Osteoporosis

Dr. Sarvesh s Patel

Definition Types Prevalence Clinical feature Pathophysiology Risk factors Causes Investigation Prevention Treatment

Definition
The National Institutes of Health Consensus Panel on Osteoporosis Prevention, diagnosis and Therapy (2009) defined osteoporosis as a skeletal disorder characterized by compromised bone strength predisposing a person to a n increased risk of fracture.

India: Some Hard Facts

Over 61 Million Indians have osteoporosis. 80% are women. On a global basis, Indians have the highest prevalence of osteopenia. Compared to Caucasians, osteoporotic fractures in the Indian population occur 10-12 years earlier in age. Osteoporotic fractures are more common in Indian men than in the West.

Types

Primary osteoporosis

Secondary osteoporosis
result of medications such as glucocorticoids or diseases such as malabsorption that severely affect skeletal health.

Juvenile and idiopathic osteoporosis

Very rare seen

Type I Osteoporosis, or post Menopausal (50-70y)

predominantly affecting trabecular bone

Type II Osteoporosis or regressive or senile (>70y)

Affecting both trabecular and cortical bone

 Worldwide, lifetime risk for osteoporotic fractures in women is 1/3 In men risk is 1/8. Over 200 million people suffer from osteoporosis worldwide. The annual hip fracture incidence is expected to increase to 6.3 million By 2050, the global cost of osteoporosis is expected to exceed $130 billion By 2050 Asia is expected to account for almost one-half of all global fractures.3,4

Forearm Fracture

Vertebral Fracture

The highest risk of hip fractures are currently found in Norway, Sweden, Iceland, Denmark and the United States,

Hip Fracture

3. Kanis JA, Johnell O, De Laet C, Jonsson B, Oden A, Ogelsby AK. International variations in hip fracture probabilities: implications for risk assessment. J Bon Miner Res. 2002 Jul;17(7):1237-44. 4. Gullberg B, Johnell O, Kanis JA World-wide projections for hip fracture. Osteoporosis Int. 1997;7(5):407-13.

India: Some more hard facts

Over 45 Lakhs Indian women above 60 have a fractured spine. Over 2.5 Lakhs Indians suffer osteoporotic hip fractures every year. Most of these fractures are never investigated for osteoporosis - and therefore never treated for the cause.

Gupta et al, Indian Journal of Medical Research 1967:55:1341-8

Clinical features
Often called the silent disease Bone loss occurs without symptoms First sign may be a fracture due to weakened bones Joint pain , back pain, tenderness Disfigurement Debilitation Patient with hip fracture, the leg is shorten and extremely rotated. Kyphosis ( common condition of a curvature of upper back )

Davidsion medicine book

Risk factors
Genetics factor more marked in white an Asians than black Sex- more in females Reduced physical activity- old age Deficiency of the sex hormones---- oestrogen in women and androgens in men Combine deficiency of calcitonin and oestrogen Hyperparathyroidism Deficiency of vitamin d A low diet of calcium Local factors Excessive use of alcohol Smoking

Family history of osteoporosis

Causes
Postmenopausal osteoporosis
Pregnancy related osteoporosis

Endocrine disease : Hypogonadism , Hyperthyroidism , Hyperparathyroidism ,Cushings syndrome

Inflammatory disease: inflammatory bowel disease , ankylosing spondylitis Gastrointestinal disease: malabsorption , chronic liver disease

Drugs: corticosteroids ,gonadotropin- releasing hormone agonist, aromatase inhibitors, thyroxine over replacement, heparin ,thiazolidenediones, sedatives, anticulvansants,alcohol excess,

Miscellaneous: Myeloma, gauchers disease, immobilization, poor diet, low body weight, HIV infection ,anorexia nervosa, Smoking, excessive alcohol intake

Pathophysiology
Occur because of defect in gaining peak bone mass and /or because of accelerate bone loss. Normal individuals : bone mas increases during skeletal growth to reach a peak between the age of 20 and 40 but falls after that. Women: there is a accelerated phase of bone loss after menopause due to oestrogen deficiency which causes uncoupling of bone resorption ,such that the amount of bone removes by osteoclast exceeds the rate of new bone formation by osteoblast. Age related bone loss is a distinct process that accounts for the gradual bone loss that occurs with advancing age in both gender. Bone resorption is not particularly increased but bone formation is reduce d and fails to keep pace with bone resorption Accumulation of fat in the bone marrow space also occurs because of an age related decline in the ability of bone marrow stem cell to differentiate in to osteoblast and an increase in their ability to differentiate in to adipocytes.

