Lecturer Dr. Heddie O. Sedano, DDS
Instructor Dr. Heddie O. Sedano DDS, Dr. Odont.
This course has been designed based on a series of question and their answers about Osteporosis in general and its possible role in the etiology of periodontal disease.
What
is osteoporosis?
Is there a sex preference and why?
What is/are the cause(s) of osteoporosis?
Is there a relationship between nutrition and
osteoporosis?
Can it be treated?
Is there a relationship between osteoporosis and
periodontal disease?
Is there a support group?
Conclusions
References
Links to Internet sites that provide information on different
aspects of Osteoporosis
Osteoporosis is a disorder characterized by a generalized low bone mass. Osteoporosis is presently defined based on measurements of bone mineral density (BMD) taken at the femoral neck of young adults. The World Health Organization (WHO) has established four diagnostic levels for BMD: Normal, Osteopenia, Osteoporosis and Established Osteoporosis. A low BMD level has replaced the previous clinical criterion of a bone fracture to establish the diagnosis of osteoporosis. The diagnostic categories are based on BMD and the presence or absence of fractures. The WHO committee has established a set of values and standard deviations (SD) for those values, based on young healthy individuals. The SD represent statistical variations.
Osteopenia is a BMD between 1 SD and 2.5 SD below average for young adults. Osteoporosis is a BMD lower than 2.5 SD below average for young adults. Established osteoporosis is a BMD lower than 2.5 SD in the presence of fractures. The adequate health of bones is maintained by a precise balance between bone apposition by osteoblasts and bone resorption by osteoclasts. When the balance is broken in favor of osteoblasts the result is increased bone formation (osteopetrosis) and when the activity of the osteoclasts increases over that of the osteoblasts osteopenia or osteoporosis ensues. This second scenario is a natural consequence to the process of aging, with increased age bones become more prone to fracture because of diminished BMD.
Is there a sex preference and why?
Forty percent of women above age 65 in Western societies present signs and symptoms of osteoporosis. Based on BMD measurements provided by a nationwide health survey it is known that in USA osteoporosis affects 6 million women and 2 million men; while osteopenia is reported as affecting 17 million women and 9 million men. The risk for an American man to suffer a bone fracture as a consequence to osteoporosis is higher than that of developing a prostatic carcinoma. It has been reported then 33% of osteoporotic men that fracture a hip die within a year of the fracture.
What is/are the cause(s) of osteoporosis?
In women estrogen deficiency is the principal pathogenic factor for osteoporosis. Several predisposing factors have been implicated as co- participating in the development of osteoporosis such as: family predisposition, old age and physical inactivity, diminished intake of calcium and vitamin D, certain medications i.e. steroids, anticoagulants and thyroxin; immoderate use of alcohol and caffeine as well as smoking; some chronic ailments such as: lung, GI tract and kidney diseases (especially related to ineffective absorption of calcium and vitamin D) and finally menopause in women and lower levels of testosterone in men.
Is there a relationship between nutrition and osteoporosis?
Calcium intake is of vital importance and it can be obtained by a proper diet. Dietary supplements of calcium are available in either chewable tablets or liquid form. Another dietary supplement is vitamin D (25 hydroxycholecalciferol) obtained as an oral tablet and injectable. Intramuscular injection of vitamin D can vary from once a year to once a month. Proper serum levels of calcium and vitamin D are the two most important factors to achieve and maintain adequate bone density. It has been indicated that the risk of fractures, especially in the elderly, can be diminished with an adequate diet in calcium and vitamin D.
Pharmacologic agents can diminish the risk of fracture further than that obtained by dietary supplementation of calcium and vitamin D. Treatment with various medications is recommended for patients with osteoporosis in conjunction with intake of adequate level of calcium and vitamin D. Several therapeutic modalities are in use either individually or in combination such as, calcitonin, hormone replacement therapy (HRT), raloxifene, which is an estrogen receptor modulator (SERM) and several bisphosphonates. Raloxifene has been proven to reduce the risk of vertebral fractures in around 30% of patients. Raloxifene does not prevent hip or other nonvertebral fractures.
Bisphosphonates are synthetic analogs of pyrophosphate which bind to hydroxyapatite and they act as specific inhibitors of osteoclast-mediated bone resorption. The three best known to be the most efficient in the prevention of fractures in osteoporotic patients are alendronate, risedronate and zoledronic acid.
A recent publication reports that a single annual infusion of zoledronic acid (the most potent bisphosphonate) can achieve similar results as those obtained with other bisphosphonates administered daily for the treatment of postmenopausal osteoporosis.
Is there a relationship between osteoporosis and periodontal disease?
