Elsevier

Bone

Volume 40, Issue 5, May 2007, Pages 1217-1221
Bone

Prediction of bone mineral density with dental radiographs

https://doi.org/10.1016/j.bone.2007.01.009Get rights and content

Abstract

There is consensus to use the bone mineral density (BMD) for the operational definition of the degree of osteoporosis and the risk of osteoporotic fractures. Dual X-ray absorptiometry (DXA) is the common technique to determine BMD. Because of high costs and limited availability of DXA equipment it is worthwhile to look for alternative diagnostic techniques. As part of a larger study, the Osteodent project, we investigated if the trabecular pattern on dental radiographs can be used to predict BMD and to identify the subjects with osteoporosis and increased risk of osteoporotic fractures.

In four clinical centers 671 women with an average age of 55 years were recruited. BMD values were measured by DXA equipment at the femoral neck, total hip, and spine. One panoramic and two intraoral radiographs were made. From 525 women a complete set of BMD values and radiographs was obtained. Four regions of interest on the radiographs were selected manually and then processed automatically. On all regions of interest mean and standard deviation of the gray values were measured and several features describing the shape of the binarized trabecular pattern. Multiple regression was used to predict BMD of total hip and spine by means of the radiographic measurements combined with age.

It was found that age accounts for 10% of the variation in total hip BMD and 14% of the variation in spinal BMD. When all measurements on the dental radiographs are used the explained variation increases to 22% and 23%. The areas under the ROC curves are comparable to those of commonly used screening instruments for osteoporosis. It is concluded that prediction of DXA measurements of BMD by means of quantitative analysis of the trabecular pattern on dental radiographs is feasible.

Introduction

Osteoporosis is a systemic disease characterized by low bone mineral density (BMD), deterioration of bone structure, and increased bone fragility according to the definition of the World Health Organization (WHO) formulated in 1994 [1], [2], [3]. An expert group under the WHO recommended to base the diagnosis of osteoporosis on measurements of BMD in the hip, spine, or lower arm by means of dual X-ray absorptiometry (DXA) [4].

Annual screening of all postmenopausal women is not recommended because it involves high costs and it has low sensitivity [3], [5]. However, it is suggested that BMD should be measured if an additional risk factor is present such as low weight or age 65 and over [4]. This still involves high costs and many facilities. Thus for screening purposes an inexpensive alternative method of assessing skeletal status is required [3]. Dental radiographs are relatively inexpensive and already made routinely in a large part of the adult population. Therefore, dental radiographs might represent an enormous potential as a screening tool for osteoporosis. The general dental practitioner might fulfil the same role with respect to osteoporosis as for example in the early diagnosis of oral cancer [6].

As osteoporosis is a systemic skeletal disease, it also affects bone density and structure of the jaws. Several review articles describe the use of dental radiographs for diagnosing osteoporosis [7], [8], [9]. Osteoporotic patients have reduced bone mass of the jaws [10], [11], [12], [13], [14]. Extensive morphologic analysis of the trabecular pattern on dental radiographs in relation to osteoporosis is also described [15], [16]. The relations between BMD and age, sex, weight, and ethnic background are too weak to allow precise prediction of BMD. The objective of the present study is to investigate the contribution of morphologic image features measured on panoramic and intraoral dental radiographs to the prediction of BMD of hip and spine.

Section snippets

Subjects

In the Osteodent project subjects from Manchester, Athens, Leuven, and Malmö were invited to participate in the study by means of articles in the local press, flyers, and by oral communication. In the project, 671 women in the age range of 39 to 71 years (average 54.6 years) were recruited. Women with possible secondary osteoporosis, primary hyperparathyroidism, poorly controlled thyrotoxicosis, malabsorption, liver disease, and alcoholism were excluded. Informed consent was obtained from all

Results

Of the subjects involved in the study, 20% were classified as having osteoporosis of the left hip or of the spine. Table 1 presents an overview of the numbers of healthy, osteopenic, and osteoporotic subjects. It clearly shows a decreasing number of healthy subjects and an increasing number of osteoporotic subjects with increasing age.

Main conclusion

When the prediction of total hip BMD or spinal BMD by means of age is taken as a reference, it is found that the predictive validity is approximately doubled by using the image features of dental radiographs. We found that age alone explains 10% of the variance in total hip BMD and 14% of the variance in spinal BMD (Table 2). Each of the three radiographs raised the percentage of explained variance with a statistically significant amount. Therefore, the overall conclusion from our findings is

Acknowledgment

This work was supported by a research and technological development project grant from the European Commission Fifth Framework Programme ‘Quality of Life and Management of Living Resources’ (QLK6-2002-02243; ‘Osteodent’).

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