osteoporosis sarvesh

7/28/2019 Osteoporosis Sarvesh

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Osteoporosis

Dr. Sarvesh s Patel


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Definition

TypesPrevalenceClinical feature

PathophysiologyRisk factorsCauses

InvestigationPreventionTreatment


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Definition

The National Institutes of Health Consensus Panel on OsteoporosisPrevention, diagnosis and Therapy (2009) defined osteoporosis as a

skeletal disorder characterized by compromised bone strengthpredisposing a person to a n increased risk of fracture.


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India: Some Hard Facts

Over 61 Million Indians have

osteoporosis.

80% are women.

On a global basis, Indians have thehighest prevalence of osteopenia.

Compared to Caucasians, osteoporotic

fractures in the Indian population occur10-12 years earlier in age.

Osteoporotic fractures are morecommon in Indian men than in the

West.


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Types

Primary osteoporosis Secondary osteoporosis

result of medications such asglucocorticoids or diseasessuch as malabsorption thatseverely affect skeletal health.

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

affecting trabecularbone

Type II Osteoporosisor regressive orsenile (>70y) Affecting both

trabecular and corticalbone

Juvenile andidiopathicosteoporosis Very rare seen


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Worldwide, lifetime risk for osteoporotic fractures in women is 1/3 Inmen risk is 1/8.

The highest risk of hip fractures arecurrently found in Norway, Sweden,Iceland, Denmark and the UnitedStates,

Over 200 million people suffer

from osteoporosis worldwide.

By 2050, the global cost ofosteoporosis is expected toexceed $130 billion

The annual hip fracture incidence isexpected to increase to 6.3 million

By 2050 Asia is expected toaccount for almost one-half of all

global fractures.

3,4

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 BonMiner 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.

Forearm

Fracture Vertebral

Fracture

Hip

Fracture


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India: Some more hard facts

Over 45 Lakhs Indian women above 60have a fractured spine.

Over 2.5 Lakhs Indians suffer osteoporotic

hip fractures every year.

Most of these fractures are neverinvestigated for osteoporosis - and

therefore never treated for the cause.

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


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Clinical features

Patient with hip fracture, the leg is shorten and extremely rotated.

Joint pain , back pain, tenderness

Disfigurement

Debilitation

Kyphosis ( common condition of a curvature of upper back )

Davidsion medicine book

Often called the silent disease

Bone loss occurs without symptoms

First sign may be a fracture due toweakened bones


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Risk factors

Sex- more in females

Reduced physical activity- old age

Deficiency of the sex hormones---- oestrogen inwomen and androgens in men

Combine deficiency of calcitonin and oestrogen

Hyperparathyroidism

Deficiency of vitamin d

A low diet of calcium

Local factors

SmokingExcessive use of alcohol

Family history of osteoporosis

Genetics factor more marked in white an Asians than black


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Causes

Endocrine disease : Hypogonadism , Hyperthyroidism ,

Hyperparathyroidism ,Cushings syndrome

Inflammatory disease: inflammatory bowel disease ,

ankylosing spondylitis

Gastrointestinal disease: malabsorption , chronic liver disease

Postmenopausal osteoporosis

Pregnancy related osteoporosis


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

Smoking, excessive alcohol intake

Drugs: corticosteroids ,gonadotropin- releasing hormone agonist,

aromatase inhibitors, thyroxine over replacement,

heparin ,thiazolidenediones, sedatives,

anticulvansants,alcohol excess,


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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 toreach 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 tooestrogen deficiency which causes uncoupling of bone resorption ,suchthat the amount of bone removes by osteoclast exceeds the rate of newbone formation by osteoblast.

Age related bone loss is a distinct process that accounts for the gradualbone loss that occurs with advancing age in both gender.

Bone resorption is not particularly increased but bone formation isreduce d and fails to keep pace with bone resorption

Accumulation of fat in the bone marrow space also occurs because of anage related decline in the ability of bone marrow stem cell to differentiatein to osteoblast and an increase in their ability to differentiate in toadipocytes.


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Heavy alcohol intake is a

recognize cause of osteoporosisand fracture , but moderate intake

does not substantially alter risk

account up to 80%of thepopulation variance in peak bonemass and other determinants ofthe fracture risk, such as boneturn over and bone size.

Polymorphisms have beenidentified in several gene thatcountrbute to the pathogenesis ofosteoporosis.

