Bone loss and oral state in patients on home parenteral nutrition

Osteoporosis, jawbones and periodontal disease

The association between osteoporosis and jawbones remains an argument of debate. Both osteoporosis and periodontal diseases are bone resorptive diseases; it has been hypothesized that osteoporosis could be a risk factor for the progression of periodontal disease and vice versa. Hypothetical models linking the two conditions exist: in particular, it is supposed that the osteoporosis-related bone mass density reduction may accelerate alveolar bone resorption caused by periodontitis, resulting in a facilitated periodontal bacteria invasion. Invading bacteria, in turn, may alter the normal homeostasis of bone tissue, increasing osteoclastic activity and reducing local and systemic bone density by both direct effects (release of toxins) and/or indirect mechanisms (release of inflammatory mediators). Current evidence provides conflicting results due to potential biases related to study design, samples size and endpoints. The aim of this article is to review and summarize the published literature on the associations between osteoporosis and different oral conditions such as bone loss in the jaws, periodontal diseases, and tooth loss. Further well-controlled studies are needed to better elucidate the inter-relationship between systemic and oral bone loss and to clarify whether dentists could usefully provide early warning for osteoporosis risk.

[Clinical practice guidelines for evaluation and treatment of osteoporosis associated to endocrine and nutritional conditions. Bone Metabolism Working Group of the Spanish Society of Endocrinology]

OBJECTIVE

To provide practical recommendations for evaluation and treatment of osteoporosis associated to endocrine diseases and nutritional conditions.

PARTICIPANTS

Members of the Bone Metabolism Working Group of the Spanish Society of Endocrinology, a methodologist, and a documentalist.

METHODS

Recommendations were formulated according to the GRADE system (Grading of Recommendations, Assessment, Development, and Evaluation) to describe both the strength of recommendations and the quality of evidence. A systematic search was made in MEDLINE (Pubmed), using the following terms associated to the name of each condition: AND "osteoporosis", "fractures", "bone mineral density", and "treatment". Papers in English with publication date before 18 October 2011 were included. Current evidence for each disease was reviewed by two group members, and doubts related to the review process or development of recommendations were resolved by the methodologist. Finally, recommendations were discussed in a meeting of the Working Group.

CONCLUSIONS

The document provides evidence-based practical recommendations for evaluation and management of endocrine and nutritional diseases associated to low bone mass or an increased risk of fracture. For each disease, the associated risk of low bone mass and fragility fractures is given, recommendations for bone mass assessment are provided, and treatment options that have shown to be effective for increasing bone mass and/or to decreasing fragility fractures are listed.

Aluminum contamination of parenteral nutrition and aluminum loading in children on long-term parenteral nutrition

BACKGROUND

Children who are receiving parenteral nutrition are at risk of aluminum overload, which may contribute to such side effects as osteopenic bone disease. The aim of the present study is to determine the aluminum contamination of parenteral nutrition solutions and their components, and to assess the aluminum status of children on long-term parenteral nutrition.

METHODS

Aluminum concentrations were determined by graphite furnace absorption spectroscopy in components and in final parenteral nutrition solutions. The urinary aluminum excretion and plasma aluminum concentration were determined in 10 children on long-term parenteral nutrition.

RESULTS

The mean aluminum concentration in the administered parenteral nutrition solutions was 1.6 +/- 0.9 micromol x l(-1)(mean +/- standard deviation (SD)). The resulting mean aluminum daily intake of the 10 patients was 0.08 +/- 0.03 micromol x kg(-1) x day(-1).

CONCLUSIONS

Compared to two previous studies performed in 1990 and in 1995 in our hospital, the aluminum contamination of parenteral nutrition solutions and the daily aluminum intake of the children seemed to decrease. However, the plasma aluminum concentration and daily urinary aluminum excretion of the children still remain above normal standards. The children had no clinical symptoms of bone disease but aluminum accumulation in tissue can not be excluded. To prevent this iatrogenic toxicity, the aluminum contamination of parenteral nutrition should be assessed regularly.

Trabecular alveolar bone in the human mandible: a dual-energy x-ray absorptiometry study

OBJECTIVE

The purpose of this study was to evaluate the potential use of dual energy x-ray absorptiometry for the assessment of bone mineral content and bone mineral density before implant placement.

MATERIALS AND METHODS

The material examined consisted of 63 mandibular bone specimens cut from 21 fresh cadavers (11 men; 10 women). Three specimens were cut per cadaver in the incisal, premolar, and molar regions. Three regions of interest (G, R1, and R2) were delineated. The global bone specimen (G) consisted of the whole specimen (ie, both cortical and trabecular bone). R1 and R2 were delineated in the trabecular bone of the alveolar process.

RESULTS

In all subjects, the combined bone mineral content of the whole mandible specimens (global bone mineral content) was significantly correlated with age. The difference between the mean bone mineral densities of the male and female mandibles was found to be significant for G (P = .009). The mean bone mineral densities of dentate and edentulous specimens were also found to be significantly different for G and R1, respectively (P = .001 and P = .02), but not for R2. A positive correlation could be detected among the mean bone mineral density of G and R1, G and R2, and R1 and R2 of (1) male and female specimens, (2) dentate and edentulous specimens, and (3) incisal, premolar, and molar specimens.

