ISSN 0974-3618 (Print) www.rjptonline.org
0974-360X (Online)
RESEARCH ARTICLE
Dental Health in Osteoporotic Women
Dr. Annas Alyasiry1, Dr. Zainab Mahmood
Aljammali1, Dr. Ahmed M. Almosawy1,
Dr. Sabbah Alrubbaie2
1Dentistry College, Dentistry Department,
Babylon University
2Medicine College, Dentistry Department,
Babylon University
*Corresponding Author E-mail:
ABSTRACT:
Objective. The
aim of the study was to examine the condition of periodontal tissues, the
mobility of teeth, and the TMJ condition in osteoporosis women in different
degree and age.
Subjects/
Methods.
In this study 68healthy women with osteoporosis only were included; on the
basis of the absolute value and T-score. The examined people were mainly
females, aged between 30 and 70years, they were divided into three groups
according to degree of osteoporosis. The clinical parameters used for
determining the condition of periodontal tissues and the TMJ included:
protrusion of mandible ,limited opening, drifting to one side, TMJ clicking,
TMJ tender ,bleeding, gum recession, periodontitis, gingivitis, mobility of
teeth and carious teeth was notified.
Results. All
the patient in this study have TMJ tender with clicking (100%). The protrusion
of the mandible in group one is the least than the other group. The limiting of
mouth opening percentage was larger in the group 3 in older patient than the
younger patient in the same group and in the other groups, and it was obvious
that the periodontitis, gingivitis and bleeding were increased in group (1
&2) in older age. The number of missing teeth was the largest in older age
group, and proportional to the osteoporosis degree increase.
Conclusion. The
osteoporosis has effects on the oral health and associated with TMJ tender and
clicking, protrusion of the mandible, drifting of jaw to one side and limiting
of mouth opening percentage, and all these effects increased in the older age
patient than the younger patient. The percentage of carious teeth, gingivitis,
the bleeding and the number of missing teeth was increase with the osteoporosis
degree increase.
KEYWORDS: Dental
health, osteoporosis, women.
INTRODUCTION:
Osteopenia is a reduction in bone mass due
to an imbalance between bone resorption and formation, favoring resorption,
resulting in demineralization and leading to osteoporosis. Osteoporosis is a
disease characterized by low bone mass and fragility and a consequent increase
in fracture risk.(1)
There are
many causes of osteoporosis such as: Failure to attain adequate peak bone mass
in early 20’s, chronic illness e.g
chronic liver disease, chronic renal failure, thyroid disease, particularly hyperthyroidism or
excessive thyroxine replacement, smoking, sedentary lifestyle, excessive caffeine intake (> 5 – 6 cups/day), excessive alcohol intake, lifelong low calcium intake, increasing age, genetic factors and ethnic factors (Caucasian and
Asians), hormone deficiency states (late menarche,
premature menopause ,menopausal state, testosterone deficiency in males), vitamin D deficiency, primary hyperparathyroidism, prolonged immobilization, Cushing’s syndrome or
disease, corticosteroid therapy (doses of
prednisolone > 5 – 7.5 mg dailyor an equivalent dose of another
glucocorticoid for greater than 2 months; any dose of glucocorticoid in the
elderly > 65 yrs), malabsorptive illnesses
eg Coeliac disease, Crohn’s disease, eating
disorders (Anorexia nervosa, Bulimia), rheumatoid
arthritis, organ transplant recipients, treatments for certain malignancies e.g
breast cancer, prostate cancer.(2)
Osteoporosis and periodontitis are diseases
which affect a large number of women and men, with incidence increasing with
advancing age. Periodontitis is characterized by inflammation of the supporting
tissues of the teeth, resulting in resorption of the alveolar bone as well as
loss of the soft tissue attachment to the tooth and is a major cause of tooth
loss and edentulousness in adults.(1) Both osteoporosis and periodontal disease share
many risk factors and since both are bone resorptive diseases it has been
hypothesized that osteoporosis could be a risk factor for progression of
periodontal disease.(3)
In the United States
osteoporosis affects more than 25 million people and predisposes patients to
more than 1.3 million fractures annually.(4) Since alveolar bone
loss is a clinical feature of periodontal disease, disturbances in bone
metabolism and decreases in the bone mineral density(BMD) of the skeleton,
especially in the jaws, may be a factor in periodontal disease.(5)
The clinical importance
of generalized bone loss as a contributor to alveolar bone loss and subsequent
tooth loss is unclear. To date, the evidence for an association between tooth
loss and bone mineral density in the extra-cranial skeleton has been derived
from cross-sectional studies and results have been inconclusive.(6)
Bando et al.(7) suggested that
sufficient masticatory function with periodontally healthy dentition may
inhibit or delay the progress of osteoporotic changes in skeletal bone, or that
edentulous women may be more susceptible to osteoporosis. The role of
osteoporosis or osteopenia in the etiology of periodontal disease is not fully
understood. An observational study supported the possible role of low skeletal
BMD or osteoporosis as risk indicators for reduced alveolar crestal height.(5)
Several large studies
conducted in early postmenopausal women failed to find significant associations
between tooth status and BMD. Elders et al.(8) found no relationship
between the number of missing teeth and either spine BMD or metacarpal
thickness. Krall et al.(9)conducted a longitudinal study on
associations between tooth loss and bone loss in whole bodies, in the femoral
neck, and in the spine. This study included 189 healthy white dentate
postmenopausal women who participated in three intervention trials conducted
within a 7-year period. Forty-five women (24%) reported having lost one or more
teeth. The rates of BMD changes at all three sites (whole body, femoral neck,
spine) were independent predictors of tooth loss in the multivariate models
supporting a role of systemic bone loss in the development of tooth loss among
post-menopausal women. Epidemiologic research shows that chronic periodontitis
is related to osteoporosis. Several studies have already indicated that
insufficient estrogen is closely related to periodontitis and osteoporosis.
