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 Table of Contents  
REVIEW ARTICLE
Year : 2016  |  Volume : 5  |  Issue : 4  |  Page : 199-203

Osteoporosis: A periodontal perception


Department of Periodontology, Swargiya Dadasaheb Kalmegh Smruti Dental College and Hospital, Nagpur, Maharashtra, India

Date of Web Publication15-Nov-2016

Correspondence Address:
Dr. Snehal Prabhakar Deotale
Department of Periodontology, Swargiya Dadasaheb Kalmegh Smruti Dental College and Hospital, Hingna, Nagpur - 441 110, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-344X.194079

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  Abstract 

Osteoporosis is a bone resorptive disorder which results in diminished bone strength predisposing the patient to a risk of fracture. Extensive research in the medical fraternity has shown that India bears a large population which is exposed to this skeletal disorder. Lately, the relationship between osteoporosis and periodontal disease has been brought into the limelight. The overlap of etiological factors of both the disease entities cannot be overlooked. In lieu of this, pain-staking research and modern concepts derived to ease the evaluation of the two pathologies have taken a boost since the last decade. Further, it is necessary to identify if either of the two diseases could be coined as a risk factor for the other. Adequate knowledge about the interrelationship could aid in apt diagnosis and subsequently an appropriate treatment planning. The following narrative review of literature is an encapsulation of facts that have been procured to affiliate the two diseases with each other.

Keywords: Bone resorptive disorder, osteoporosis, periodontal disease


How to cite this article:
Deotale SP, Gattani DR. Osteoporosis: A periodontal perception. Int J Health Allied Sci 2016;5:199-203

How to cite this URL:
Deotale SP, Gattani DR. Osteoporosis: A periodontal perception. Int J Health Allied Sci [serial online] 2016 [cited 2019 Sep 20];5:199-203. Available from: http://www.ijhas.in/text.asp?2016/5/4/199/194079


  Introduction Top


Osteoporosis is defined as a disorder of the bone comprising of compromised bone strength predisposing a person to an increased risk of fracture by The National Institute of Health Consensus Panel on Osteoporosis Prevention, Diagnosis, and Therapy (2009). This multifaceted, age-related metabolic skeletal disorder is characterized by diminished bone mineral density (BMD) which leads to the degradation of the microarchitecture of cancellous bone, alterations in its tensile properties, and exaggerated bone fragility giving rise to an increased risk of fractures.[1] Weakening of the skeleton is first observed in the spine, wrist, and hip. Thus, to label osteoporosis as a cause of morbidity and mortality cannot be overlooked.

Enumerable literature penned down across the globe shows that osteoporosis is increasing in significance as the population of the world both grows and ages. A comprehensive research on the systemic disorder has revealed certain facts. A 2001 census report revealed that by the year 2015, the population of Indians above the age of 50 will be 230 million.[2] According to a factsheet released by the International Osteoporosis Foundation, one out of eight males and one out of three females in the nation suffers from osteoporosis, making India one of the largest affected countries in the world. Moreover, the Indian population affected by osteoporosis lies in the age range of 50-60 years which is 10-20 years younger than their Western counterparts.[3]

A calculated inference states that the yearly incidence rate of osteoporotic fractures in women is more than the combined incidence rates of heart attack, stroke, and breast cancer. The World Health Organization (WHO) has conferred on osteoporosis as the second most common global health-care problem after cardiovascular disease.[4] This detailed research has facilitated the need to evaluate the various aspects of osteoporosis as a global threat to humanity.

On parallel grounds, periodontal disease is a locally occurring immunoinflammatory response to bacteria in the oral cavity resulting in alveolar bone loss. Both disease entities show synonymous risk factors and hence it has become inevitable to acknowledge the interrelationship between the two bone resorptive diseases.


  Method of Data Acquisition Top


Following a PubMed search using the keywords "osteoporosis," "periodontal disease," and "bone mineral density," several articles published until March 2016 were identified. A possible link between osteoporosis and periodontal disease was acknowledged, and a review of literature was designed to compile all important facts.


  Osteoporosis: At a Bird's View Top


Commonly known as the "symptomless silent disease," patients may acknowledge the presence of the disease as a broken bone. It may so happen that patients with osteoporosis may be unaware that they have the disease until their bones become so weak that a sudden accident causes a hip fracture or a vertebral collapse. There are four types of osteoporosis such as primary, secondary, osteoporosis imperfecta, and idiopathic juvenile osteoporosis.

BMD which forms an integral part of bone strength directly influences fracture risk. The latter is expressed as weight of mineral per area or volume (i.e., g/mm2 or g/mm≥). To evaluate this parameter, a BMD test is performed in the most common sites of fracture. Hence, it serves as an important diagnostic criterion for the same.

