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Hence, the aim of this study was to determine the validity of the Klemetti Index KI measured on panoramic radiographs, in the diagnosis of osteoporosis so as to ascertain the possibility of prediction of skeletal BMD from the changes on the panoramic radiographs in post-menopausal women. The subjects were randomly selected from the out patients visiting the department of Oral Medicine and Radiology. Time period for the study was in between the year All subjects were advised panoramic radiographs for dental purposes.

Further, they were explained the need and design of the study and the benefit of undergoing through clinical, radiographic and BMD investigations. Subjects who agreed to undergo these procedures were included in the study and instructed to read and sign the consent form. The postmenopausal women who had a history of chewing or smoking tobacco, betel quid with slaked lime or medications that affect bone metabolism were excluded from the study. Even the subjects from the regions of Endemic fluorosis were excluded as the fluoride can alter bone density.

The subjects who have undergone hysterectomy or oophrectomy or who had metabolic bone diseases, diabetes, significant renal impairment, bone-destructive lesions in the jaw and non-vertebral osteoporotic fractures were also excluded.

Osteoporosis: Protecting Bones, Preventing Breaks - MedscapeTV

Institutional ethical clearance was obtained. The subjects were made to sit comfortably on the physiological dental chair with artificial illumination and routine dental check up was done. The data such as name, age, sex, address, occupation, chief complaint or any significant medical history, dental history and duration of menopause was recorded in the proforma.

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All panoramic radiographs were obtained with an Advapex digital panoramic machine at 12 mA and 14 seconds with 75 kVp. Print outs of the radiographs were then obtained on a radiographic film using Konika printer Dry Pro Model All the panoramic radiographs OPG were evaluated by 5 different oral radiology specialists.

Only print outs of the digital OPGs were provided to all the five observers so as to prevent biased interpretation. The thinning of inferior mandibular cortex was observed in the premolar molar region and findings of panoramic radiographs were then categorized and graded according to Klemetti Index [ 14 - 21 ] as follows:.

The same group of participants was then subjected to bone mineral density tests using DEXA machine to detect the risk of osteoporosis. The in vivo short-term precision error for spine BMD of the machine used was 1. The data obtained was analyzed by the software provided by the manufacturer. This data was displayed as a graph with a summary of the bone density measurements.


Height and weight were measured at the time of the DEXA scanning. The results of grading of the panoramic radiographs interpreted by the five oral radiologists and the results of the BMD tests were tabulated. Unpaired t-test was applied for the comparison of two groups.

Further, Qualitative or categorical variables were described as frequencies and proportions. All the patients were in the age range of years with a mean age of The mean height and weight were found to be All the patients on an average were found to have attained menopause at the age of The mean body mass index was found to be The findings of all the observers are shown in Table 1.

There was no statistically significant intra observer difference found with P value of 0. The mean values of age, height, weight, age of attaining menopause and body mass index of the patients who were found to be normal and osteoporotic on DEXA scan Table 3 and were analyzed statistically. Similarly the mean heights of the patients presenting as normal and osteoporotic were This difference was also non-significant. Both the groups presented with the same mean age of occurrence of menopause at On the contrary, the difference in the weight and Body mass index was found to be statistically significant in both the groups with P value of 0.

There was no statistically significant difference found when the DEXA results were compared with the results of all the 5 observers individually. The accuracy for observer I was calculated according to the formula:. Similarly, Observer II correctly identified 10 normal cases out of the 15, 11 cases of osteopenia out of the 25 and 15 cases of osteoporosis out of the 20 when compared to DEXA scan with the percentage within DEXA of Observer III correctly identified 16 normal cases out of the 25, 9 cases of osteopenia out of the 20 and 10 cases of osteoporosis out of the 15 when compared to DEXA scan with percentage within DEXA of The accuracy for observer III was Observer IV correctly identified 10 normal cases out of the 14, 14 cases of osteopenia out of the 31 and 12 cases of osteoporosis out of the 15 when compared to DEXA scan with the percentage within DEXA of Observer V correctly identified 12 normal cases out of the 19, 12 cases of osteopenia out of the 22 and 15 cases of osteoporosis out of the 19 when compared to DEXA scan with percentage within DEXA of It is a duly acknowledged fact that early detection of osteoporosis is of utmost importance as it will lead to institution of preventive measures as well as early treatment [ 20 , 21 ].


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Since Osteoporosis is associated with low trauma fractures, it may lead to heavy outcomes as for as the morbidity, mortality and cost of health care is concerned [ 17 ]. Several studies have been performed regarding the efficacy of various indexes for osteoporosis [ 2 ] and to clarify whether dentists could be beneficial enough to warn for the risk of osteoporosis [ 2 - 10 ]. Many risk factors have been implicated for osteoporosis.