Recently, an increasing number of researchers suggest that PMO promotes
periodontitis.(6,10,11) It has been demonstrated that periodontal
bacteria promote the alveolar bone loss in periodontitis. The invasion of
periodontal bacteria may reduce bone density and enhance osteoclastic activity
by releasing toxins and/or inflammatory cytokines (12). These
cytokines believed to be involved in alveolar bone remodeling are also highly
expressed in PMO(13).Since estrogen inhibits the expression of the
inflammatory cytokines, it might be that larger amounts of these cytokines are
presented in an inflammatory alveolar bone with estrogen deficiency. Therefore,
estrogen deficiency may contribute to the alveolar bone absorption in
periodontal disease, either by reducing the bone mass of alveolar bone or by
causing increased expression of inflammatory cytokines. However, the underlying
mechanisms are still not clear. Rondernos et al.(14) studied the
possible association of periodontal disease with femoral BMD in a large sample
of U.S. adults (N = 11,655). Their finding indicates that, in the presence of
high calculus scores, females with osteoporosis are at an increased risk for
attachment loss. In a study population of 70 post-menopausal Caucasian women
aged 51-78, skeletal systemic BMD was assessed by DXA. Clinical attachment loss
and inter proximal alveolar bone loss represented periodontal disease severity.
Mean alveolar bone loss significantly correlated with systemic BMD. A trend for
a correlation between clinical attachment levels and BMD was found(6).
The aim of the study was to examine the condition of periodontal tissues
,the mobility of teeth, and the TMJ evaluation in osteoporosis women who were
diagnosed with osteoporosis in different degree and age.
MATERIALS
AND METHODS:
The study was
conducted in Marjan Teaching Hospital at Rheumatology Department from October
/2014
to December /2014.In thisstudy68healthy women who diagnosis with osteoporosisonly
were included; on the basis of the absolute value of T-score, excluding the
diabetics, hypertensive, and cardiac disease patient. The examined people were
females, aged between 30 and 70,they were divided into three groups according
to degree of osteoporosis (OP) as follow:
Group 1: 22 patients who have OP1-2 degree.
Group 2: 24 patients who have OP2-3 degree.
Group 3: 22 patients who
have OP more than 3 degree.
The clinical
parameters used for determining the condition of periodontal tissues and the
TMJ condition included: protrusion of mandible ,limited opening, drifting to
one side, TMJ clicking, TMJ tender, bleeding, gum recession, periodontitis,
gingivitis, mobility of teeth and carious teeth was notified. The instruments
used periodontal probe, dental probe, dental mirror, twizer,
and Dual
X-ray absorptiometry (DXA).
Figure (1): Dual
Energy X-Ray Absorptiometry in Merjan Teaching Hospital. (Zahraa,
Almamory,2013)
Procedure
of Bone Mineral Density Measurement:
Weight
and age were measured for each patient. Height should be measured with a
stadiometer, with shoes off, using standard techniques (patient standing erect
with the head in the Frankfort horizontal plane)and weight (in kilograms) were
measured with standard weighting scale, to calculate body mass index (BMI) (BMI
calculated by dividing the weight of the patient in kilograms by the height in
square meter) with patient age, sex,
ethnic group for each patient was entered in densitometry(15).
