|Year : 2016 | Volume
| Issue : 3 | Page : 62-66
Symphysis menti: A strong indicator of osteoporosis
Dur-e-Shahwar Rehman1, Naila Parveen2, Imran Ishaq3
1 Department of Basic Sciences, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
2 Department of Physiology, Liaquat National Hospital and Medical College, Karachi, Pakistan
3 Department of Anatomy, Jinnah Medical and Dental College, Karachi, Pakistan
|Date of Web Publication||21-Dec-2016|
Department of Basic Sciences, King Saud Bin Abdulaziz University for Health Sciences, Riyadh
Source of Support: None, Conflict of Interest: None
Context: Osteoporosis is a highly prevalent disease especially in elderly females. Orthopantomogram (OPG) X-ray is a commonly employed technique in dental clinics which shows bony details for both mandible and maxilla. It can be used as a window to the whole skeleton if the bone density changes on dual energy X-ray absorptiometry (DXA) scan correlates with the changes in the morphology of mandible. Aim: This study aims to establish a relation between changes in height of body of mandible at symphysis (HS) on OPG with DXA scan of the femoral neck and spine to see whether OPG can be employed for screening and early detection of osteoporosis. Settings and Design: Patients, attendants, volunteers visiting the Dow Radiology and Patel Hospital participated in this cross-sectional study. Materials and Methods: Female participants aged 25-85 years were selected randomly. DXA scan was performed to determine bone mineral density. OPG was performed to measure HS. Correlation between the two was studied in a sample of size of 174 females. Statistical Analysis: Statistical analysis was done by using the Statistical Package for the Social Sciences version 16. For intragroup comparisons, Kruskal-Wallis Test was applied in the groups where normality assumption was not fulfilled. One-way analysis of variance was applied to evaluate the significance between subgroups. For multiple comparisons in the subgroups of both groups, Tukey's B test was applied. Independent samples t-test was applied for intergroup comparison. Results: Highly significant decrease in height HS was observed in intergroup comparison of Group I (P < 0.001) and Group II (P < 0.001). In intergroup comparisons between subgroups of Groups I and II, significant decrease in HS was observed between osteopenic and osteoporotic subgroups (P = 0.038 and P = 0.001, respectively), and highly significant decrease between normal participants (P < 0.001). Conclusion: Because the decrease in HS is seen in younger and older groups of females at osteopenia stage, this variable can be conveniently used for early detection of osteoporosis for both age groups. The findings conclude that the OPG can be used as a screening tool for osteoporosis.
Keywords: Dual energy X-ray absorptiometry, orthopantomogram, osteopenia, osteoporosis, postmenopausal, premenopausal
|How to cite this article:|
Rehman De, Parveen N, Ishaq I. Symphysis menti: A strong indicator of osteoporosis. J Oral Maxillofac Radiol 2016;4:62-6
| Introduction|| |
Osteoporosis is a disease in which microarchitectural changes cause the bone to become fragile. The decrease in bone mineral density and bone strength  takes place because of imbalance in the activity of osteoclasts and osteoblasts.  The patients present with microfractures, complaints of nonspecific bone pain, and even deformity.  There can be musculoskeletal pain, numbness, and decrease in body height.  It is important to diagnose the condition early before the patient presents to the emergency with a fractured hip or spine. 
Osteoporosis is mostly postmenopausal which takes place as a result of lack of estrogen. , With increase in life expectancy, the number of cases of osteoporosis are also rising.  Not only females of old age but young Pakistani females also are at an increased risk of developing osteoporosis.  Increase in the number of reproductive years is protective against osteoporosis because of estrogen.  It is well known that estrogen is protective to the alveolar bone ridges.  Studies have been conducted on sham operated and ovariectomized monkeys, preparing postmenopausal models. Changes in the alveolar bone were found to be consistent with that of the lumbar spine. 
In addition to estrogen, a number of other factors affect the causation of osteoporosis. Increase in the number of members in a Pakistani family may increase the incidence of osteoporosis as it is expected to affect the quantity and quality of food they eat.  In this part of the world, homeopathic medicines are very commonly used. ,, These drugs are suggested to have steroids in and 80% of them have been proved to have steroids in some form or another.  Studies claim that doses greater then or equal to 5mg/day of prednisolone is associated with significant reduction in bone mineral density (BMD) and an increase in fracture risk within 3 to 6 months of treatment initiation.  It has been reported that among the population of Pakistan, 72% people are disinclined to exercise.  Not only in the present but childhood milk consumption is protective against osteoporosis.  A strong association is seen between deficiency of both calcium and estrogen in the causation of osteoporosis in sham and ovariectomized rats.  Low levels of activated form of vitamin D are normally seen in individuals with low bone mass.  Even infants have been found to be deficient.  Many studies have shown that low levels of vitamin D are found in Pakistani women. ,, In Karachi Pakistan, among hip fracture patients, only 8% have been shown to have osteomalacia. 
