This document provides information on osteoporosis for dentists. It defines osteoporosis as a disease characterized by low bone mass and deterioration of bone tissue, leading to increased bone fragility and fracture risk. Key points include: osteoporosis has no symptoms until a fracture occurs; it is a major public health issue; risk factors include age, gender, family history and lifestyle factors; and diagnosis involves clinical evaluation, radiography, bone density tests and laboratory tests. Treatment focuses on diet, exercise, fall prevention and medications to build bone density and reduce fractures. The document also discusses the relationship between osteoporosis and dental health, and potential jaw bone complications from osteoporosis medications.

1. A Review for dentists

3. 1. Definition
 The internationally agreed description of 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’

4. The Silent Disease
 Osteoporosis can weaken bones and cause them to break
easily, especially those in the wrist, spine, or hip.
 It is often called “the silent disease” because bone loss
occurs without symptoms. Many people may not know
that they have osteoporosis until they experience a fracture
due to weak bones.

6. 2- Epidemiology of Osteoporosis
 Osteoporosis is a major public health threat in the United
States.
 10 million Americans have osteoporosis
 34 million have low bone mass, (high risk)
 One out of every two women & one in four men over the
age of 50 will have an osteoporosis related fracture in their
lifetime. Each year, osteoporosis is responsible for:
 300,000 hip fractures
 700,000 vertebral fractures
 250,000 wrist fractures
 More than 300,000 other types of fractures.
 Expenses for these fractures are estimated to be
approximately $14 billion each year.

7. Relative Occurance
 The lifetime risk for hip, vertebral and forearm
(wrist) fractures have been estimated to be
approximately 40%, similar to that for coronary
heart disease.
 Following hip fracture in women
 5–20% mortality within 1 year
 20% severely impaired mobility after 12 months,
requiring long-term nursing care
 50% do not regain previous mobility

9. Repartition of the Participants (total 18000) according to their
BMD status
Normal Osteopenic Osteoporotic
% % %
Femoral
Neck
2772 15.4% 9666 53.7% 5562 30.9%
Lumbar
Spine
7128 39.6% 6894 38.3% 3978 22.1%
Both Sites 1089 6.05% 11178 62.1% 5724 31.8%
309
1073
618
793
765
442
121
1243
636
0
200
400
600
800
1000
1200
1400
Femoral Neck Lumbar Spine Both Sites
Normal Osteopenia Osteoporosis

11. 3- Pathogenesis
 Throughout your lifetime, new bone is added to the
skeleton and old bone is removed.
 New bone is added faster during childhood and
teenage years, resulting in larger, heavier, and denser
bones. Bone continues to be added until around age
30, when peak bone mass is reached.
 After age 30, bone loss slowly begins to exceed bone
formation. Osteoporosis develops when bone loss
exceeds bone replacement.

12. Bone
Remodelling
Balance

13. Causes

15. I- CAUSES OF OSTEOPOROSIS:
2ry to Disease/ 1ry OP

16. II - Risk Factors
Risk factors that you cannot change:
 Age—The older you are, the greater your risk of developing
osteoporosis.
 Gender—You have a greater chance of developing osteoporosis
if you are female. Women do not have as much bone tissue as
men and lose it more rapidly because of menopause.
 Body size—Small, thin-boned women are at greater risk for
developing osteoporosis.
 ■ Family History—If you have a family history of fractures, you
have a greater risk. Osteoporosis may be hereditary.
 ■ Ethnicity—Caucasian and Asian women have the highest risk
for developing osteoporosis. African-American and Latino
women have a risk, but not as significant.

17. II- Risk Factors
Risk factors that you can change:
 Diet—People with a lifetime diet that is low in calcium and
vitamin D have a higher risk for developing osteoporosis.
 Alcohol—Excessive use of alcohol puts you at higher risk for
osteoporosis.
 Cigarette smoking—Smoking increases your risk.
 Physical activity—An inactive lifestyle increases your risk of
developing osteoporosis.
 Hormones—Low estrogen levels in women and low
testosterone levels in men have been linked to an increased risk
for osteoporosis.
 Medications—Certain medications, such as glucocorticoids or
some anticonvulsants, increase the risk of osteoporosis.

18. III - According to Incidence
 Frequent Types:
1. Postmenopausal OP (Type I)
2. Senile OP (Type II)
3. Immobilization OP
4. Neoplastic OP
 Infrequent Types:
1. Osteogenesis Imperfecta
2. Chromosomal Abnormalities
3. Migratory Cushing Syndrome
4. Hyperthyroidism
5. Iron Storage Diseases
6. Disappearing Bones

19. A- Clinical Diagnosis
B- Radiographic Diagnosis
C-Laboratory Diagnosis
D- Bone Densitometry
E- Bone Biopsy

20. 1- CLINICAL DIAGNOSIS
 History of positive risk factors.
 Clinical presentation:
 Loss of height.
 Diffuse kyphosis.
 Pains.
 Fractures.
 Worry and psychic effects.