Including oestrogen receptorgene, lipoprotein receptor relatedprotien 5 gene, the gene thatencode osteoprotegerin , RANKand the alpha1 chain type 1collegen.

such as exercise and calciumintake during growth andadolescence are important inmaximizing peak bone massand in regulating rates of postmenopausal bone loss.

Smoking has a detrimentaleffect on BMD and isassociated with an increasedfracture risk , partly becausefemale smokers have an earlier

menopause than non smokers

pick bone mass and bone loss regulated by

Genetic factors environmental factors


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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.

INESTIGATION


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Investigation

Densitometric analysis

DEXA FRAX

Morphometric analysis

Mental index Gonial index Antegonial index

Panoramic mandibular index Mandibular cortical index


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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 mandibularcortex 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: 349

356.

Dervis E. Oral implications of osteoporosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005; 100: 349 356


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

mental foramina.

) h l d


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mandibular cortical thickness measured on the bisector of theangle between the tangent lines to the posterior border of theramus and the mandibular base (normal greater than or equal to1.0 mm)

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


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


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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.

Di ill t ti th l ifi ti f th d t l i f i t i di h


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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.

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


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1: a line parallel to the long axis of the mandible and tangential to theinferior 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)

Measurements on the panoramic radiograph, made with Wical and Swoope technique.

The inferior edge of the mental foramen was traced to the inferoir border.


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Densitometric analysis

Dual-energy x-ray absorptiometry (DEXA)

There are two types of DXA equipment:.

Measure bone density in the hipand spine .

usually located in hospitals and

medical offices.

Measure bone density in the wristand heel .

available in drugstores and on

mobile health vans in thecommunity.

a central device a peripheral device

DEXA k h i i l h l i i b f b


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

DEXA work on the principle that calcium in bone attenuates passage of x-ray beamin proportion to amount of minaral present.

Dual Energy X-Ray Absorptiometry (DEXA) [Fig. 3] is considered thegold standard method of determining BMD

Benefits

simple, quick and noninvasiveprocedure

No anesthesia is required

The amount of radiation used isextremely small

the most accurate method

No radiation remains in a

patient's body after an x-rayexamination

Limitations

A DXA test cannot predict whowill experience a fracture but canprovide indications of relativerisk.

Central DXA devices are moresensitive than pDXA devices butthey are also somewhat moreexpensive.


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Common Fracture/BMD measurement Sites


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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.


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Who to Treat?

Therapy Decision

High Risk

Treat

Moderate Risk

Treat if other risk factors

Low Risk

Check again in 1-2 years

T-Score*

Below -2.5

-1.0 to -2.5

Above -1.0

International Osteoporosis Foundation. 1998.

P ti f t i


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Prevention of osteoporosis

Osteoporosis can be prevented by weight-

bearing exercise

a diet rich in calcium and vitamin D ,

healthy habits, with no smoking or excessivealcohol intake

bone density testing

the use of certain medications that promote

bone health,

minimal use of medications such as glucocorticoids andanticonvulsants, which contribute to bone loss


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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 patientstops taking calcium and vitamin D the chances for tooth lossimmediately increase.

Deficiency of vitamin K and excessive intake of vitamin A also may

contribute to osteoporotic fractures

High sodium intake increases urinary calcium loss

low protein intake----protein-calorie malnutritionThis deficiency stimulates bone resorption and impedes

bone formation directly and indirectly through a reduction in serum

insulin like growth factor I


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Pharmacotherapies for osteoporosis

National Institutes of Health. Optimal calcium intake. NIH Consensus Statement Online 1994(June 6 8);12(4):131. Available at:

http://consensus.nih.gov/cons/097_statement.htm. Accessed August 11, 2004.

Management

Surgery, kypoplasty and vertebroplasty

CalciumVitamin DHormone replacement therapySelective oestrogen replacement therapyCalcitoninBisphosphonatesAnabolic agents

parathyroid hormone

Strontium renelate
http://consensus.nih.gov/cons/097_statement.htmhttp://consensus.nih.gov/cons/097_statement.htmhttp://consensus.nih.gov/cons/097_statement.htmhttp://consensus.nih.gov/cons/097_statement.htm


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Calcium and vitamin d reduce risk of fracture in those who are

housebound or living in care homes.

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/dayNot on estrogens----------------------> 1500mg/day

Over 65 y--------------------------------> 1500mg/day

Pregnant and nursing----------------> 120011500mg/day

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

Vitamin D2 and vitamin D3 altogether 400 IU/day

Bisphosphonate


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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, thusreducing the rate of bone turn-over.

They also are potent inhibitors of osteoclasts and reduce the rate at which new boneremodeling units are formed, thereby reducing the depth of resorption.