Osteoporosis shares equal concerns in both medical and dental communities.  If both of them work hand in hand, referring patients from dental clinics to orthopedic clinics, osteoporosis can be taken care of in the early stages. Different methods have been employed considering the significance of this matter. Bone densitometry has been tried, however, the anatomical shape and structure of mandible makes it difficult to perform. Patients do not maintain their position, and highly skilled radiographers are required. In a few patients, superimposition of the two sides of mandible was not found.  However, studies have been conducted on mandible in which orthopantomogram (OPG) X-ray was successfully used to study changes in cortical width, incisures depth, and angle of mandible. ,, OPG X-ray has been proven to be superior to plain X-ray of the skull as it provides ear-to-ear view of the mandible and positioning of the patient is easy to maintain.  Dual energy X-ray absorptiometry (DXA) scan remains the gold standard for diagnosing osteoporosis. , The accuracy of the DXA scan of spine ranges from 0.05 to 1%, whereas that of the femoral neck is 2-5%.
Our study aims to examine the changes in the morphology of mandible on OPG X-ray, and correlating and confirming these changes with the DXA scan of femoral neck and spine to devise a tool for screening and early detection of osteoporosis.
| Materials and Methods|| |
This being a cross-sectional involving human participants, ethical consideration was forwarded to the ethical committee of Dow University of Health Science (DUHS). No information was given to any unconcerned individual without taking permission from the concerned patient, and full confidentiality was ensured. Study tools used were a questionnaire, DXA scan, and OPG X-ray. Patients visiting Dow Radiology, their attendants, volunteers, patients from dental and orthopedic outpatient department (OPD), Ojha campus, and patients from dental OPD Patel Hospital participated in the study. The study stretched over a period of 8 months and was completed in July 2012.
Only females between the ages of 25 and 85 years were included in the study. Females with endocrine disorders, menorrhagia, oligomenorrhea, and polymenorrhea were not included. Pregnant and lactating females, people addicted to beetle nut and pan chewing, females on oral contraceptive pills (OCP), and hormone replacement therapy (HRT) were excluded from the study. Total number of participants included in the study was 174. The sample size was calculated by OPEN EPI (version 3.01) sample size calculator. Consecutive sampling technique was used.
Informative posters were pasted at different campuses in DUHS inviting females to participate. Having signed a consent form and information sheet proforma regarding participants's history was filled, on the basis of which they were divided into premenopausal (Group I) and postmenopausal (Group II) groups. Group I included 85 females whereas Group II included 89 females. Bone mineral density of the femoral neck and spine was studied on DXA scan which uses the T-score system. T-score is the comparison of bone mineral density of an individual to that of a young adult reference population. According to World Health Organization, T-score of −2.5 or below is defined as osteoporotic, T-score of −1.0 or greater is normal, and T-score between −1.0 and −2.5 is osteopenia. DXA scan was performed at Dow Radiology, and on the basis of the T-score, the females were subdivided into normal (pre A, post A), osteopenic (pre B, post B) and osteoporotic (pre C, post C) groups. Group pre A and pre B included 37 females each whereas pre C included 11 females. Group post A included 25, post B included 38, and post C included 26 females. OPG X-ray was conducted at Patel hospital.
Height of body of mandible at symphysis (HS) was worked out bilaterally on OPG X-rays at zoom factor ×0.84 by using the software K-Pacs-Lite (DICOM) by IMAGE Information System Ltd. Version 2007. The observations were made by the first author, supervisor, and co-supervisor under the guidance and counter-checking of the Head of the Radiology Department, Patel Hospital and Dow Radiology. The mean of the two measurements from both sides of the mandible was subjected to statistical analysis. Intraobserver and interobserver analysis gave a difference of 0.5 mm each time.
A line along the inferior border was drawn in the midline on an OPG X-ray. A perpendicular was drawn from this line to the alveolar border and HS was measured. 
Subgroups of Group I, i.e. pre A, pre B, and pre C, were compared among each other within the group. Comparisons of subgroups of Group II, i.e., post A, post B, and post C, were made within the same groups. Kruskal-Wallis Test was applied in the groups where normality assumption was not fulfilled. One-way analysis of variance (ANOVA) was applied to evaluate the significance between the subgroups of Group I (premenopausal) and Group II (postmenopausal). For multiple comparisons in the subgroups of both the groups, Tukey's B test was applied.
Subgroups of Group I, i.e., pre A, pre B, and pre C, were compared to the subgroups of Group II, i.e., post A, post B, and post C. Independent samples t-test was applied for intergroup comparison.
| Results|| |
The present study was designed to observe the radiological changes that take place in young and old individuals after dividing them into normal, osteopenic, and osteoporotic groups. Each variable was then studied in comparison with the subgroups of the same Group and with the subgroups of the other group. The results were expressed as mean ± standard deviation and P < 0.05 was considered statistically significant, with a 5% margin of error and 95% confidence interval (CI). The findings are as discussed below.