CONCLUSIONS

The intra-alveolar trabecular bone of these 21 mandibles is affected by the same local and systemic influences as cortical bone, whereas the infra-alveolar trabecular bone is mostly sensitive to dental status. The cortical and trabecular bone of the 10 mandibles from women is more sensitive to systemic influences, whereas that from men is more sensitive to local influences. This is somewhat in agreement with some studies that found an association between osteoporosis and oral bone loss, which is a metric measure.

Periodontal diseases and osteoporosis: association and mechanisms

There is increasing evidence that osteoporosis, and the underlying loss of bone mass characteristic of this disease, is associated with periodontal disease and tooth loss. Periodontitis has long been defined as an infection-mediated destruction of the alveolar bone and soft tissue attachment to the tooth, responsible for most tooth loss in adult populations. Current evidence including several prospective studies supports an association of osteoporosis with the onset and progression of periodontal disease in humans. The majority of studies have shown low bone mass to be independently associated with loss of alveolar crestal height and tooth loss. However studies that focus on the relation of clinical attachment loss and osteoporosis are less consistent. To date, the majority of studies on the relationship between periodontal disease and osteoporosis have been hindered by small sample sizes, limited control of other potential confounding factors, varying definitions of both periodontal disease and osteoporosis, and few prospective studies where the temporality of the association can be established. Potential mechanisms by which host factors may influence onset and progression of periodontal disease directly or indirectly include underlying low bone density in the oral cavity, bone loss as an inflammatory response to infection, genetic susceptibility, and shared exposure to risk factors. Systemic loss of bone density in osteoporosis, including that of the oral cavity, may provide a host system that is increasingly susceptible to infectious destruction of periodontal tissue. Studies have provided evidence that hormones, heredity, and other host factors influence periodontal disease incidence and severity. Both periodontal disease and osteoporosis are serious public-health concerns in the United States. Prevalence of both osteoporosis and tooth loss increase with advancing age in both women and men. Understanding the association between these common diseases and the mechanisms underlying those associations will aid health professionals to provide improved means to prevent, diagnose, and treat these very common diseases. This paper reviews the current evidence on the association between periodontal disease and osteoporosis.

Post-extraction remodeling of the adult mandible

Following tooth loss, the mandible shows an extensive loss of bone in some individuals. This may pose a significant problem in the prosthodontic restoration of function and esthetics. The many factors which have been proposed as being responsible for the inter-individual variation in post-extraction remodeling mean that a perfunctory analysis of the literature, in which well-controlled, relevant studies are scarce, may not provide the whole story. This article reviews the local and systemic factors which may play a role in the post-extraction remodeling of the mandible. Since severe residual ridge resorption may occur even when the bone status in the rest of the skeleton is good and vice versa, it is concluded that local functional factors are of paramount significance. It is now essential to determine how they can be modified and applied to help maintain ridge height and quality in our aging, edentulous population.

Clinical Management of the Adult Home Nutrition Support Patient

Nutrition Support Consultant features issues pertinent to the clinical aspects of pharmacy nutritional support practice. The column is edited by Roland N. Dickerson, PharmD, BCNSP, CNS, FACN, Associate Professor of Clinical Pharmacy, University of Tennessee, Memphis.

Home enteral and parenteral nutrition in children

The prevalence of home enteral and parenteral nutrition programmes is rising rapidly all over the world, in children as in adults. Home artificial nutrition, especially parenteral nutrition, is an expensive technology but is life-saving for many patients. The only possible alternative to home treatment is keeping patients in hospital, and cost-benefit studies have demonstrated that home nutrition is about 70% more cost-effective than hospital-based therapy. Although home nutrition is usually considered by children and families to lead to an improvement in their quality of life, the complications of these techniques, including psychological consequences, have to be carefully assessed and prevented.

Home parenteral nutrition. 25 years later

After 25 years, there is enough clinical outcome experience to determine appropriate use of home parenteral nutrition in different disease states and age groups. Information regarding how to avoid complications and how patients and families can find necessary psychosocial support is provided in this article. Currently, small bowel transplantation is not a safer choice, unless there is severe liver disease caused by home parenteral nutrition or lack of central intervenous access.

Osteoporosis and oral bone loss

This paper is a review of the literature on the possible association between osteoporosis and oral bone loss, with an emphasis on radiological studies. Such an association was first suggested in 1960. Subsequent histomorphometric and microradiographic studies showed that after the age of 50 there was a marked increase in the cortical porosity of the mandible, with this increase being greater in the alveolar bone than the mandibular body; and that with this increase in porosity, there was a concomitant decrease in bone mass, which appeared to be more pronounced in females than in males, with the loss in bone mineral content estimated to be 1.5% per year in females and 0.9% in males. These studies also demonstrated a considerable amount of variation in the amounts of cortical and trabecular bone within and among individuals. Subsequent clinical studies reported associations between the bone densities of jaws and (1) metacarpals, (2) forearm bones, (3) vertebrae and (4) femurs. These studies indicated that women had lower mandibular bone mineral content (BMC) than men and that age-related loss of bone was more pronounced in women after the age of 50 years than in men of the same age, as was the case for the rest of the body. It was suggested that systemic factors responsible for osteoporotic bone loss may combine with local factors (periodontal diseases) to increase rates of periodontal alveolar bone loss. Although not all studies found associations between osteoporosis and oral bone loss, the conclusion of this review is that such an association exists; yet additional longitudinal investigations are needed to confirm this, and before the implications of this association could be fully utilized in clinical dentistry, inexpensive methods must be developed for sensitive and specific measures of oral bone loss.