Patient
should wear comfortable clothing, avoiding garments that have zippers, belts or
buttons made of metal. Objects such as keys or wallets that would be in the
area being scanned should be removed, in the central DXA examination, which measures bone density in the hip
and spine, the patient lies on a padded table. An X-ray generator is located
below the patient and an imaging device, or detector, is positioned above. To
assess the spine, the patient's legs are supported on a padded box to flatten
the pelvis and lower (lumber)spine. To assess the hip, the patient's foot is
placed in a brace that rotates the hip inward, in both cases, the detector is
slowly passed over the area, generating images on a computer monitor, the technologist will walk behind a wall or
into the next room to activate the X-ray machine.
The DXA bone
density test is usually completed within 10 to 30 minutes, depending on the
equipment used and the parts of the body being examined (Figure 1).
RESULTS:
Table (1) showed the range of age distribution. Table (2,3,4)showed that
proximally all the patient in this study have TMJ tender and clicking
(100%).Table (2) show that the protrusion of the mandible in group one is the
least than the other group. Table (2,3,4)showed that the drifting of jaw to one
side in group 1 and 2 is equal with slight increase in group 3.Table (4) show
that the limiting of mouth opening percentage was larger in the group 3 in
older patient than the younger patient in the same group and in the other
groups. Table (7) show that the percentage of carious teeth , gingivitis, and
the bleeding was the least in the group (3), and it was obvious that the
periodontitis ,gingivitis and bleeding were increased in group (1 &2) in
older age. From the figure (2,3,4) we notice that the number of missing teeth
was the largest in older age range, and increase with the osteoporosis degree
increase.
Discussion:
The
protrusion of the mandible is the least in age range (30-49) but in older
patient it (100%) and the probable explanation is that the presence of teeth
specially in upper and lower jaw prevent the protrusion while in older age
after missing of teeth protrusion of the mandible will occur. The percentage of
carious teeth , gingivitis, and the bleeding was the least in the group (3),
this can be explained by the number of missing teeth was larger in this group,
so the absent of teeth was the reason for this result ,this edentulousness
could be due to periodontal disease that occurred earlier in the individual’s
life, so the tooth loss can alter the interpretation of the current status of
periodontal disease. Loss of several periodontally involved teeth can result in
an improvement of periodontal scores, but in general it was obvious that these
scores increased in osteoporosis patient.
The percentage of teeth mobility increased in the osteoporotic women
this can be explained by increased the periodontal ligament loss ,this result
was agreed with the results of American Dental Association Council on Access(16)
and with Marcus et al(17)
The periodontitis ,gingivitis , gum recession, mobility of teeth and
bleeding were increased in group (1 &2) in older age(50-70 year), this due
to post menopause woman that there is insufficient estrogen which is closely
related to periodontitis and osteoporosis. And this result was agree with the
result of Brennan et al(10) and Tezalet al(6)who suggest
that PMO promotes periodontitis and with Pihlstrom et al(12)which
has been demonstrated that periodontal bacteria promote the alveolar bone loss
in periodontitis, and the invasion of periodontal bacteria may reduce bone
density and enhance osteoclastic activity by releasing toxins and/or
inflammatory cytokines . These cytokines believed to be involved in alveolar
bone remodeling are also highly expressed in PMO (13). Since
estrogen inhibits the expression of the inflammatory cytokines, it might be
that larger amounts of these cytokines are presented in an inflammatory
alveolar bone with estrogen deficiency. Therefore, estrogen deficiency may
contribute to the alveolar bone absorption in periodontal disease, either by
reducing the bone mass of alveolar bone or by causing increased expression of
inflammatory cytokines. In the other hand this result disagree with the study
of Lundstromet al(18) which
found that there was no statistical significant differences were found in
gingival bleeding, probing pocket depths, gingival recession or marginal bone
level between the women with osteoporosis and the women with normal BMD. The
number of missing teeth was increase with the osteoporosis degree increase and
this result was agree with the study of Kribs(19).
The
most widely used techniques for assessment of bone mineral density are
dual-energy X-ray absorptiometry(DXA) and quantitative computed tomography(20,21).Dual
energy X-ray absorptiometry is the most precise and the diagnostic measure of
choice as quantitative computed tomography though being more sensitive, causes
greater radiation exposure(21).
Conclusion:
With the limitation of this study, we can conclude that the osteoporosis
has effects on the oral health ,by causing TMJ tender and clicking, protrusion
of the mandible, drifting of jaw to one side and limiting of mouth opening
percentage, and all these effects mostly the older patient than the younger
patient. The percentage of carious teeth , gingivitis, the bleeding and the
number of missing teeth was increase with the osteoporosis degree increase.
Recommendations:
Made a study for more duration period (long
duration), compare between male and female patient, and compare between the
healthy and rheumatoid arthritis patient.
Acknowledgement:
First of all,
thanks to god almighty for inspiring us the will, the patience and strength to
complete this work.