Highly significant decrease in the HS was observed between prenormal (Pre A) vs. Preosteopenic (Pre B) as shown in [Radiograph 1 [Additional file 1]] and [Radiograph 2 [Additional file 2]] and preosteopenic (Pre B) vs. preosteoporotic (Pre C) groups. When the means of two were compared, P value was <0.001, as shown in [Figure 1].
Highly significant decrease in the HS was observed between postnormal (Post A) vs. postosteoporotic (Post C) and postosteopenic (Post B) vs. postosteoporotic (Post C) groups. When the means of two were compared, the P value was <0.001, as shown in [Figure 1].
HS was compared among subgroups of Group I and Group II.
When the means of prenormal (Pre A) and postnormal (Post A) groups were compared, the P value was <0.001, as shown in [Figure 1]. A highly significant decrease in the HS was observed.
When the means of preosteopenic (Pre B) and postosteopenic (Post B) groups were compared, the P value was 0.038, as shown in [Figure 1]. A significant decrease in the HS was observed.
When the means of preosteoporotic (Pre C) and postosteoporotic (Post C) groups were compared the P value was 0.001, as shown in [Figure 1]. A significant decrease in the HS was observed.
| Discussion|| |
This study aimed at observing the changes in mandible where comparison is done among young and old females excluding the age changes that occur along with decreasing bone mass. Changes observed can help the orthopedic community in the early detection of osteoporosis as the study shows changes at stage of osteopenia. Our study tends to change the mindset because OPG X-ray not only shows the toothset but the mandible and maxilla as well. OPG X-ray is far more economical then DXA scan and can be used by the orthopedicians along with the dental community. The current study instead of using radiological indices closely examines the the mandibular changes in a simple manner in terms of changes in morphology that can be easily accessed on an OPG X-ray.
Reduction of HS is highly significant between prenormal (Pre A) vs. preosteopenic (Pre B) and preosteopenic (Pre B) vs. preosteoporotic (Pre C) in Group I. This makes it to be an indicator of osteoporosis at the stage of osteopenia in young age group. A highly significant change was observed in HS in Group II between postnormal (Post A) vs. postosteopenic (Post B) and postosteopenic (Post B) vs. postosteoporotic (Post C). This again suggests that osteoporosis can be detected at an earlier stage of osteopenia in older female population. It came out to be highly significant in prenormal (Pre A) vs. postnormal (Post A), and significant in preosteopenic (Post B) vs. postosteopenic (Post B) and preosteoporotic (Post C) vs. postosteoporotic (Post C) groups of Group I vs. Group II. High significance between prenormal (Pre A) vs. postnormal (Post A) excludes age changes; whereas significance between preosteopenic (Pre B) vs. postosteopenic (Post B) and preosteoporotic (Pre C) vs postosteoporotic (Post C) groups suggests that in postmenopausal age group the changes of low bone density overwhelm changes in premenopausal age group. Similar results were found by Merrot et al.  in 2005 while working with old females with and without teeth. This makes it to be an indicator of age as well as of changing bone mass by our study results.
Eight separate parameters were studied in this project in relation to the T-score. Six out of eight parameters were noted to be significant. This article only depicts one i.e., height at symphysis (HS). The study hypothesized that the changes in mandibular morphology on OPG correlated with BMD of femoral neck and spine on DXA scan in normal and osteoporotic females. The outcome measures of the study were in accordance with the hypothesis.
As the prevalence of osteoporosis is more in females compared to males, the phenomenon of changes in osteoporosis was not studied in the male population. Reduction in the number and height of alveolar ridges and trabecular bone separation could not be studied because of limited resources and financial constraints. The hormonal levels were not measured and all participants were assumed to have normal estrogen levels. Prevalence of osteoporosis could have been studied if a bigger sample size was considered. Collectively, factor analysis for all parameters of mandible was not conducted as a part of this study. This is the reason why an aggregate correlation could not be established.
The study still succeeds to show findings with respect to age in addition to low bone mass which could be looked forward by orthopedic community.
Though the findings of the study are strikingly positive, clinical implementation of this facility is still a question; further studies in this regard could help find a solution. The facts regarding maxilla, alveolar ridges, trabecular separation, cortical shape, and relative bone density in relation to age and osteoporosis were overlooked in this study because of certain limitations. Further investigations are needed to examine these facts. In addition, acceptance from dental community that the OPG X-ray is not just their domain, it is a full-fledged radiological technique that could help not only dental but orthopedic patients can help the situation.
| Conclusion|| |
Early detection of osteoporosis for both premenopausal and postmenopausal groups can be done from the decrease in HS, as this variable shows marked changes at stage of osteopenia. In addition to this, as significant decrease is seen between normal females of both young and old groups, this variable is a marker to exclude age changes. Therefore, OPG X-ray, a cost-effective technique, can be used as a screening tool for osteoporosis.
Financial support and sponsorship
Dow University of Health Sciences; Patel Hospital.
Conflicts of interest
There are no conflicts of interest.
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