The relationship between panoramic radiomorphometric indices and the femoral bone mineral density of edentulous patients

Radiomorphometric indices of the mandible as indicators of decreased bone mineral density and osteoporosis - meta-analysis and systematic review

This review aims to evaluate the accuracy of various mandibular radiomorphometric indices in comparison with DEXA BMD measurements in the diagnosis of osteopenia and osteoporosis based on a meta-analysis of the sensitivity and specificity of the indices. PRISMA statement was followed. The materials for analysis were collected in August 2023 by searching three databases: PubMed Central, Web of Science, and Scopus. The selection of studies consisted of three selection stages, and 64 articles were finally obtained. Quality assessment was performed with the QUADAS-2 tool, and the general methodological quality of retrieved studies was low. Statistical analysis was performed based on 2 × 2 tables and estimated sensitivity and specificity were obtained using SROC curves. The most used indices were MCI, MCW and PMI. The best results in detecting reduced BMD obtained for MCW ≤ 3 mm, estimated sensitivity and specificity were 0.712 (95% CI, 0.477-0.870) and 0.804 (95% CI, 0.589-0.921), respectively. The most prone to the risk of bias is the MCI due to the examiner's subjectivism. Radiomorphometric indices of the mandible can be useful as a screening tool to identify patients with low BMD, but should not be used as a diagnostic method. Further research needs to focus on analysing the ability of the indices to detect osteoporosis and also in combination the indices with clinical parameters.

Changes in mandibular radiomorphometric indices in osteoporosis patients treated with denosumab: a retrospective case-control study

BACKGROUND

Radiomorphometric indices measured on Dental Panoramic Radiography (DPR) can reflect Bone Mineral Density (BMD). The aim of our study is to evaluate changes in DPR radiographic markers in patients undergoing antiresorptive therapy with denosumab and correlate them to BMD and serum bone turnover markers (BTM).

METHODS

We evaluated two radiomorphometric indices: Mandibular Cortical Width (MCW) and Panoramic Mandibular Index (PMI), in patients undergoing antiresorptive therapy with denosumab at T0 (before starting the therapy) and at T1 (after 12 months), comparing results with a control group of healthy patients who performed two DPRs at a one-year time distance. Correlation analysis was performed in the denosumab group, as well as ROC curves were obtained for both indices.

RESULTS

The study included 18 patients and 21 controls according to specific inclusion and exclusion criteria, matched by gender and age. Both MCW and PMI were significantly lower at T0 in the denosumab group, consistently with lower BMD. MCW showed significant correlation with femoral and lumbar DEXA and was significantly lower in patients with osteoporosis compared to osteopenia. Only PMI index increased significantly in the denosumab group from T0 to T1. After one year (T1), there weren't any differences between patients and controls for both indices. No significant correlations were found with BTMs. Sensitivity and specificity for MCW and PMI were also calculated.

CONCLUSIONS

Our results show how CMW shows sufficient sensitivity and specificity to be used as a radiographic marker to screen and intercept patients with osteoporosis. PMI seems to be able to reflect changes in response to antiresorptive therapy with denosumab. Further studies are needed to confirm our hypothesis.

Comparison of mandibular index values determined from standard panoramic versus cone beam computed tomography reconstructed images

OBJECTIVE

The aim of this study was to compare mandibular index values, including the mandibular cortical index (MCI), mental index (MI), and panoramic mandibular index (PMI), determined on the basis of cone beam computed tomography (CBCT) and panoramic reconstructed (PR) images.

STUDY DESIGN

PR and CBCT images of 182 patients were retrospectively analyzed. Cross-sectional (CS) and PR images were obtained from CBCT data. The MCI, MI, and PMI were assessed on CS, PR, and panoramic images and evaluated for intra- and interobserver agreements by κ-value or intraclass correlation coefficient (ICC) analysis. Agreement among measurement methods was assessed by using the Bland-Altman method, with CS images as the gold standard for linear measurements.

RESULTS

Measurements from PR and CS images agreed with those from panoramic images in 66.7% and 53.8% of C3 classifications of MCI (porous cortices forming many endosteal residues), respectively. Panoramic and CBCT images exhibited good agreement in MI findings (ICC 0.91) and moderate (PR and panoramic images: ICC 0.79) to good (CS and panoramic images: ICC 0.87) agreement in PMI findings.

CONCLUSIONS

Because of the overlapping of buccal and lingual cortices, panoramic images are especially inadequate for determining the C3 category of MCI. However, CS images obtained from available CBCT data provide better visibility compared with panoramic images and, therefore, can be used for evaluating mandibular indices.

Evaluation of renal osteodystrophy in the dental clinic by assessment of mandibular and phalangeal cortical indices

OBJECTIVES

Secondary hyperparathyroidism (SHPT) is a disease that affects patients with chronic kidney disease, and is characterized by mineral disturbance and bone loss, known as renal osteodystrophy. The aim of this study was to assess the validity of using intraoral phosphor storage plates to take radiographs of the middle phalanges to evaluate bone loss resulting from SHPT during follow-up of these patients.

