Faces of Osteoporosis

Journal of Osteoporosis

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Utricular otoconia of both groups of rats examined by conventional and epifluorescence microscopy, labeling with calcein showed lack of external calcium turnover into otoconia of adult female rats [ 33 ]. Several other factors also affect the dental management of this disease. Patients diagnosed with or at high risk for developing osteoporosis often have other chronic diseases.

They usually have major dental requirements and their poor oral health can cause systemic health deterioration.

Famous Faces of Osteoporosis

Preserving the natural dentition of those patients promotes better nutrition and improves appearance [ 34 , 35 ]. On the other hand, poor oral health in this population can contribute to increased morbidity and decreased quality of life [ 35 — 37 ]. People with chronic diseases and poor oral health are at increased risk of developing opportunistic infections such as pneumonia and of xerostomia induced by medications [ 35 , 36 ].

Therefore, dental care is indicated for these patients; to provide satisfactory care, dentists need to understand osteoporosis, its treatments and its complications. A number of review articles about osteoporosis and periodontal disease discussed various issues regarding BMD and oral alveolar bone loss, premature teeth loss and increased severity of periodontal disease in patients with osteoporosis [ 39 — 41 ].

Common risk factors for osteoporosis and periodontal disease include smoking, old age, and low intake of calcium and vitamin D [ 8 ].

Since both osteoporosis and periodontitis are highly prevalent and markedly associated with aging, studies have been performed to investigate the association between these diseases over the past decades [ 39 , 40 , 42 ]. Experimental results [ 43 ] suggest that despite those studies, no clear association between these diseases exist other than common risk factors.

Through recognizing common risk factors for both osteoporosis and periodontal disease and performing clinical and radiographic dental examinations dentists identify patients who are at risk of developing osteoporosis. The results of radiographic assessment of the alveolar trabecular pattern can be a clinical indicator of BMD [ 44 ].

Other studies suggest that routine panoramic radiographs also can be used to detect low BMD, osteoporosis and risk of experiencing vertebral fracture in postmenopausal women [ 45 — 48 ]. These studies also showed that providing special training to dental practitioners on specific evaluation techniques and reading panoramic radiographs enhanced their detection of osteoporosis related radiographic changes.

Briefly, the radiographic examination of the mandibular inferior cortex can reveal changes that vary from normal with the endosteal cortical margins being even and sharp bilaterally, to mild or moderate erosion of the inferior cortex, to severe erosion and presence of heavy endosteal cortical residues and porosity of the inferior mandibular cortex, unilaterally or bilaterally.

Panoramic X-rays are cheap and routinely performed in many patients, in contrast with DXA which may be too expensive to be widely implemented in population screening programs. Some authors concluded that panoramic X-rays can help detect a high percentage of postmenopausal women with undetected low BMD, as well as undetected spinal fractures which may then be referred for DXA [ 45 — 52 ]. The cost-effectiveness of the program has been documented [ 51 — 58 ].

Physicians and dentists have a shared interest to identify patients at risk of developing osteoporosis and periodontal disease. Collaboration between these professionals to early diagnose osteoporosis and osteopenia can lead to early osteoporosis therapy and prevention of fractures. Osteonecrosis of the jaws ONJ was initially described as an oral complication resulting from undergoing bisphosphonate therapy and is to date defined as the presence of necrotic bone anywhere in the oral cavity in a patient who is taking a bisphosphonate, who has not received radiation to the head and neck and in whom the necrotic area does not heal within eight weeks after diagnosis after receiving proper care [ 7 , 59 , 60 ].

Patients with ONJ were classified in three stages, while in a stage 0 was also proposed [ 61 ] and subsequently adopted Table 1 [ 59 , 62 ]. Most reported cases of ONJ have been associated with the intravenous administration of zoledronic acid or pamidronate in patients with cancer-related conditions, including bone metastases in the context of solid tumors such as breast cancer, prostate cancer, and lung cancer, and lytic lesions in the setting of multiple myeloma [ 62 — 64 ]. ONJ also has been diagnosed, although in a smaller number, in patients taking oral bisphosphonates such as alendronate, risedronate, ibandronate and clodronate for the prevention and treatment of osteoporosis [ 65 — 67 ].