The WHO criteria (2007) have defined osteoporosis as a BMD that lies 2.5 standard deviations or more below the average value for young healthy women. However, since the absolute fracture risk can be mutated due to other factors, WHO developed more recently the fracture risk assessment tool (FRAXTM ) to overcome this drawback. The tool reckons a 10-year probability of fracture on the basis of readily accessible online calculation methods. The risk factors for osteoporotic fractures included in FRAXTM are age (50-90 years), sex, weight, height, low femoral neck BMD, prior fragility fracture, parental history of hip fracture, current tobacco smoking, use of glucocorticoids, rheumatoid arthritis, excessive alcohol intake, and other causes of secondary osteoporosis such as hyperthyroidism and Type 1 diabetes mellitus. At present, the WHO advocates that all the above-mentioned factors should be inculcated in the history and clinical examination of patients undergoing diagnostic assessment for osteoporosis-related fractures.[5]

Of the several tools available to measure BMD, the most widely recognized is dual energy X-ray absorptiometry (DEXA). Noninvasive DEXA has received global appreciation because of its high precision and resolution, high accuracy, low-radiation dose, and low cost. Disregarding a few flaws, it remains the gold standard assessment of osteoporosis.[6] The use of cone-beam computed tomography to assess the radiographic density of the mandible has also shown optimal results in the diagnosis of osteoporosis.[7] [Table 1] enumerates the various diagnostic assessment methods.
Table 1: Diagnostic tools for osteoporosis


Click here to view


A dental panoramic radiograph (DPR) can measure the thickness of the mandibular inferior cortex (MIC) below the mental foramen. The trabecular bone is easily manipulated by dental infections and hence cortical bone is chosen for greater consistency among readings. Klemetti in 1994 gave a classification for undiagnosed osteoporosis by evaluating the porosity of the MIC. This method has great potential because DPRs are taken as a part of routine dental examinations. Assessment of MIC erosion or thin cortical width can be used to identify young postmenopausal osteoporotic women.[4] Classification of MIC is elaborated as below in [Table 2].
Table 2: Klemetti's classification of mandibular inferior cortex


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Several physicians have claimed that osteoporosis is both under diagnosed and under treated. It is underdiagnosed because of patient negligence to get a bone density test done, sometimes even after they suffer a fracture. The condition is undertreated because some patients avoid drug therapy for fear of side effects, while others take their medications unpunctually or stop taking them altogether without consulting their doctors.


  Osteoporosis and Periodontal Disease Top


Groen in 1968 first brought into light the influence of osteoporosis on the progression of periodontal disease. Examining the affiliation between the two diseases requires addressing these factors, as well as the type of study design. Both osteoporosis and periodontal diseases share the common risk factors which can be modifiable or nonmodifiable as enlisted in [Table 3].[4]
Table 3: Common risk factors for osteoporosis and periodontal disease


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A plausible link between osteoporosis and periodontal disease was the study of cytokines, the presence of which was observed in both diseases. Cytokines, such as receptor activator of nuclear factor kappa-B ligand and osteoprotegerin, C-terminal telopeptides play a consequential role in the production of bone-resorbing osteoclasts. It was observed that higher levels of the same were seen in an osteoporotic postmenopausal population as compared to a nonosteoporotic population.[8]

A peculiar finding that came across in the NHANES III study in 2000 suggested that calculus played a significant role in a three-way interaction with clinical attachment level (CAL) and BMD. High calculus scores exhibited an inverse association between BMD and CAL.[9]

Several longitudinal studies conducted to evaluate if changes in mandibular trabecular patterns could identify osteoporosis showed that skeletal bone loss was associated with a decrease in alveolar bone mass and that the latter was a highly significant predictor of future fracture risk.[5] A longitudinal study conducted by Pereira et al. to associate osteoporosis and periodontal disease showed that statistically significant changes in the gingival bleeding index were observed as baseline osteopenic patients progressed to becoming osteoporotic in a span of 3 years.[10]

The studies of utmost interest were those using DPR to determine MIC classification of oral bone loss. Every 1 mm decrease in MIC thickness or presence of mild to moderate MIC erosion raised the likelihood of osteoporosis by 83%.[11]

The cross-sectional studies on the periodontal assessment of CAL in postmenopausal osteoporotic women indicated that 2.5 times greater risk of having periodontal disease existed in the study group, confirming the previous findings. Osteoporotic women presented with higher CAL values than those with BMD levels in normal or osteopenic women.[12] This would suggest that timely diagnosis of low BMD prior to detection of periodontal disease may be beneficial to prevent periodontal disease.

