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Year : 2019  |  Volume : 30  |  Issue : 5  |  Page : 747-750
Do Patients with Osteoporosis Have Higher Risk to Present Reduced Alveolar Ridge Height? An Imaging Analysis

1 Department of Oral Diagnosis, University of São Paulo, São Paulo, Brazil
2 Department of Stomatology, University of São Paulo, São Paulo, Brazil
3 Department of Oral Pathology, University of São Paulo, São Paulo, Brazil

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Date of Submission13-Jun-2018
Date of Decision01-Feb-2019
Date of Acceptance05-Jun-2019
Date of Web Publication18-Dec-2019


Background: Osteoporosis and periodontitis are both diseases that induce bone resorption. The objective of this study was to verify through panoramic radiography analysis whether patients with osteoporosis have a greater risk of periodontal disease (horizontal alveolar bone defect and vertical alveolar bone defect) when compared with patients without osteoporosis. Methods: In all, 100 women were selected: 50 with osteoporosis (T-score < -2.5 DP) and 50 without osteoporosis (T-score > -2.5 DP), using the T-score of proximal radius. Logistic regression test was performed to assess the risk of panoramic radiographic periodontal defects (horizontal and vertical bone defect), age, and bone mineral density influence. Results: Advanced age women were three times more likely to present osteoporosis. Patients with osteoporosis have significantly higher risk (4.46 times) of presenting horizontal alveolar bone defect. Vertical alveolar bone defect results were nonsignificant. Conclusion: Our study results corroborate the literature trend that osteoporosis may influence the progression of alveolar ridge height loss (horizontal alveolar bone defect). Panoramic radiography may be used as a screening tool to help the diagnosis of periodontal bone loss in patients with osteoporosis.

Keywords: Osteoporosis, panoramic, periodontal disease, radiology

How to cite this article:
Munhoz L, Takahashi DY, Nishimura DA, Ramos EA, Tenorio Jd, Arita ES. Do Patients with Osteoporosis Have Higher Risk to Present Reduced Alveolar Ridge Height? An Imaging Analysis. Indian J Dent Res 2019;30:747-50

How to cite this URL:
Munhoz L, Takahashi DY, Nishimura DA, Ramos EA, Tenorio Jd, Arita ES. Do Patients with Osteoporosis Have Higher Risk to Present Reduced Alveolar Ridge Height? An Imaging Analysis. Indian J Dent Res [serial online] 2019 [cited 2022 Jan 20];30:747-50. Available from:

   Introduction Top

Osteoporosis is a systemic disease characterized by reduced bone mass and bone tissue architectural microdeterioration which leads to higher fragility and susceptibility to fractures. In the past, osteoporosis was considered as a physiological process associated with aging; however, it has been currently recognized as a chronic multifactorial disease.[1]

Periodontal diseases comprise a wide range of inflammatory conditions that affect the supporting structures of the teeth (the gingiva, alveolar bone, and periodontal ligament), leading to tooth loss and contributing to systemic inflammation. Periodontal disease initiation and propagation are through a dysbiosis of commensal oral microbiota (dental biofilm) interacting with host immune defenses, which leads to inflammation and disease.[2] Several experimental and epidemiological studies evidence numerous risk factors associated with the initiation, progression, and severity of periodontal disease such as smoking and diabetes mellitus.[3]

Osteoporosis and periodontitis are high prevalence conditions and are characterized by bone resorption process. Several hypotheses have related systemic osteoporosis to the osteoporotic changes in the jaws, alveolar bone defects, and dental support tissue loss.[4] During chronic inflammatory process, immune system cells, such as T lymphocytes, B lymphocytes, macrophages, and dendritic cells, are hyperactivated and induce the production of proinflammatory cytokines, important mediators in osteoimmunology, known for its role in osteoclastogenesis.[5] Since immunological pathways mediate bone resorption in both disease processes, many authors have considered the connection between the etiopathogenesis of periodontal diseases and osteoporosis.[6],[7],[8] Therefore, this study aimed to verify whether patients with osteoporosis would have greater risk of periodontal disease (horizontal alveolar bone loss and vertical bone defect) when compared with healthy patients and to analyze whether bone mineral density (BMD) reduction would lead to horizontal or vertical bone defect risk increase.

