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International Poster Journal of Dentistry and Oral Medicine
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Int Poster J Dent Oral Med 8 (2006), No. 2     15. June 2006

Int Poster J Dent Oral Med , Vol No , Poster 319

Relationship between systemic osteoporosis and periodontal disease

Language: English

Authors:
Assist. Prof. Dr. Dr. Alexandrina L. Dumitrescu,
Assist. Prof. Dr. Ioana Madalina Maftei-Galopentia,
Department of Oral Surgery, School of Dental Medicine, University of Medicine and Pharmacy 'Carol Davila', Bucharest, Romania

Date/Event/Venue:
July 16th-18th 2005
National Congress of the French Society of Periodontology and Implantology (SFPIO)
Bordeaux, France

Introduction

Osteoporosis and osteopenia are characterized by reductions in bone mass and may lead to skeletal fragility and fracture. Periodontitis is an inflammatory disease characterized by loss of connective tissue and alveolar bone. Like osteoporosis, it is a silent disease, not causing symptoms until late in the disease process when mobile teeth, abscesses and tooth loss may occur. While the etiologic agent in periodontitis is a pathogenic bacterial plaque in a susceptible patient, periodontitis and osteoporosis have several risk factors in common. They include an increased prevalence with increasing age, smoking and influence of disease or medications that may interfere with healing. In addition, the pathophysiology of both diseases appears to have hereditary or, at least, familial component (Reddy, 2001). It is unknown whether the rate of progression of periodontitis is related to systemic osteopenia (Jeffcoat, 1998).

Objectives

This poster reviews the current evidence on the association between periodontal disease and osteoporosis.

Material and Methods

1. Methods for assessing bone mass and density
a) Radiographs
- panoramic radiographs (Figure 1a, b)
- periapical radiographs
b) Dual energy X-ray absorption (DXA)
- uses an X-ray source
- measurements of bone mass as 'areal density' in units of grams/cm2
c) Absorptiometry
- utilizes a gamma source
- measure bone mass in grams (approximate ash weight) per cm along the axis of the bone.
Single photon absorptiometry uses gamma source such as I125
Dual photon absorptiometry uses isotopes with 2 gamma ray energies such as gadolinium153
d) Quantitative computed tomography (QCT)
- permits direct measurement of either trabecular or total bone density
- provides measures of bone 'apparent' density in units of grams/cm3

Figure 1. Regions for measuring mandibular bone changes in vivo on panoramic radiographs
A. Thickness of the mandibular angular cortex with a marking gauge (GO) (Bras et al., 1982)
B. Calculation of PMI (PMI superior margin= c / a; PMI superior margin= c / b) (Benson et al., 1991)
C. Changes in inferior cortex (C1-C3) detected on both sides of mandible, distally from the mental foramen (Klemetti et al., 1994)

2. Techniques used to assess periodontitis and oral bone loss (Figure 2 and 3)
- Radiographic measures of alveolar crestal height and residual ridge resorption
- Probing measures to assess clinical attachment level
- Measures of tooth loss

Figure 2. Measuring method for the height of ridge on panoramic radiograph - from the inferior border to the superior edge of the alveolar crest in the region of the mental foramen (IC), divided by the distance from the inferior border to the lower edge of the mental foramen (IM) to calculate the percent of bone remaining (Kribbs, 1990)

Figure 3 A. Diagrammatic representation of Periodontal Probing Figure 3 B. The measurement of the mean alveolar bone loss (mm) on bitewing radiographs, between the bone level of the alveolar crest (AC) and the cemento-enamel junction (CEJ), perpendicular to the occlusal surface of the tooth (Elders et al., 1992)

Results

Cross-sectional studies correlating bone mineral density with tooth count have not shown similar results and are not likely in themselves to provide a definitive answer to the temporal relationship between the onset of loss of bone mineral density and teeth (Table 1 and Table 2).

Table 1: Studies on the relationship of tooth loss and osteoporosis
Authors Type of study Population Association
Kribbs (1990b) Cross-sectional 85 women with osteoporosis;27 normal women S
Elders et al. (1992) Cross-sectional 286 women NS
Klemetti et al. (1994) Cross-sectional 355 postmenopausal women NS
Taguchi et al. (1995a) Cross-sectional 64 women S
Taguchi et al. (1995b) Cross-sectional 269 healthy patients S
Krall et al. (1996) Longitudinal 7 years 189 healthy, white, dentate, postmenopausal women S
Mohammad et al. (1997) Cross-sectional 44 non white women NS
Hidebolt et al. (1997) Cross-sectional 135 postmenopausal women NS
Bando et al. (1998) Cross-sectional 14 periodontally healthy women; 12 edentulous women S
Taguchi et al. (1999) Cross-sectional 90 Japanese women S

