C1. Cortical thinning of mandible was regarded as the indicator of alteration in mandible. BMD (T-score) was significantly correlated with MCI with significant P < 0.001. In a study by Bensen et al. also, similar results were obtained.  IC of PMI correlated with T-score also showed a positive correlation.
| Conclusion|| |
The results in this study suggested that panoramic radiography could be significantly reliable in screening the low BMD. Detection of MCI was found useful for identifying postmenopausal women with increased risk of osteoporotic fracture. As very few studies were conducted on this topic, there was a need to conduct the study to correlate panoramic radiography for the screening of osteoporosis. We do realize that sample size in our study is small and should be conducted on a larger sample to conclude and obtain results beneficial for a larger population.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]