   Methods Top

Study participants and inclusion and exclusion criteria

This study was held at the School of Dentistry, University of São Paulo, between the years 2010 and 2014. It was approved by the local human ethics committee (protocol no. FR358902; protocol 145/10), in accordance with the Declaration of Helsinki of 2013. In all, 100 women were selected and allocated in two different groups: osteoporosis (n = 50 women with osteoporosis, T-score <-2.5 DP) and nonosteoporosis (n = 50 women without osteoporosis, T-score >-2.5 DP). For bone density assessment, it used the proximal radius T-score, according to World Health Organization classification.[9] All patients had undergone panoramic radiographic examination concomitant with forearm dual X-ray absorptiometry (DXA) (Norland Medical Systems, Inc., White Plains, NY, USA). For both groups, the main inclusion criteria were the presence of at least 14 teeth in the oral cavity and they could not be smokers. We excluded patients with confirmed history of aggressive periodontitis, with metabolic bone diseases such as hyperthyroidism and diabetes, and those with related history of bone metabolism medication intake (e.g. bisphosphonate or glucocorticoids).

Panoramic radiographic image analysis

All digital panoramic radiographic images were taken using the same device (Kodak 8000; Eastman Kodak Company, Rochester, NY, USA), and were processed by ImageJ software (National Institute of Health, Bethesda, MD, USA). Panoramic bone defect evaluation (horizontal alveolar bone defect and vertical defect presence) was performed randomly by two trained observers (i.e., dentists with expertise in oral radiology) [Figure 1]. Intraobserver reliability was assessed between measurements performed 2 weeks apart to eliminate memory bias. Intra- and interobserver agreement results were assessed using kappa test.
Figure 1: Horizontal alveolar bone loss (left) and vertical defect (right)

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Dual X-ray absorptiometry

Forearm bone densitometry measurements were conducted through peripheral DXA by a radiology technician with previous experience in performing the examination. The scanning resolution was 1.00 × 1.00 mm.

Statistical analysis

Statistical analysis was divided into different stages. Normality Shapiro–Wilk test was performed for continuous variables. Conditional logistic regression test was used to evaluate the associations between DXA results and the variables: age, vertical and horizontal bone defects (presence/absence), considering the influence of BMD. DXA results were stratified using the value -2.5 standard deviation (SD) as a cutoff point.[10] For age, the cutoff point was chosen from the median values obtained from the sample population age. Estimated risk was presented as odds ratios (ORs) with 95% confidence intervals. The ORs were adjusted for potential confounders of age and BMD. All statistical analyses were performed at 5% significance level, using IBM program SPSS® Statistics 17 (SPSS, Inc, Chicago, IL, USA).

   Results Top

This study included 50 patients in the osteoporotic group and 50 patients in the nonosteoporotic group. [Table 1] summarizes the T-score, age, body mass index, and last check-up at the dentist data. The median age was 69 years for both groups, with a minimum of 41 years and a maximum of 84 years. Intra- and interobserver agreement results were 0.89 and 0.82, respectively.
Table 1: Primary characteristics of the study patients

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The results also evaluated the ethnicity of study population, verifying the major number of Caucasian women in both groups when compared with African-Brazilian and Asian groups [Table 2]. OR analysis evaluates the association of osteoporosis and horizontal and vertical bone loss and age. The results revealed that women with advanced age (>69 years) were three times more likely to be osteoporotic (adjusted OR = 3.85; p < 0.013). It was also possible to verify that osteoporotic patients presented 4.46 times more horizontal alveolar bone defect when compared with systemically healthy patients [Table 3].
Table 2: Distribution of patients according to ethnicity and presence or absence of osteoporosis

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Table 3: Data associated with age and horizontal and vertical bone loss

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   Discussion Top

Worldwide aging process is a consequence of better lifestyle. The advance of elderly contributes to changes in oral and systemic health and the development of inevitable systemic and local chronic diseases, such as osteoporosis. Osteoporosis is a bone metabolism degenerative condition with global high prevalence and is characterized by BMD decrease, bone microarchitecture deterioration, and elevated bone fracture risk,[11] frequently observed in postmenopausal women.[12],[13],[14]

Patients are considered osteoporotic when the DXA examination presents BMD lower than the value of -2.5 SD, below the mean for normal young Caucasian women (T-score of -2.5).[10],[12] To determine osteoporosis in patients in this study, DXA was measured at proximal radial bone.[9]