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They include post menopausal women, low body weight, smoking habits and use of oral glucocorticoid therapy for more than three months [ 17 ]. It further includes excessive thyroxine doses, low calcium intake, low physical activity and alcohol intake more than two times a day [ 2 - 8 ]. Systemic conditions associated with increased risk for osteoporosis include chronic obstructive pulmonary disease, gastrectomy, hyperparathyroidism, hypogonadism, multiple myeloma and celiac disease [ 2 - 12 ].

Only post-menopausal women aged years and above were included in this study. This is so because according to the National Osteoporosis Foundation, bone deterioration is greater in women as compared to men and furthermore, there is increased bone deterioration in post-menopausal women [ 2 , 16 ].

This may be attributed to the fact that after the menopause, the general skeletal bone mass decreases owing to estrogen deficiency, and this process often leads to osteoporosis [ 2 ]. Literature also reveals that by the year , the world population of menopausal and post menopausal women with osteoporosis is expected to increase to 1.

An atlas of genetic influences on osteoporosis in humans and mice | Nature Genetics

Access to screen for osteoporosis is often limited. Various methods as already described have been used to assess bone density. All these techniques use ionizing radiations to assess bone mineral density. The DEXA scan was selected because of the fact that it is considered to be very precise and accurate with negligible radiation.

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Moreover, it is a reproducible predictor for osteoporotic fracture and is excellent measure for response to treatment. DEXA can also distinguish regional as well as whole body parameters of body composition. However, panoramic radiographs are frequently taken in dental office for maxillofacial region and are cost-effective [ 2 ]. As far as the maxillofacial area is concerned, it has been reported that the Bone Mineral Density of mandibular cancellous bone at the level of mental foramen is related to the bone mineral density of Lumber spine in post menopausal women [ 14 ].

Furthermore, BMD of mandibular cancellous bone in osteoporotic group was found to be significantly lower than in normal group. In the present study, Klemette index was applied on the panoramic radiographs [ 14 , 15 ]. Furthermore, a significant correlation was observed between the Klemette classification and vertebral BMD. To add on, in the same study, the intra and inter observer agreement was found to be substantial.

This showed that bone mineral density significantly decreases in post-menopausal women. There was no statistically significant difference found between the mean age, height as well as the age of attaining menopause in the women who presented as Normal and Osteoporotic on the basis of DEXA scan. But it was interesting to note that there existed a significant difference regarding the mean weight as well as mean BMI in between those postmenopausal women which were designated as normal and osteoporotic by DEXA scan.

Hence, it can be commented that the postmenopausal women can fall prey to osteoporosis regardless of the age, height and time of menopause. Further, each panoramic radiograph was then evaluated by 5 different Oral Radiology specialists so as to evaluate the reliability of panoramic radiographs regarding assessment of osteoporotic risk based on Klemetti Index. It was found that there was no statistically significant difference between the results of all 5 observers individually when compared to DEXA scans. The results obtained suggested that panoramic radiographs can serve as a significant adjunct in determining the osteopenic and osteoporotic changes in post-menopausal women.

This was in accordance with the results obtained by Akira Taguchi et al. Similarly, Anders Hailing et al. Various other authors like Horner and Devlin in also confirmed the validity of using dental panoramic tomogram for the measurement of mandibular bone mineral content for the diagnosis of osteoporosis [ 20 ]. Stuart White et al. So, it was concluded that the dentists can refer postmenopausal women for bone densitometry on the basis of incidental findings on dental panoramic radiographs [ 15 ]. This study has been supported by Akira Taguchi et al in and several others who suggested that the findings on dental panoramic radiographs may be an indicator of bone turnover as well as spine BMD in postmenopausal women [ 22 - 26 ].

Further literature even provides the reference of the possibility to show positive correlations between BMD of skeleton and changes in the mandibular cortex on the panoramic images [ 27 - 29 ] when large sample size was used. This same point has been confirmed in this study. Some of the authors commented that the osteoporosis risk for even a single person can be diagnosed with certainty by using panoramic X-ray images [ 26 ]. Henceforth, in agreement with several studies [ 31 , 32 ], it can be concluded that panoramic X-ray images can yield suitable information to diagnose patients at the risk of osteoporosis.

Furthermore, in the light of panoramic radiographs being highly prescribed with added advantageous features of low cost as well as ease of interpretation, they can be widely used to assess asymptomatic population regarding osteoporosis risk. Hence, the findings of panoramic radiographs can serve as a useful method for osteoporosis detection and referring the patients for further investigations [ 33 , 34 ].

Al-Hashimi graduated with B. She received a Master degree and Ph. Currently, Dr. Al-Hashimi has published over scientific publications and she is the founding of Salivary Dysfunction Clinic in Dallas. The Open Dentistry Journal is an Open Access online journal, which publishes research articles, reviews, letters, case reports and guest-edited single topic issues in all areas of dentistry and oral cavity.

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