Various aetiopathogenetic paradigms have been proposed. Table 2 briefly summarizes those most plausible. Predisposing factors that have been proposed to be associated with the development of ONJ in patients under BP treatment include dental extractions [ 68 — 70 ], use of dentures [ 68 , 69 ], presence of periodontal disease [ 69 , 71 ], smoking [ 68 , 69 , 72 ], diabetes mellitus [ 62 ], glucocorticoid use [ 62 ] and prolonged bisphosphonate therapy [ 69 , 73 ].

Thus, reports of ONJ have implications for the dental care of patients with osteoporosis [ 65 ]. It is important for dental practitioners to identify patients who are taking a bisphosphonate. Due to the fact that the majority of bisphosphonates are administred either weekly or monthly, patients frequently forget to disclose to dentists that they are taking the medication. Including specific questions about osteoporosis and bisphosphonate use in the dental history may facilitate the identification of those under BP treatment.

The ideal dental management protocol for patients taking oral bisphosphonates has been a matter of debate. Existing evidence; however, provides no scientific grounds to support the theory that discontinuation of bisphosphonate therapy will improve treatment outcomes [ 67 , 92 ]. Therefore, before discontinuing bisphosphonate therapy, dentists and physicians must collaborate to determine the best way to manage the treatment of each patient.

Several health indicators, including BMD, degree of risk of experiencing spine and hip fractures and duration of bisphosphonate therapy would need to be discussed in such a consultation. This consultation also would help health care practitioners make a decision about whether a drug holiday is acceptable for any individual [ 8 ].

The risk of fracture following treatment over a period of time and subsequent discontinuation of an oral bisphosphonate for patients with osteoporosis has not been well established. Investigators found that BMD was maintained and bone remodeling was suppressed with no detectable increase in fracture risk [ 93 ]. In the group of women who discontinued oral alendronate use after five years, the BMD and bone remodeling were maintained at higher levels than those obtained at baseline.

The BMD and bone marker changes suggested some residual effect from 5 years of alendronate treatment that is evident for at least 5 years after discontinuation [ 93 ]. The association of hip fracture with high mortality also is important, however the potential savings from hip fracture prophylaxis may be overestimated by studies that fail to consider differential risk, mortality, and long-term followup [ 94 ].

Managing the care of a patient who has ONJ and is taking a bisphosphonates is based mostly on expert opinion [ 95 ].

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Several strategies have been attempted, including sequestrectomy, surgical local debridement and periodontal flap surgery, as well as less invasive procedures like antibiotic therapy and mouthrinses [ 67 , 78 , 86 , 95 , 96 ]. Treatment outcomes vary from complete healing to partial healing to no healing. Both practitioners and dentists must keep in mind that the management of ONJ is difficult and no definite treatment exists to date.

The osteonecrotic process usually does not respond to routine therapy, and more aggressive surgical manipulation of the area is not recommended [ 97 ]. In those ONJ cases when there is clinical evidence of active infection, conservative approaches such as minor local debridement and systemic antibiotic therapy are indicated. When there is trauma to the soft tissues sharp bone edges should be eliminated.

Routine oral hygiene maintenance is indicated, and it can be complemented with topical chlorhexidine rinses [ 59 , 62 , 67 , 97 ]. Table 1 summarizes proposed interventions for patients receiving BPs but also for those who developed ONJ. When a patient taking oral bisphosphonate needs to undergo a surgical procedure, Marx et al. CTX is used to measure bone resorption and detect the fragments of collagen type I peptide released in the circulatory system when osteoclasts resorb bone.

The authors recommended that when the CTX level is higher than picograms per milliliter, the risk of developing ONJ following an invasive dental surgical procedure is diminished [ 98 ]. An expert panel recommended that using this test may not be an evidence-based approach as a control group was missing in the initial study [ 99 ]. Other authors also commented on the lack of quality evidence with regard to the predictive value of CTX [ ] while a study with limited followup concluded that serum CTX is not a valid preoperative test to accurately assess the level of risk of developing ONJ and is not indicated in the oral surgery patient [ ].

The reported incidence of ONJ in patients taking oral bisphosphonates is relatively low, which may be due to underreporting, different duration of therapy in countries that have adopted bisphosphonates more recently and different definitions of ONJ [ 65 , 66 ]. There are an estimated 0. However, some geographic variations in incidence are being reported such as in Australia, where the number of cases could be much higher [ ].