21. A- LOSS OF HEIGHT
 VERTEBRAL COMPRESSION.
 VERTEBRAL WEDGING.
 LOWER LIMB BONES BOWING.

22. KYPHOSIS
 DIFFUSE.
 DORSAL.
 DORSO-LUMBAR.
 SLOWLY PROGRESSIVE.

23. B- PAINS
 MICROFRACTURES.
 LONG STANDING KYPHOSIS.
 ASSOCIATED OSTEOMALACIA.
 OSTEOPOROTIC FRACTURES.
 MUSCULAR.
 FIBROMYOSITIS.

24. C- FRACTURES
 FRAGILITY FRACTURES.
 MINOR TRAUMA.
 COMMON SITES:
 Spine.
 Proximal end of femur.
 Distal end of radius.
 Proximal end of humerus.

26. 2- Radiographic findings in
osteoporosis
AB + CD >/=
medulla
AB+CD/XY >/=
1/2
In ostepenia < 1/2
Midshaft of
index finger is
used for
measurement

27. Assessment of Fractures
 Radiologically performed

28. Primary axial osteoporosis
65 year-old female with a few years history of pain in the back

29. Fracture Neck of Femur
75 year-old female with a frail constitution, hospitalized in an institution for
chronic diseases; fractures of the right neck of femur at the age of 68,
intertrochanteric fracture at 72, in both instances due to a slight fall.

30. 3- Laboratory diagnosis and
Biochemical assessment of
osteoporosis
 Serum and urine
calcium.
 Alkaline phosphatase.
 Hydroxyproline.
 Ostecalcin.
 Hydroxylysine
glycosides.
 Procollagen I extension
peptides
 Crosslink assays
 Alpha2 HS glycoprotein
 Acid phosphatase
 Biochemical estimation
of bone loss.

31. 4- Bone Densitometry
(why is it used?)
 Conventional radiograph:
 not sensitive (needs 30% reduction in mineral
content)
 not accurate
 Implications in Orthopaedic practice:
 evaluation and management of bone-loss syndromes
 evaluation of periprosthetic bone-remodeling

32.  At present, the assessment of bone mineral is the only
aspect that can be readily measured in clinical
practice, and it now forms the cornerstone for the
general management of osteoporosis.
 Bone mineral density is the amount of bone mass
per unit volume (volumetric density, g/cm3), or per
unit area (areal density, g/cm2), and both can be
measured in vivo by densitometric techniques.
 A wide variety of techniques is available to assess bone
mineral that are reviewed elsewhere
Assessment of Osteoporosis by
Bone Mineral Density

33.  Based on X-ray absorptiometry in bone, since the absorption of
X-rays is very sensitive to the calcium content of tissue, of
which bone is the most important source.
 Particularly DXA (= dual-energy X-ray absorptiometry).
 The most widely used bone densitometric technique.
 It can be used to assess bone mineral content of :
 the whole skeleton
 Specific sites, including those most vulnerable to fracture.
 Other techniques:
 Quantitative ultrasound (QUS).
 Quantitative computed tomography (QCT) applied both to the
spine and hip and to the appendicular skeleton (pQCT).
 Digital X-ray radiogrammetry.
 Radiographic absorptiometry.
Techniques to detect BMD

34. DEXA Scan

35. Osteoporosis of the Lumbar Spine
T-score -4

36. Osteoporosis of the Femur Neck
T-score -2.7

38. Quantitative Ultrasound (QUS)

39. E- Bone Biopsy

40. Bone Biopsy
Red-stained osteoid seams lined
with OB (osteblasts) and OC
(osteoclasts) versus poor osteoid
seams and little osteoblasts and
osteclasts in bone resorption
Tetracycline labeling on fluorescent
microscopy showing normal bone with
yellow lines at mineralization front versus
absence of bone formation.
T= bone trabecula M= marrow

41. A- Diet
B- Physical Activity
C- Medications

42. A- Diet
 Treatment of osteoporosis focuses on diet, physical activity,
fall prevention, medication, and changing behaviors that
are linked to the development of the disease.
 Diet—Calcium and vitamin D are necessary for :
 Developing strong bones.
 Regulating heart, muscle, and nerve functioning.
 As you age, your body becomes less efficient at absorbing
calcium and other nutrients;
 The recommended daily intake of calcium for adults age 51
and older is 1,200 mg.
 Dietary calcium is found in:
 Low-fat dairy products, such as cheese, yogurt, and milk.
 Nondairy sources of calcium include canned salmon and sardines
with bones, dark-green leafy vegetables, such as broccoli, orange
juice, and breads made with fortified calcium.

43. A- Diet
 Vitamin D is necessary for calcium absorption.
 Our bodies manufacture vitamin D when exposed to
sunlight.
 Vitamin D production decreases in the winter for those
who are housebound and not able to get enough light.
 Vitamin D supplements may be necessary to ensure daily
intake of 400 to 800 Ius.