This study showed 100 women with a median age of 69 years divided into two groups (osteoporosis and nonosteoporosis). Patients with osteoporosis were four times more likely to present higher horizontal alveolar bone loss than nonosteoporosis patients. This result suggests an association between osteoporosis and periodontitis, represented by horizontal bone defect. Periodontal attachment loss and gingival recession may occur independent of the periodontopathogenic biofilm present in elderly people with osteoporosis due to bone metabolism changes by this disease.[15],[16],[17]

In our study, panoramic radiography allowed to investigate the presence of alveolar bone loss in osteoporotic patients. This imaging examination has also been used as a screening tool for other systemic diseases such as atherosclerosis and chronic renal failure.[18],[19]

A recent study[20] evaluated the association between osteoporosis and periodontal disease among postmenopausal Indian women and they found periodontal clinical parameters such as dental biofilm scores, gingival bleeding, and clinical attachment loss were significantly higher among women with osteoporosis compared with nonosteoporotic women. These authors concluded that BMD was related to clinical attachment loss, gingival bleeding, and gingivitis, suggesting an association between osteoporosis and periodontal diseases.[20] In addition, a systematic review with meta-analysis has shown that clinical attachment loss was statistically higher among postmenopausal women with low BMD when compared with women with normal BMD.[21] These data not only reinforce what was found in this study but also support new studies that seek to correlate the etiopathogenesis of osteoporosis and periodontal disease.

According to Savic Pavicin et al.,[22] the differences in results may be affected because most studies that evaluate the relationship between osteoporosis and periodontitis are cross-sectional with different study samples. Thus, the same authors concluded that an ideal study should be a longitudinal investigation evaluating women at the perimenopausal age and that alterations in BMD and periodontal status be analyzed over a longer period.[22]

This study had some limitations as the use of panoramic radiography to analyze alveolar ridge height and also the fact that it did not include postmenopausal women exclusively. In addition, considering this study as being a retrospective study conducted in a radiology department, it was not possible to access information about periodontal status, such as periodontal treatment history, probing depth, gingival bleeding, and clinical attachment loss, among other parameters.

   Conclusion Top

Our study confirms the trend in the literature that osteoporosis may influence the progression of alveolar ridge height loss (horizontal alveolar bone loss) and concludes that panoramic radiography may be a helpful tool for screening alterations such as alveolar ridge height loss (horizontal alveolar bone loss) in osteoporotic patients.


The authors thank the Department of Stomatology, University of São Paulo, for the support.

There are no conflicts of interest.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

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Wactawski-Wende J. Periodontal diseases and osteoporosis: Association and mechanisms. Ann Periodontol 2001;6:197-208.  Back to cited text no. 15
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Penoni DC, Leao ATT, Fernandes TM, Torres SR. Possible links between osteoporosis and periodontal disease. Rev Bras Reumatol Engl Ed 2017;57:270-3.  Back to cited text no. 17
Guerreiro da Silva Junior N, Pedreira EN, Tuji FM, Warmling LV, Ortega KL. Prevalence of calcified carotid artery atheromas in panoramic radiographs of HIV-positive patients undergoing antiretroviral treatment: A retrospective study. Oral Surg Oral Med Oral Pathol Oral Radiol 2014;117:67-74.  Back to cited text no. 18
Kanjanabuch P, Sinpitaksakul P, Chinachatchawarat S, Pacharapong S, Kanjanabuch T. Oral and radiographic findings in patients undergoing continuous ambulatory peritoneal dialysis. J Med Assoc Thai 2011;94(Suppl 4):S106-12.  Back to cited text no. 19
Richa, RY, Puranik MP, Shrivastava A. Association between osteoporosis and periodontal disease among postmenopausal Indian women. J Invest Clin Dent 2017;8.doi: 10.1111/jicd. 12223.  Back to cited text no. 20
Penoni DC, Fidalgo TK, Torres SR, Varela VM, Masterson D, Leao AT, et al. Bone density and clinical periodontal attachment in postmenopausal women: A systematic review and meta-analysis. J Dent Res 2017;96:261-9.  Back to cited text no. 21
Savic Pavicin I, Dumancic J, Jukic T, Badel T. The relationship between periodontal disease, tooth loss and decreased skeletal bone mineral density in ageing women. Gerodontology 2017;34:441-5.  Back to cited text no. 22

Correspondence Address:
Prof. Daniela Y Takahashi
Av. Prof. Lineu Prestes, 2227 - Butantã, São Paulo - SP,05508-900
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijdr.IJDR_497_18

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  [Table 1], [Table 2], [Table 3]


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