Others believe that the incidence of ONJ is low, considering the millions of patients with osteoporosis who are taking oral bisphosphonates [ 67 ]. The development of new bisphosphonates may enhance the safety of this medication. The trial demonstrated a significant reduction of the risk of vertebral, hip and other fractures. Only two cases of ONJ were detected; one in the treatment group, and one in the placebo group [ ]. It is not uncommon, however, that drug adverse events emerge only after the drug receives US Food and Drug Administration approval on a postmarket basis and is widely adopted in everyday clinical use [ 7 ].

Denosumab rapidly decreases bone turnover markers resulting in a significant increase in bone mineral density and reduction in fracture risk [ 26 , 27 , 88 ].

Faces of Osteoporosis

Amgen's denosumab was approved under the brand name Prolia for osteoporosis in mid [ ]. The safety and efficacy of Prolia in the treatment of postmenopausal osteoporosis was demonstrated in a three-year, randomized, double-blind, placebo-controlled trial of 7, postmenopausal women ages 60 to 91 years.

In the study, Prolia reduced the incidence of vertebral, nonvertebral, and hip fractures in postmenopausal women with osteoporosis [ ]. Of note, in the latter study previous bisphosphonate administration was a possible confounder; however, the issue has been addressed by the authors [ ]. Recently, denosumab was granted with FDA approval for the prevention of skeletal-related events in patients with bone metastases from solid tumors under the trade name Xgeva [ ]. While ONJ incidence with denosumab in clinical trials has been negligible in those patients with osteoporosis, in metastatic cancer patients ONJ has been recorded as an adverse effect [ 88 , ].

Importantly, it has been suggested that since denosumab exhibits the advantage of short clearance time when compared to bisphosphonates, more feasible treatment and earlier healing of denosumab-related ONJ when compared to bisphosphonate-related ONJ could be anticipated [ 88 ]. Unlike bisphosphonates, the current first-line agents for the prevention of fractures, which act primarily by inhibiting bone resorption, teriparatide increases bone density and strength primarily by stimulating osteoblastic bone formation.

Thus, teriparatide stimulates bone remodeling, whereas bisphosphonates decrease it [ ]. A recent study reported improved clinical outcomes, greater resolution of alveolar bone defects, and accelerated osseous wound healing in a yearly followup in the oral cavity of patients with chronic periodontitis who underwent periodontal surgery and received daily injections of teriparatide or placebo, along with oral calcium and vitamin D supplementation, for 6 weeks [ ].

Teriparatide may offer therapeutic potential for localized bone defects in the jaw. Furthermore, teriparatide has been reported to promote the spontaneous resolution of ONJ.

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Despite the fact that the only three cases have been published to date [ — ], given the FDA approval of teriparatide for osteoporosis and the limited existing evidence with regard to ONJ healing, it could be justified to prescribe teriparatide to patients with bisphosphonate-treated osteoporosis who already have ONJ. The facial skeleton is a region of particular interest in patients with osteoporosis. Firstly, inner ear pathophysiology and manifestations may be related to calcium metabolism.

Evidence suggests that sex hormones convey changes to the otoconia of the cochlea and the vestibule. Postmenopausal osteoporosis is known to be associated with sex hormone changes, and may be associated with benign paroxysmal positional vertigo. Practitioners should be aware of these symptoms and early refer their patients to ENT surgeons. Secondly, although the relation between osteoporosis and periodontal disease has not been quantified, maintenance of optimal oral hygiene would likely be beneficial for osteoporosis patients.

Furthermore, panoramic X-rays widely used in dentistry are of importance to early refer selected patients for DXA screening. Good knowledge of osteoporosis specific alterations in panoramic X-rays is a prerequisite and dentists should be keen on referring these patients. Thirdly, osteonecrosis of the jaws is one of the most discussed complications resulting from bone mass preservation treatment. Prevention and timely diagnosis of this complication requires awareness and collaboration from both physicians and dentists.

Similar to the paradigm of bisphosphonates and ONJ, the broad introduction of denosumab and teriparatide might bear skeletal-related complications but it might also introduce new therapeutic potentials. Please enter a valid email address Subscribe We respect your privacy. Who should be screened for it, and when?

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