Lin et al. conducted a nationwide, population-based, cohort study to determine the relation of gender to affiliate osteoporosis and periodontal disease by retrieving data from the National Health Insurance Research Database, Taiwan. A multiple logistic regression analysis of the demographic status of periodontally challenged osteoporotic patients revealed that this correlation was significantly prominent among women.[13]


  Is Osteoporosis a Risk for Dental Implant TherapY? Top


The advent of implants in the treatment of severely resorbed edentulous arches has become an accepted alternative to conventional prosthetic dentistry. Successful osseointegration depends on the state of the host bone bed and its healing capacity. Hence, concerns have been raised about conditions affecting its quality and quantity. Bone resorptive diseases like osteoporosis may therefore represent a possible contraindication/risk factor for osseointegration.

Osteoporotic patients exhibit a wide range of skeletal changes such as greater alveolar ridge resorption than average, altered trabecular pattern in the anterior maxilla and posterior mandible, erosions of the inferior border of the mandible as compared to unaffected individuals, and increased resorption and thinning of the mandibular inferior cortical margin.[14] These findings may have an impact on placing dental implants.

Various implant studies have reported increased failure rates of implants placed in jaws with a thin layer of compact bone surrounding a core of low-density trabecular bone which is classified as Type 4 according to Lekholm and Zarb, 1985. This typical bone quality is seen in osteoporotic patients.[15] Histological findings to assess the implant-bone contact of re-acquired failed implants found no differences whether the implant came from patients with or without osteoporosis. On the other hand, it has been proposed that dental implant placement may help to preserve alveolar bone in patients with osteoporosis due to more favorable mechanical loading and stimulation of the bone.[16]

Abiding by the available literature on this subject, a need for more clinical studies, to accurately determine if dental implant outcomes are affected in osteoporotic patients, is felt.


  Treatment Modalities for Osteoporosis Top


Current treatment approaches in osteoporosis include lifestyle approaches, balanced diet comprising substantial amounts of calcium and Vitamin D for bone development. Maintenance strategies include weight bearing exercises, smoking prevention, and pharmacological interventions. Systemic pharmacological treatment modalities, which aim to increase bone mass include estrogen replacement therapy, bisphosphonates, selective estrogen receptor modulators, calcitonin, and parathyroid hormone.

All cases of osteonecrosis of the jaw (ONJ) related to the administration of antiresorptive therapeutic agents are termed "Antiresorptive Agent-Induced ONJ" (ARONJ). This term encompasses bisphosphonate-associated/induced cases, as well as cases associated with the use of other antiresorptive agents. This is one of the most commonly encountered disease entities seen after the use of antiresorptive agents for osteoporosis. The dentist may face the decision of whether or not to treat such cases. The panel of the American Dental Association advises that a patient with active dental or periodontal disease should be treated in spite of the risk for ARONJ because no treatment bears more risks and consequences that would likely outweigh the risks of developing ARONJ.


  Management of Periodontal Diseases in Patients with Osteoporosis Top


Nonsurgical periodontal therapy can be unanimously administered in osteoporotic patients on antiresorptive therapy who have active periodontal disease combined with the commonly recommended reevaluation at 4-6 weeks. Although surgical therapy is not contraindicated in such conditions, minimization of dentoalveolar manipulation is generally preferred. Because dental extractions constitute a risk factor for ARONJ, patients should be regularly monitored and treated with the goal of preventing progression of periodontal disease to the point where dental extractions are necessary. The surgical periodontal treatment should be performed to obtain access to root surfaces, and preference should be placed on the use of atraumatic techniques when possible.

There is a scarcity in published studies that evaluate successful treatment following regenerative periodontal procedures in osteoporotic patients. The use of the same should be judiciously considered based on patient need. Primary soft tissue closure following periodontal surgical procedures is desirable, when feasible, though extended periosteal bone exposure for the sake of primary closure may increase, rather than decrease, the risk of ARONJ. Patients without periodontal disease should receive preventive therapy or instruction for the prevention of periodontal disease.

The risk of ARONJ and/or implant failure in female patients with a history of bisphosphonate use has been examined in several relatively small, short-term studies. One hundred percent implant success was seen in 61 patients due to absence of ARONJ postoperatively with an average duration of bisphosphonate use of 3.3 years.[17] One hundred and one implants placed in 42 bisphosphonate users evaluated from 6 months to 11 years duration prior to implant placement, showed no ARONJ and an implant success rate of 95%.[18] The above-mentioned studies show the encouraging results and hence patients may be informed that the risk of ARONJ as a result of antiresorptive therapy is low and that the success rates of implants placed in bisphosphonate users appear to be the same as that in systemically healthy patients. At present, antiresorptive therapy does not appear to be a contraindication for dental implant placement. However, larger and long-term studies are needed to support the hypothesis.