pick bone mass and bone loss regulated by Genetic factors

account up to 80% of the

environmental factors such as exercise and calcium intake during growth and adolescence are important in maximizing peak bone mass and in regulating rates of post menopausal bone loss. Smoking has a detrimental effect on BMD and is associated with an increased fracture risk , partly because female smokers have an earlier menopause than non smokers

population variance in peak bone mass and other determinants of the fracture risk, such as bone turn over and bone size. Polymorphisms have been identified in several gene that countrbute to the pathogenesis of osteoporosis. Including oestrogen receptor gene, lipoprotein receptor related protien 5 gene, the gene that encode osteoprotegerin , RANK and the alpha1 chain type 1 collegen.

Heavy alcohol intake is a recognize cause of osteoporosis and fracture , but moderate intake does not substantially alter risk

INESTIGATION
LABORATORY ANALYSES

Calcium and Phosphorus quantification in serum;

electrophoresis of serum proteins; speed of erythrosedimentation; alkaline serum phosphatase (increase in presence of fractures); dosing of the serum parathormon (PTH); Osteocalcine serum; Calciuria; Urinary excretion of peptides containing Hidrossyproline and of the Pyridin peptide.

Investigation
Densitometric analysis DEXA FRAX Morphometric analysis

Mental index Gonial index Antegonial index Panoramic mandibular index Mandibular cortical index

Morphomertyic analysis
1) Mental Index: which measures the mean width of the inferior cortex below the two mental foramina. Devlin and Horner suggested that such a measurement could be an accurate osteoporotic measure45,49 2)The Gonial Index : which measures the mean thickness of the inferior mandibular cortex at the angle of the mandible 3) The Antegonial Index: measures it in the antegonial notch region. Bras suggested that a gonial cortical thickness of less than 1 mm was an indicator of osteoporosis45,50.
49. Devlin H, Horner K. Mandibular radiomorphometric indices in the diagnosis of reduced skeletal bone mineral density. Osteoporos Int 2002; 13: 373 378. 50. Bras J, van Ooij CP, Abraham-Inpijn L, Kusen GJ, Wilmink JM. Radiographic interpretation of mandibular angular cortex: a diagnostic tool in metabolic and tooth loss. Part I normal state. Oral Surg Oral Med Oral Pathol 1991; 71: 349356. Dervis E. Oral implications of osteoporosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005; 100: 349 356

1) Mental Index: which measures the mean width of the inferior cortex below the two mental foramina.

2)The Gonial Index : which measures the mean thickness of the inferior
mandibular cortex at the angle of the mandible

mandibular cortical thickness measured on the bisector of the angle between the tangent lines to the posterior border of the ramus and the mandibular base (normal greater than or equal to 1.0 mm)

3) The Antegonial Index: measures it in the antegonial notch region.

4)The Panoramic Mandibular Index (PMI): is the ratio of the thickness of mandibular cortex below the mental foramen, to he distance between the inferior border of mental foramen and the inferior mandibular cortex 8,45,51

5) In Mandibular Cortical Thickness (MCT): Measurements of the lower border cortical thickness are made along this line on both sides and the mean is calculated11.

Diagram illustrating the classification of the endosteal inferior cortex on panoramic radiographs

C1: The endosteal margin of the cortex is even and sharp on both sides of the mandible. C2: The endosteal margin has semilunar defects (resorption cavities) with cortical residues one to three layers thick on one or both sides. C3: The endosteal margin consists of thick cortical residues and is clearly porous.

Measurements on the panoramic radiograph, made with Wical and Swoope technique. The inferior edge of the mental foramen was traced to the inferoir border.

1: a line parallel to the long axis of the mandible and tangential to the inferior border of the mandible was drawn. 2: A line perpendicular to this tangent intersecting the inferior border of the mental foramen was constructed. B: Distance from the lower border to the inferior edge of the mental foramen (h). C: thickness of the mandibular cortex (MI)

Densitometric analysis
Dual-energy x-ray absorptiometry (DEXA)

There are two types of DXA equipment:.

a central device a peripheral device

Measure bone density in the hip and spine . usually located in hospitals and medical offices.

Measure bone density in the wrist and heel . available in drugstores and on mobile health vans in the community.

 DEXA work on the principle that calcium in bone attenuates passage of x-ray beam in proportion to amount of minaral present. Dual Energy X-Ray Absorptiometry (DEXA) [Fig. 3] is considered the gold standard method of determining BMD

The DXA bone density test is usually completed within 10 to 30 minutes.