Overall, the result is to produce a positive bone balance at individual remodelingunits, which increases bone mass

Alendronate: dose 10mg per day

This medication must be taken on an empty stomach on rising in the morning with6 to 8 ounces of water. The patient must stay upright for 30 minutes after takingthe medication and not consume any food or other medications during that time.

contraindicated: in patients with esophageal emptying delays, such as stricture orachalasia, and it can cause esophagitis, a potentially serious sideeffect in a small percentage of patients.

Alendronate may also cause taste alterations.


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Risedronate :dose 5 mg per day orally

differs from alendronate in its chemical structure, but the instructions for itsuse are similar.

may increase the gastrointestinal side effects of aspirin and nonsteroidal anti-inflammatory drugs.

Patients taking either of these bisphosphonates should be taking supplementalcalcium 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 isonly 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


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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 inpatients under going tooth extraction but there is no evidence that thisis necessary or alters the occurrence of ONJ.

Anabolic agents


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Anabolic agents

Teriparatide 1-34 fragment of PTH given by single daily subcutaneous injection of20 microg

It increases BDM by 10% or more in osteoporotic subjects and reduce risk ofvertebral fracture by about 65% and non vertebral fracture by 50%.

Also effective in corticosteroid induce osteoporosis , and male osteoporosis

parathyroid hormone and strontium renelate have an anabolic action on theskeleton.

Very expensive and usually reserved for patients with severe osteoporosis. Andwho have failed to respond adequately to other treatment.

Recommended duration of treatment is 24 months, after which patient shouldreceive an anti resorptive drugs, such as bisphosphonates.

Teriparatide and bisphosphonate should not be taken at same time because this

blunts the anabolic effect.

It stimulates new bone formation on trabecular and cortical (periosteal orendosteal) bone surfaces by preferential stimulation of osteoblastic activity overosteoclastic activity.

parathyroid hormone

Prosthodontic management


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.

Prosthodontic management

Screening for osteoporosis before providing any Prosthodontictreatment is necessary .

modifications in the treatment plan to reduce the stresses onjaw bones is recommended.

osteoporotic women over the age of 50 years indicated thatthey required new dentures three times more frequently thanwomen of the same age not suffering from clinical osteoporosis,

and required specific precautions in the construction of theirdentures.

The largest amount of resorption has been shown to occur inthe mid lateral aspects of the body of the mandible, while less

resorption occurred anteriorly .

Removable dentures and osteoporosis

Precaution:


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The type of denture base in osteoporotic patient metal denturebases exhibiting the greatest reduction in alveolar ridge heightin comparison with the other groups, soft-lined denture basesshowing the least reduction probably due to its dampeningaction.

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 ofposterior teeth,

4)periods of extended tissue rest (by keeping dentures outof the mouth for 1012 h daily)

5) optional use of soft liners

fixed partial dentures and osteoporosis1


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Some studies suggest that fixed partial dentures may beavoided until treatment for osteoporosis is instituted, as itmay accentuate alveolar bone loss in periodontally

compromised abutment areas.

Implants and osteoporosis

fixed partial dentures and osteoporosis1

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 unaffectedindividuals .

increased resorption and thinning of the mandibular inferior corticalmargin.

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


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Another review completed on 192 women who were 50 yearsof age or older at the time of dental implant placement, alsoconcluded that a diagnosis of osteoporosis or osteopeniadidnot contribute to an increased risk of implant failure 62

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

There could be differences in bone healing and remodelling

between the long bones and the jaw after dental implant

placement60.

It was shown that oestrogen deficiency may danger to bone

healing around dental implants, while oestrogen therapy may

actually prevent per iimplant bone loss.


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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).

In a large retrospective cohort of 2004 patients having 6946

implants analyses with multivariate statistics identifiedosteoporosis as a significant variable associated with earlydental implant failure

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).

The bone quality was classified on a scale from 1 to 4


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q ydepending on ratio of trabecular : compact bone. by Lekholm andZarb in 1985.

Type 1 bone is when homogeneous

compact bone is present at the entire jaw.

Type 2 when a thick layer ofcompact bone surrounds a coreof dense trabecular bone.

Type 3 when a thin layer ofcompact bone surrounds a core ofdense trabecular bone.

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

Type 1

Type 2

Type 3

Type 4

Various longitudinal implant studies have reported increased failure ratesof implants placed in jaws with type 4 bone (Jaffin and Berman, 1991;

b l 99 )

osteoporosis sarvesh

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