METHODS

The sample consisted of 24 patients with chronic kidney disease, 12 with parathyroid hormone (PTH) levels ≥500 pg/ml, and 12 with PTH levels <500 pg/ml, who underwent hemodialysis weekly. For each patient, a panoramic radiograph and digital radiographs of the ring, index, and middle fingers of both hands were taken. The Mandibular Cortical Index (MCI) and the Trabecular Bone Pattern Index (TBP) were applied to the panoramic radiographs, while the Phalangeal Cortical Index (PCI) was applied to the digital radiographs of the phalanges. Three evaluators performed all analyses.

RESULTS

Significant correlations were found between the PTH levels and the MCI (p = 0.023), the PCI (p = 0.039) and the TBP index (p = 0.032). These parameters were also significantly interrelated (MCI × PCI = 0.001; MCI × TBP = 0.004 and PCI × TBP = 0.009). The PCI was shown to have the highest correlation with PTH levels.

CONCLUSION

In patients with chronic renal disease, it is clinically relevant to use panoramic and digital radiographs using intraoral storage plates to assess a number of quantitative parameters that can be linked to PTH levels.

Analysis of mandibular changes using panoramic-based indices in patients with chronic renal failure

INTRODUCTION

Chronic renal failure (CRF) is a progressive disease affecting many systems and causing dental and periodontal problems, in particular a decrease or loss in the amount of cortical bone that is visible on radiographs. Panoramic radiography is useful for determining these changes. The aim of this study was to evaluate cortical parts of the mandible using panoramic-based indices in patients with CRF.

METHODS

70 subjects with CRF were included in the study. The measurements of panoramic indices were made according to the visibility (mandibular cortical index, MCI) and thickness (mental index, MI) of the inferior cortex of the mandible. Then, these indices, obtained from 70 healthy controls of the same age and gender, were assessed and the results were compared. The effects of dental status and hemodialysis duration on MCI and MI were also investigated.

RESULTS

The frequency of an eroded cortex was significantly elevated in patients with CRF (p<0.05). The mean MI was lower in patients with CRF than in healthy subjects (5.53 ± 1.62 and 5.73 ± 1.31 mm, respectively), but the difference was not statistically significant (p>0.05). No correlation was found between hemodialysis duration and mandibular indices (p>0.05). Dental status was not associated with mandibular indices (p>0.05).

CONCLUSIONS

These results suggest that MCI might be a useful radiographic parameter for evaluating changes occurring in the cortical parts of the mandible in CRF patients. Clinicians should be aware of these changes while planning invasive dental treatments in CRF patients.

Feasibility of cone beam computed tomography radiomorphometric analysis and fractal dimension in assessment of postmenopausal osteoporosis in correlation with dual X-ray absorptiometry

OBJECTIVES

The aim of the present study was to assess the feasibility of using mandibular CBCT radiomorphometric indices and box-counting fractal dimension (FD) to detect osteoporosis in post-menopausal females, compare them with the healthy control group and to correlate the findings with the bone mineral density measured by dual X-ray absorptiometry (DXA).

METHODS

This study consisted of 50 post-menopausal females, with age ranging from 55 to 70 years. Based on their DXA results, they were classified into osteoporotic and control groups. Mandibular CBCT radiomorphomertic indices and FD analysis were measured.

RESULTS

Significant differences were found for the CT cortical index scores (CTCI), CT mental index (CTMI) and CT mandibular index (CTI) between the control and osteoporotic groups. The control group showed higher mean values than the osteoporotic group. For FD values, no significant differences were found between the two groups.

CONCLUSIONS

CBCT radiomorphometric indices could be used as an adjuvant tool to refer patients at risk of osteoporosis for further assessment.

Panoramic measures for oral bone mass in detecting osteoporosis: a systematic review and meta-analysis

Different quantitative and qualitative indices calculated on oral panoramic radiographs have been proposed as useful tools to screen for reduced skeletal bone mineral density (BMD). Our aim was to systematically review the literature on linear and qualitative panoramic measures and to assess the accuracy of these indices by performing a meta-analysis of their sensitivity and specificity. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement was followed. Fifty studies were included in the qualitative appraisal and 19 were considered for meta-analysis. The methodological quality of the retrieved studies, assessed with the QUADAS-2 tool, was on average low. Three indices were reported by most of the studies: mandibular cortical width, panoramic mandibular index, and the Klemetti index. Mandibular cortical width presented with a better accuracy in excluding osteopenia/osteoporosis (specificity), since patients with a cortical width more than 4 mm had a normal BMD in 90% of the cases. Almost all studies used a cutoff of 0.3 for the panoramic mandibular index, resulting in an estimated sensitivity and specificity in detecting reduced BMD, respectively, of 0.723 (SE 0.160; 95% confidence interval [CI], 0.352-0.926) and 0.733 (SE 0.066; 95% CI, 0.587-0.841). The presence of any kind of mandibular cortical erosion gave an estimated sensitivity and specificity in detecting reduced BMD, respectively, of 0.789 (SE 0.031; 95% CI, 0.721-0.843) and 0.562 (SE 0.047; 95% CI, 0.47-0.651) and a sensitivity and specificity in detecting osteoporosis, respectively, of 0.806 (SE 0.105; 95% CI, 0.528-0.9200) and 0.643 (SE 0.109; 95% CI, 0.417-0.820). The mandibular cortical width, panoramic mandibular index, and Klemetti index are overall useful tools that potentially could be used by dentists to screen for low BMD. Their limitations are mainly related to the experience/agreement between different operators and the different image quality and magnification of the panoramic radiographs.