  Conclusion Top


From the review of the pertinent literature, a definite association between osteoporosis and periodontal disease can be noted. Of major concern is the inability to easily correlate the two conditions due to the lack of uniformity in diagnosing periodontal disease. Adjunctive actions for prevention, evaluation, and treatment of periodontal diseases and osteoporosis will result in a minimal risk of reduced BMD ultimately yielding a healthier life for the diseased, reducing comorbidities and oral health care cost.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Wasnich RD. Epidemiology of osteoporosis. Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism. Philadelphia: Lippincott-Raven; 1996. p. 249-51.  Back to cited text no. 1
    
2.
Gupta AK, Samuel KC, Kurian PM, Rallan RC. Preliminary study of the incidence and aetiology of femoral neck fracture in Indians. Indian J Med Res 1967;55:1341-8.  Back to cited text no. 2
    
3.
Damodaran P, Subramaniam R, Omar SZ, Nadkarni P, Paramsothy M. Profile of a menopause clinic in an urban population in Malaysia. Singapore Med J 2000;41:431-5.  Back to cited text no. 3
    
4.
Dodd DZ, Rowe DJ. The relationship between postmenopausal osteoporosis and periodontal disease. J Dent Hyg 2013;87:336-44.  Back to cited text no. 4
    
5.
Kanis JA, Johnell O, Oden A, Johansson H, McCloskey E. FRAX and the assessment of fracture probability in men and women from the UK. Osteoporos Int 2008;19:385-97.  Back to cited text no. 5
    
6.
Carey JJ, Delaney MF, Love TE, Richmond BJ, Cromer BA, Miller PD, et al. DXA-generated Z-scores and T-scores may differ substantially and significantly in young adults. J Clin Densitom 2007;10:351-8.  Back to cited text no. 6
    
7.
Barngkgei I, Al Haffar I, Khattab R. Osteoporosis prediction from the mandible using cone-beam computed tomography. Imaging Sci Dent 2014;44:263-71.  Back to cited text no. 7
    
8.
Jabbar S, Drury J, Fordham J, Datta HK, Francis RM, Tuck SP. Plasma Vitamin D and cytokines in periodontal disease and postmenopausal osteoporosis. J Periodontal Res 2011;46:97-104.  Back to cited text no. 8
    
9.
Ronderos M, Jacobs DR, Himes JH, Pihlstrom BL. Associations of periodontal disease with femoral bone mineral density and estrogen replacement therapy: Cross-sectional evaluation of US adults from NHANES III. J Clin Periodontol 2000;27:778-86.  Back to cited text no. 9
    
10.
Pereira FM, Rodrigues VP, de Oliveira AE, Brito LM, Lopes FF. Association between periodontal changes and osteoporosis in postmenopausal women. Climacteric 2015;18:311-5.  Back to cited text no. 10
    
11.
Taguchi A, Sanada M, Krall E, Nakamoto T, Ohtsuka M, Suei Y, et al. Relationship between dental panoramic radiographic findings and biochemical markers of bone turnover. J Bone Miner Res 2003;18:1689-94.  Back to cited text no. 11
    
12.
Aspalli SS, Shetty VS, Parab PG, Nagappa G, Devnoorkar A, Devarathnamma MV. Osteoporosis and periodontitis: Is there a possible link? Indian J Dent Res 2014;25:316-20.  Back to cited text no. 12
[PUBMED]  Medknow Journal  
13.
Lin TH, Lung CC, Su HP, Huang JY, Ko PC, Jan SR, et al. Association between periodontal disease and osteoporosis by gender: A nationwide population-based cohort study. Medicine (Baltimore) 2015;94:e553.  Back to cited text no. 13
    
14.
Bollen AM, Taguchi A, Hujoel PP, Hollender LG. Case-control study on self-reported osteoporotic fractures and mandibular cortical bone. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:518-24.  Back to cited text no. 14
    
15.
van Steenberghe D, Quirynen M, Molly L, Jacobs R. Impact of systemic diseases and medication on osseointegration. Periodontol 2000 2003;33:163-71.  Back to cited text no. 15
    
16.
Beikler T, Flemmig TF. Implants in the medically compromised patient. Crit Rev Oral Biol Med 2003;14:305-16.  Back to cited text no. 16
    
17.
Fugazzotto PA, Lightfoot WS, Jaffin R, Kumar A. Implant placement with or without simultaneous tooth extraction in patients taking oral bisphosphonates: Postoperative healing, early follow-up, and the incidence of complications in two private practices. J Periodontol 2007;78:1664-9.  Back to cited text no. 17
    
18.
Bell BM, Bell RE. Oral bisphosphonates and dental implants: A retrospective study. J Oral Maxillofac Surg 2008;66:1022-4.  Back to cited text no. 18
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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