Table 2: Studies on the relationship of periodontal disease and osteoporosis
Authors Type of study Population Osteoporosis assessment Periodontitis evaluation Oral hygiene monitoring Association
Kribbs et al. (1989) CS 85 edentulous postmenopausal women Total body calcium; SPA of the radius; DPA of the vertebrae; Cortical thickness at the gonion PD, GR, BOP - S
Kribbs (1990a) CS 50 normal women 20-90 yrs SPA of the radius; DPA of the vertebrae; Mandibular bone mass on radiographs made distal to the mental foramen; Cortical thickness at the gonion PD, GR, BOP - S
Kribbs (1990b) CS 85 women with osteoporosis(50-84 yrs); 27 normal women Cortical thickness at the gonion; Radiographic evidence of vertebral compression fractures; Mandibular bone mass and density PD, GR, BOP - NS
Elders et al. (1992) CS 286 women (46-55 yrs) Lumbar BMD; MCT Alveolar bone loss, PD, BOP Oral cleaning NS
Von Wowern et al. (1992) L 17 acute nephritic dentate patients undergoing intensive long-term high- dose steroid treatment DPA measurements of BMC of mandible and forearm BOP, CAL on 6 selected teeth Visible plaque (Oil) NS
Von Wowern et al. (1994) CS 12 women with osteoporotic fractures; 14 normal women BMC of the mandible at the standard site (DPA); BMC of the forearm (DPA) Same as above Visible plaque (Oil) S
Mohammad et al. (1996) CS 22 women with low mean spine bone density; 20 normal women Spine bone mineral density (DPA) PD, GR, CAL Plaque Index S
Wactawski - Wende et al. (1996) CS 70 post-menopausal women (51-78yrs) DXA of the lumbar spine and femur CAL, Alveolar bone loss - S
Hildebolt (1997) CS 135 postmenopausal women (41-71 yr) DXA of postcranial (vertebral and proximal femur) BMD CAL, PD, GR - NS
Payne et al. (1999) L 17 women with osteoporosis of the lumbar spine; 21 control DXA of the lumbar spine Alveolar bone height loss Plaque Index S
Payne et at. (2000) L 59 postemenopausal women as subjects: 38 non-smokers, 21 smokers BMD of the lumbar spine (L2-L4) (DXA) Alveolar bone height loss Plaque Index S
Weyant et at. (1999) CS 292 dentate women (average age 75.5 yrs) Systemic BMD at 8 anatomic sites (hip, radius, spine, calcaneus) by SPA, DPA BOP, CAL, PD Calculus NS
Tezal et al. (2000) CS 70 postmenopausal (51- 78yrs) BMD at lumbar spine and femur (DXA) BOP, PD, CAL, Alveolar bone loss on Rx Plaque, calculus S
Ronderos et al. (2000) CS 11655 adults (5733 males, 5922 females) BMD of the proximal femur (DXA) PD,CAL, BOP Calculus index NS
Von Wowern et al. (2001) L 24 young patients with severe periodontitis (22- 42yrs) BMC or BMD at the standard site of the mandible (DPA), lumbar spine and the left femoral neck (DXA) PD, CAL, Alveolar bone loss - S
Persson et al. (2002) CS 1084 subjects 60-75 yrs Self reported history of osteoporosis Alveolar bone loss - S
Mohammad et al. (1997) CS 44 non Hispanic white women (aged 50 to 75 yrs) Mandibular cortex index on panoramic Rx; self reported history of osteoporosis; DXA GI, CAL, PD, GR PI S

Discussion

Cross-sectional studies correlating bone mineral density with tooth count have not shown similar results and are not likely in themselves to provide a definitive answer to the temporal relationship between the onset of loss of bone mineral density and teeth.
1. It is impossible to determine the cause of a lost tooth from a single examination. Teeth may be lost for many reasons other than decreased bone support including, but not limited to caries, endodontic involvement, fractures, trauma and restorative considerations;
2. Few teeth actually exfoliate, rather dentists extract them for a variety of sound diagnostic, prognostic, esthetic, patient preference and financial reasons;
3. Patient recall of reasons for extraction is not always reliable, and if records of treatment are secured, they do not uniformly contain the information required to determine the reason for extraction

A positive association between osteoporosis and loss of alveolar crestal height was showed in the limited number of published studies presented. Large scale and long-term studies are needed.

Literature

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Abbreviations

AC - alveolar bone crest
BMD - bone mineral density
BOP- bleeding after probing
CAL - clinical periodontal attachment loss
CEJ - cemento-enamel junction
CS - Cross-sectional
DPA - dual-photon absorptiometry
DXA - dual energy X ray absorptiometer
GI - Gingival Index
GR - gingival recession
L - Longitudinal
MCT - Metacarpal cortical thickness
PD - pockets depths
PI - Plaque Index
Rx - Radiographs

This Poster was submitted by Assist. Prof. Dr. Dr. Alexandrina L. Dumitrescu.

Correspondence address:
Assist. Prof. Dr. Dr. Alexandrina L. Dumitrescu.
Department of Periodontology
School of Dental Medicine
University of Medicine and Pharmacy 'Carol Davila'
str. Calea Plevnei 19
010232 Bucharest
Romania