44. B- Physical Activity
 Physical Activity—Bones respond to physical activity
that involves weight-bearing exercise, such as walking
or jogging.
 These activities help improve bone health and increase
muscle strength, resulting in fewer fractures from falls.
 Fall Prevention—Falls increase the chance of a bone
fracture in the wrist, hip, or spine and other parts of
the skeleton.
 It is important that individuals with osteoporosis
discuss with their physician physical changes that may
affect their sense of balance and ability to walk.

45. C- Medications
 Aim: To stop or slow bone loss and increase bone
density, resulting in reduced risk of fractures.
1. bisphosphonates that can help in the prevention
and treatment of osteoporosis.
 Reduces bone loss and increases bone density in both the
spine and the hip.
2. Calcitonin is a naturally occurring non-sex
hormone involved in calcium regulation and bone
metabolism.
 It is currently available as an injection or nasal spray.
3. Estrogen/Hormone Replacement therapy (HRT)
 It is most commonly administered in the form of a pill or
skin patch.

46. The best way to prevent osteoporosis is to live a healthy
lifestyle and practice behaviors that promote positive bone
health. As we age, it is important to be aware of the risks
associated with osteoporosis and to talk with a physician if
you think you might be at risk for osteoporosis to
determine if testing is necessary.

48. Optimal Treatment of Osteoporosis in
Postmenopausal Women

49. A- Oral Radiographs as a way of Diagnosis
B- Effect of Osteoporosis on Dental Bone.
C- Osteoradionecrosis of Jaw (ONJ) due to Bisphosphanates.

50. A- Dental Radiograph as a low
costed screening method
 Many Authors recommended screening all women
older than 65 years.
 In many countries, bone assessment methods are:
 Not widely available.
 Costing high fees, larger than Panoramic Views in most
of places.
 Dental screening of patients at high risk of OP among
the population would be practical and cost effective in
such countries.
 Thus Dentists may be able to help detect the first
stages of osteoporosis.

51. Mandibular Inferior Cortex
 Panoramic Radiographs are used to detect
osteoporosis from assessment of the Mandibular
inferior cortex (MIC), which was detected to be 0.54
mm thinner in subjects with OP fracture, in relation
to controls.
 Devlin & Horner in 2002, reported a diagnostic
threshold of 3 mm or less, for referral for Bone
densitometry in women.

53. Osteoporosis . Cropped panoramics images shows a relative
radiolucency of both jaws with reduced definition and
mandibular inferior cortex moderately eroded, evidence of
lacunar resorption (right-D) or cortex severely eroded (left-E).

54. Regular Checkups
 Periodic dental checkups using dental radiographs shows
the amount of jaw bone loss.
 This is dependent on:
 The experience of the dentist
 Exposure and film processing variations.
 The problem of this idea in Egypt, that the least of
patients, are those who go to the dentist regularly for
checkups, and from those the minority are having regular
dental Radiographs.
 More and more, the reserved radiographs are missed in
clinics, a problem which will be solved by electronic
registration and digital radiography and photography.

55. B- Effect of Osteoporosis on
Dental Hygiene.
 Early Signs of Osteoporosis may include:
 More severe gingivitis,
 Bone loss around the teeth represented as
periodontitis and teeth loss.
 Dentures become ill-fitted leading to mouth
sores.

56. Alveolar Bone Mass, structure and
thickness:
 Local Functional factors mainly influence Mandibular
Bone Mass (MABM) and alveolar thickness in molar
region, whereas BMD influences the trabecular
structure.
 In Lower Premolar Region, Longitudinal Alterations in
BMD are related to:
 Longitudinal changes in grey-level value.
 Bone texture
 Alveolar thickness: Decrease in BL (buccolingual)
alveolar thickness may be due to periosteal resorption
related to skeletal bone loss.

58. C- Osteonecrosis of Jaw (ONJ)
due to Osteoporosis Therapy:
Bisphosphanates.
 A potential side effect associated with
bisphosphonates, treating osteoporosis, Paget's
disease and metastatic bone disease,
 The incidence of ONJ in the general population is
unknown.
 Case reports have discussed ONJ development in
patients with: Multiple myeloma or metastatic breast
cancer receiving bisphosphonates as palliation for
bone metastases. These patients are also receiving
chemotherapeutic agents that might impair the
immune system and affect angiogenesis.

59. ONJ due to Bisphosphanates
1. The incidence or prevalence of ONJ in patients
taking bisphosphonates for osteoporosis seems to be
very rare.
2. No causative relationship has been demonstrated
between ONJ and bisphosphonate therapy. A
majority of ONJ occurs after tooth extraction.
3. Furthermore, the underlying risk of developing
ONJ may be increased in osteoporotic patients
by other overlying diseases.
 Treatment for ONJ is generally conservative.