Systemic bone loss has been cited as a risk factor for periodontal disease but their association is still not well understood (7). A study (1) have shown that after fifty years of age the porosity of the mandibular cortical bone increases markedly especially in the alveolar bone, at the same time there is a decrease in bone mass. These changes are greater in women than in men and this is reflected in the fact that women have a lower mandibular BMC than men. This sex difference in BMC value is also observed in other bones. It has been suggested that this increase in alveolar bone porosity in combination with local factors could be of etiological importance in the rate of periodontal alveolar bone loss which leads to periodontal disease (1).
Some authors (7) have experimentally concluded that in postmenopausal women BMD is related to interproximal alveolar bone loss. This conclusion points at postmenopausal osteopenia as a possible risk factor for periodontal disease in postmenopausal women. Another study (6) have shown that women with high calculus apposition and low BMD had greater clinical gingival attachment loss than women with normal BMD and similar calculus apposition. Still other authors (5) have reported that serum estradiol supplementation, in early menopausal osteoporotic women, reduces gingival inflammation and attachment loss. A study (8) performed on digitized periapical radiographs of the maxilla and mandible obtained from osteoporotic patients and normal controls lends support to the hypothesis that osteoporotic patients present an altered trabecular pattern in the jaw bones when compared to normal controls.
Radiographic evaluation of alveolar bone loss was conducted in a 2-year longitudinal clinical study (2) on 21 women with normal BMD of the lumbar spine, and 17 women with osteoporosis or osteopenia of the lumbar spine at baseline . These 38 patients had a history of periodontitis and were non-smokers. The results of this study showed that osteoporotic/osteopenic women exhibited a higher frequency of alveolar bone height loss (p<0.05) and crestal (p<0.025) and subcrestal (p<0.03) density loss relative to women with normal BMD. Additionally it was shown that estrogen deficiency in the osteoporotic/osteopenic women was associated with increased alveolar bone crestal density loss. This study (2) data suggests that estrogen deficiency and osteoporosis/osteopenia could be considered potential risk factors for alveolar bone loss in postmenopausal women with periodontitis.
Pilgram et al (3) have concluded that there is no definite association between clinical attachment level and BMD of the lumbar spine and the femur. They also conclude that there may be a weakassociation between BMD and longitudinal changes in attachment level.
The following two National Organizations offer advice and information on Osteoporosis.
National Osteoporosis Foundation http://www.nof.org/
Osteoporosis & Related Bone Diseases National Resource Center http://www.osteo.org
The risk relationship
between osteoporosis and periodontal status have been analyzed by many
investigators for more than a decade and the various results postulated
by those investigators is controversial. With scientific fairness in mind,
presently, osteoporosis can not be postulated as one of the main causative
factors of periodontal disease, especially in menopausal females. As many
researchers are indicating the proper knowledge of the level of participation
of many systemic factors in the etiology of periodontal disease is still
in infancy. Osteoporosis being one of those factors. Further detailed
and comprehensive research is still needed to definitely prove or disprove
the participation of osteoporosis in the etiology of periodontal disease.
- Hildebolt, CF.Osteoporosis and oral bone loss. Dento-Maxillo-fac Radiol 1997;26:3-15.
- Payne, JB; Reinhardt, RA; Nummikoski, PV; Patil, KD.Longitudinal alveolar bone loss in postmenopausal osteoporotic/osteopenic women. Osteoporosis International 1999;10:34-40.
- Pilgram TK et al. Relationships between clinical attachment level and spine and hip bone mineral density: data from healthy postmenopausal women. J Periodontol 2002;73:298-301.
- Reid IR et al. Intravenous Zoledronic Acid in Postmenopausal Women with Low Bone Mineral Density. New Engl J Med 2002; 346:653-661.
- Reinhardt, RA et al. Influence of estrogen and osteopenia/osteoporosis on clinical periodontitis in postmenopausal women. J Periodontol 1999;70:823-8.
- Ronderos, M et al. 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.
- Tezal, M et al. The relationship between bone mineral density and periodontitis in postmenopausal women. J Periodontol 2000;71:1492-8.
- White, SC; Rudolph, DJ. Alterations of the trabecular pattern of the jaws in patients with osteoporosis. Oral Sur Oral Med Oral Pathol Oral Radiol Endod 1999;88:628-35.
Links to Internet sites that provide information on different aspects of Osteoporosis
New Treatment Options
for Osteoporosis
http://www.veritasmedicine.com
Learn About Osteoporosis
http://www.learn-about-osteoporosis.com
Foundation for Osteoporosis
Research and Education
http://www.FORE.org
Doctor's Guide to
the Internet - Osteoporosis
http://www.pslgroup.com/OSTEOPOROSIS.HTM
National Osteoporosis
Foundation: Calcium
http://www.nof.org/prevention/calcium.htm
Osteoporosis in Men
http://www.geocities.com/HotSprings/8741
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