Limitation:
The duration of the
study was short period, the number of patient was little, only female patients,
and only healthy patient, also the interpretations of the present study may be
limited since periodontal measures of bone such as subtraction radiography not
available.
Table(1):Distribution
of osteoporosis patients according to age:
|
No.
|
No. of patients
|
Age range
|
|
1
|
4
|
30-39
|
|
2
|
14
|
40-49
|
|
3
|
34
|
50-59
|
|
4
|
16
|
60-70
|
Table (2): group (1) from 30-39= 2 /
40-49=4/ 50-59=12 /60-70=4
|
Protrusion of mand.
|
Limited opening
|
Drifting to one side
|
TMJ clicking
|
TMJ tender
|
Name
|
No
|
|
0%
|
0%
|
0%
|
100%
|
100%
|
30-39
|
1
|
|
50%
|
0%
|
0%
|
100%
|
100%
|
40-49
|
2
|
|
100%
|
83.3%
|
66.6%
|
100%
|
100%
|
50-59
|
3
|
|
100%
|
100%
|
100%
|
100%
|
100%
|
60-70
|
4
|
Table (3) group (2) from 30-39= 2 / 40-49=6/ 50-59=12 /60-70=4
|
Protrusion of mand.
|
Limited opening
|
Drifting to one side
|
TMJ clicking
|
TMJ tender
|
Name
|
No.
|
|
100%
|
0%
|
0%
|
100%
|
100%
|
30-39
|
1
|
|
100%
|
0%
|
0%
|
100%
|
100%
|
40-49
|
2
|
|
83.3%
|
33.3%
|
66.6%
|
100%
|
100%
|
50-59
|
3
|
|
100%
|
100%
|
100%
|
100%
|
100%
|
60-70
|
4
|
Table (4) group (3) from 40-49=4/ 50-59=10
/60-70=8
|
Protrusion of mand.
|
Limited opening
|
Drifting to one side
|
TMJ clicking
|
TMJ tender
|
Name
|
No.
|
|
0%
|
0%
|
0%
|
0%
|
0%
|
30-39
|
1
|
|
66.6%
|
66.6%
|
33.3%
|
80%
|
100%
|
40-49
|
2
|
|
100%
|
60%
|
60%
|
60%
|
100%
|
50-59
|
3
|
|
100%
|
100%
|
100%
|
100%
|
100%
|
60-70
|
4
|
Table (5) group (1)from 30-39= 2 / 40-49=4/ 50-59=12 /60-70=4
|
Bleeding
|
Gum recession
|
Periodontitis
|
gingivitis
|
Mobility of teeth
|
Carious teeth
|
Name
|
No.
|
|
100%
|
0%
|
0%
|
100%
|
0%
|
100%
|
30-39
|
1
|
|
100%
|
0%
|
0%
|
100%
|
50%
|
100%
|
40-49
|
2
|
|
100%
|
50%
|
50%
|
100%
|
66.6%
|
50%
|
50-59
|
3
|
|
100%
|
100%
|
100%
|
100%
|
100%
|
100%
|
60-70
|
4
|
Table (6) group (2) from 30-39= 2 / 40-49=6/ 50-59=12 /60-70=4
|
Bleeding
|
Gum recession
|
periodontitis
|
gingivitis
|
Mobility of teeth
|
Carious teeth
|
Name
|
No.
|
|
100%
|
0%
|
0%
|
100%
|
0%
|
100%
|
30-39
|
1
|
|
100%
|
33.3%
|
33.3%
|
100%
|
33.3%
|
100%
|
40-49
|
2
|
|
100%
|
50%
|
50%
|
100%
|
33.3%
|
100%
|
50-59
|
3
|
|
100%
|
100%
|
100%
|
100%
|
100%
|
33.3%
|
60-70
|
4
|
Table (7) group(3)from 40-49=4/ 50-59=10 /60-70=8
|
Bleeding
|
Gum recession
|
periodontitis
|
gingivitis
|
Mobility of teeth
|
Carious teeth
|
Name
|
No.
|
|
0%
|
0%
|
0%
|
0%
|
0%
|
0%
|
30-39
|
1
|
|
100%
|
100%
|
100%
|
100%
|
100%
|
100%
|
40-49
|
2
|
|
80%
|
60%
|
60%
|
100%
|
60%
|
80%
|
50-59
|
3
|
|
75%
|
75%
|
75%
|
75%
|
75%
|
50%
|
60-70
|
4
|
Figure(2):Relationship between age and teeth
number in patients with osteoporosis
degree (1-1.9)
Figure(3) Relationship between age and teeth number in
patients with osteoporosis degree (2-2.9)
Figure(4) Relationship between age and teeth
number in patients with osteoporosis degree (3-3.9)
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