Can mandibular bone resorption predict hip fracture in elderly women? A systematic review of diagnostic test accuracy

OBJECTIVES

The aim of this systematic review was to determine the diagnostic accuracy of the mandibular cortical width measurements and porosity in detecting hip osteoporosis.

BACKGROUND

All of the included studies used measurements on panoramic radiographs.

MATERIALS AND METHODS

Studies were included if they compared the radiographic measurements (or index tests) with central dual energy X-ray absorptiometry (DXA) of the hip as the reference standard. A measure of diagnostic accuracy such as sensitivity and specificity or area under the receiver operating characteristic curve was also required for inclusion.

RESULTS

Seven studies were identified. Meta-analysis was not possible because of the heterogeneity of the studies. The studies all demonstrated moderate diagnostic accuracy.

CONCLUSION

If a patient with a thin or porous mandibular cortex is identified by a chance radiographic finding, additional clinical risk factors need to be considered and the patient referred for further investigation with DXA where necessary.

Severe secondary hyperparathyroidism and panoramic radiography parameters

OBJECTIVES

Renal osteodystrophy (RO) are skeletal abnormalities seen in patients with secondary hyperparathyroidism (SHPT). This study aims to evaluate the effects of RO using panoramic radiography parameters. Furthermore, the correlation between these parameters and parathyroid hormone (PTH) levels was tested.

MATERIALS AND METHODS

Qualitative (mandibular cortical index/trabecular bone pattern) and quantitative parameters (mental index/calcification and resorption foci) were applied from panoramic radiographs of chronic kidney disease (CKD) patients and controls. Frequency distribution and descriptive analysis were used to compare the results of both groups. Spearman's correlation coefficient evaluated the correlation between serum PTH levels of CKD patients and the radiographic parameters. Intra- and interobserver agreement was tested using the intraclass correlation coefficient and kappa index.

RESULTS

Intra- and interobserver agreement was respectively excellent (0.81-1.00) and good (0.61-0.80). Qualitative parameters demonstrate significant difference compared with the control group. Mean mental index was lower in patients with CKD (3.17 ± 1.35 mm), but the difference was not significant. Calcification/resorption foci (3.63 ± 2.07) of CKD patients were significantly more present than in the control group (p = 0.0001). PTH levels were correlated with mental index, mandibular cortical index and trabecular bone pattern (respectively, 0.0034, 0.0315, and 0.0370).

CONCLUSIONS

RO presented a number of characteristic bone metabolic effects in the jaws that could be observed on panoramic radiographs. Radiographs of CKD patients demonstrate significantly more calcification and resorption.

CLINICAL RELEVANCE

The mental index, mandibular cortical index, and trabecular bone pattern are good parameters for evaluating the effects of RO on severe secondary hyperparathyroidism.

Correlation between hand/wrist and panoramic radiographs in severe secondary hyperparathyroidism

OBJECTIVES

Hand/wrist and dental radiographs are important for osteoporosis analysis in secondary hyperparathyroidism (SHPT). This study evaluated whether a correlation exists between the effects of the disease on the hands and jaws, and investigated the association between osteoporosis progression in the hands and parathyroid hormone (PTH) levels in chronic kidney disease (CKD) patients.

MATERIALS AND METHODS

Four panoramic radiographic parameters (mental index, mandibular cortical index, trabecular bone pattern, and calcification/resorption) and four corresponding hand/wrist radiographic parameters (metacarpal cortical thickness, phalangeal cortical index, trabecular bone pattern, and calcification/resorption) were applied to investigate possible correlation between the effects of SHPT on the jaws and hands/wrists, by Spearman's correlation coefficient. PTH levels and the hand/wrist radiographic parameters were also tested by spearman's correlation coefficient (p < 0.05). The presence of brown tumors, vascular calcifications, and acroosteolysis on the hands was also evaluated.

RESULTS

Mandibular cortical index was strongly correlated with the phalangeal cortical index (p = 0.000). Phalangeal cortical index and trabecular bone pattern of hand/wrist correlated with PTH levels (0.002 and 0.000, respectively). Brown tumors occurred in four CKD patients, while both vascular calcifications and acroosteolysis were observed in 19 patients.

CONCLUSION

There is a significant correlation between the morphological changes caused by secondary hyperparathyroidism in hand and jaw bones. The morphological status can be assessed using the mandibular cortical index, besides the phalangeal cortical index. The latter correlates well with parathyroid hormone levels of advanced chronic kidney disease.

CLINICAL RELEVANCE

Panoramic images reveal morphological changes in the jaw bone, indicating likewise changes in the hand/wrist in severe secondary hyperparathyroidism. The severity of the bone changes may be a reflection of the parathyroid hormone levels in advanced chronic kidney disease.