Benefits
simple, quick and noninvasive procedure the most accurate method No anesthesia is required The amount of radiation used is extremely small

Limitations
A DXA test cannot predict who will experience a fracture but can provide indications of relative risk. Central DXA devices are more sensitive than pDXA devices but they are also somewhat more expensive.

No radiation remains in a patient's body after an x-ray examination

Common Fracture/BMD measurement Sites

T score This number shows the amount of bone you have compared with a young adult of the same gender with peak bone mass. A score above -1 is considered normal. A score between -1 and -2.5 is classified as osteopenia (low bone mass). A score below -2.5 is defined as osteoporosis. The T score is used to estimate your risk of developing a fracture.

Who to Treat?
T-Score* Therapy Decision Below -2.5 High Risk Treat -1.0 to -2.5 Moderate Risk

Treat if other risk factors

Above -1.0 Low Risk

Check again in 1-2 years

International Osteoporosis Foundation. 1998.

Prevention of osteoporosis
Osteoporosis can be prevented by weightbearing exercise a diet rich in calcium and vitamin D , healthy habits, with no smoking or excessive alcohol intake

bone density testing

the use of certain medications that promote bone health, minimal use of medications such as glucocorticoids and anticonvulsants, which contribute to bone loss

Diet and nutrients Increases in the daily dose of calcium in older individuals as less efficient absorption of mineral from the intestinal tract

Vitamin D is important because it facilitates intestinal calcium absorption and new bone formation. according to work byKrall et al , although once a patient stops taking calcium and vitamin D the chances for tooth loss immediately increase. low protein intake----protein-calorie malnutrition This deficiency stimulates bone resorption and impedes bone formation directly and indirectly through a reduction in serum insulin like growth factor I High sodium intake increases urinary calcium loss Deficiency of vitamin K and excessive intake of vitamin A also may contribute to osteoporotic fractures

Management
Pharmacotherapies for osteoporosis

Calcium Vitamin D Hormone replacement therapy Selective oestrogen replacement therapy Calcitonin Bisphosphonates Anabolic agents parathyroid hormone Strontium renelate
Surgery, kypoplasty and vertebroplasty
National Institutes of Health. Optimal calcium intake. NIH Consensus Statement Online 1994(June 68);12(4):131. Available at: http://consensus.nih.gov/cons/097_statement.htm. Accessed August 11, 2004.

Calcium and vitamin d reduce risk of fracture in those who are housebound or living in care homes

Optimal calcium requirements as recommended by the National Institutes of Health Consensus Development Conference, June 68, 1994

Young adults (1124 y) ---------------------------------> 12001500mg/day Men (2565 y )--------------------------------> 1000mg/day (Over 65 y) -----------------------------> 1500mg/day Women (2550 y) --------------------------------> 1000mg/day Over 50 y (postmenopausal)--------> 1500mg/day On estrogens ---------------------------> 1000mg/day Not on estrogens----------------------> 1500mg/day Over 65 y--------------------------------> 1500mg/day Pregnant and nursing----------------> 120011500mg/day Vitamin D2 and vitamin D3 altogether 400 IU/day

Bisphosphonate
They have a phosphate carbon-phosphate bond. This class of medication induces a shift in mineralization. Binding strongly to hydroxyapatite crystals, they inhibit bone resorption, thus reducing the rate of bone turn-over. They also are potent inhibitors of osteoclasts and reduce the rate at which new bone remodeling units are formed, thereby reducing the depth of resorption. Overall, the result is to produce a positive bone balance at individual remodeling units, which increases bone mass Alendronate: dose 10mg per day This medication must be taken on an empty stomach on rising in the morning with 6 to 8 ounces of water. The patient must stay upright for 30 minutes after taking the medication and not consume any food or other medications during that time. contraindicated: in patients with esophageal emptying delays, such as stricture or achalasia, and it can cause esophagitis, a potentially serious side effect in a small percentage of patients. Alendronate may also cause taste alterations.

Risedronate :dose 5 mg per day orally

differs from alendronate in its chemical structure, but the instructions for its use are similar. may increase the gastrointestinal side effects of aspirin and nonsteroidal antiinflammatory drugs. Patients taking either of these bisphosphonates should be taking supplemental calcium and vitamin D if their dietary intake is inadequatea

s
Zoledronate: dose 5mg/12mnth i.v. The most potent , is available for intravenous administration only. It is approved for hypercalcemia of malignancy and metastatic bone disease and is only used in oncology units and hospitals [42]. The potential side effect of significance to dentistry is oral candidiasis [42].

Gage TW, Pickett FA. Dental drug reference. 6th edition. St Louis (MO): Mosby; 2003

Common side effect with intravenous bisphosphonates: Transient influenza like illness characterized by fever , malaise, anorexia which occurs in first 24 to48 hours after administration . Rare side effects : atrial fibrillation, osteonecrosis of the jaw

Patients who have received high doses of intravenous bisphosphonates

Some advise that bisphosphonates should be temporarily stopped in patients under going tooth extraction but there is no evidence that this is necessary or alters the occurrence of ONJ.

Anabolic agents
parathyroid hormone and strontium renelate have an anabolic action on the skeleton.

parathyroid hormone
Teriparatide 1-34 fragment of PTH given by single daily subcutaneous injection of 20 microg It stimulates new bone formation on trabecular and cortical (periosteal or endosteal) bone surfaces by preferential stimulation of osteoblastic activity over osteoclastic activity. It increases BDM by 10% or more in osteoporotic subjects and reduce risk of vertebral fracture by about 65% and non vertebral fracture by 50%. Also effective in corticosteroid induce osteoporosis , and male osteoporosis Very expensive and usually reserved for patients with severe osteoporosis. And who have failed to respond adequately to other treatment. Recommended duration of treatment is 24 months, after which patient should receive an anti resorptive drugs, such as bisphosphonates.

Teriparatide and bisphosphonate should not be taken at same time because this blunts the anabolic effect.

Prosthodontic management
Screening for osteoporosis before providing any Prosthodontic treatment is necessary . modifications in the treatment plan to reduce the stresses on jaw bones is recommended.

Removable dentures and osteoporosis

osteoporotic women over the age of 50 years indicated that they required new dentures three times more frequently than women of the same age not suffering from clinical osteoporosis, and required specific precautions in the construction of their dentures. The largest amount of resorption has been shown to occur in the mid lateral aspects of the body of the mandible, while less resorption occurred anteriorly .

Precaution:

1)mucostatic and open mouth impression techniques,

2) use of acrylic non- or semi-anatomic teeth rather than porcelain ones, 3)narrowing the occlusal table and/or decreasing number of posterior teeth, 4)periods of extended tissue rest (by keeping dentures out of the mouth for 1012 h daily) 5) optional use of soft liners The type of denture base in osteoporotic patient metal denture bases exhibiting the greatest reduction in alveolar ridge height in comparison with the other groups, soft-lined denture bases showing the least reduction probably due to its dampening action.

fixed partial dentures and osteoporosis1

Some studies suggest that fixed partial dentures may be avoided until treatment for osteoporosis is instituted, as it may accentuate alveolar bone loss in periodontally compromised abutment areas.

Implants and osteoporosis

Reported findings relted toosteoporosis
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 .

increased resorption and thinning of the mandibular inferior cortical margin.

As a characteristic feature of the disease, subjects with osteoporosis show a decrease in the number and thickness of trabecular plates.

 It was shown that oestrogen deficiency may danger to bone healing around dental implants, while oestrogen therapy may actually prevent per iimplant bone loss.

There could be differences in bone healing and remodelling between the long bones and the jaw after dental implant placement60.

Several studies have recorded that osteoporosis is not a risk factor for osseointegration of oral implants

Another review completed on 192 women who were 50 years of age or older at the time of dental implant placement, also concluded that a diagnosis of osteoporosis or osteopenia didnot contribute to an increased risk of implant failure 62

 Various longitudinal implant studies have reported increased failure rates of implants placed in jaws with type 4 bone (Jaffin and Berman, 1991; Friberg et al, 1991), which concomitantly is the typical bone quality seen in osteoporosis patients (van Steenberghe et al, 2003).
In a large retrospective cohort of 2004 patients having 6946 implants analyses with multivariate statistics identified osteoporosis as a significant variable associated with early dental implant failure

It has also 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 (Beikler and Fleming, 2003).

The bone quality was classified on a scale from 1 to 4 depending on ratio of trabecular : compact bone. by Lekholm and Zarb in 1985. Type 1 bone is when homogeneous compact bone is present at the entire jaw. Type 2 when a thick layer of compact bone surrounds a core of dense trabecular bone. Type 3 when a thin layer of compact bone surrounds a core of dense trabecular bone.
Type 1

Type 2

Type 3

Type 4 when a thin layer of compact bone surrounds a core of low density trabecular bone.

Type 4

Various longitudinal implant studies have reported increased failure rates of implants placed in jaws with type 4 bone (Jaffin and Berman, 1991; Friberg et al, 1991).