Observer performance in diagnosing osteoporosis by dental panoramic radiographs: results from the osteoporosis screening project in dentistry (OSPD).

Mandibular cortical erosion detected on dental panoramic radiographs (DPRs) may be useful for identifying women with osteoporosis, but little is known about the variation in diagnostic efficacy of observers worldwide. The purpose of this study was to measure the accuracy in identifying women at risk for osteoporosis in a worldwide group of observers using DPRs. We constructed a website that included background information about osteoporosis screening and instructions regarding the interpretation of mandibular cortical erosion. DPRs of 100 Japanese postmenopausal women aged 50 years or older who had completed skeletal bone mineral measurements by dual energy X-ray absorptiometry were digitized at 300 dpi. These were displayed on the website and used for the evaluation of diagnostic efficacy. Sixty observers aged 25 to 66 years recruited from 16 countries participated in this study. These observers classified cortical erosion into one of three groups (none, mild to moderate, and severe) on the website via the Internet, twice with an approximately 2-week interval. The diagnostic efficacy of the Osteoporosis Self-Assessment Tool (OST), a simple clinical decision rule based on age and weight, was also calculated and compared with that of cortical erosion. The overall mean sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the 60 observers in identifying women with osteoporosis by cortical erosion on DPRs were 82.5, 46.2, 46.7, and 84.0%, respectively. Those same values by the OST index were 82.9, 43.1, 43.9, and 82.4%, respectively. The intra-observer agreement in classifying cortical erosion on DPRs was sufficient (weighted kappa values>0.6) in 36 (60%) observers. This was significantly increased in observers who specialized in oral radiology (P<0.05). In the 36 observers with sufficient intra-observer agreement, the overall mean sensitivity, specificity, PPV, and NPV in identifying women with osteoporosis by any cortical erosion were 83.5, 48.7, 48.3, and 85.7%, respectively. The mean PPV and NPV were significantly higher in the 36 observers with sufficient intra-observer agreement than in the 24 observers with insufficient intra-observer agreement. Our results reconfirm the efficacy of cortical erosion findings in identifying postmenopausal women at risk for osteoporosis, among observers with sufficient intra-observer agreement. Information gathered from radiographic examination is at least as useful as that gathered from the OST index.

Detection of vascular disease risk in women by panoramic radiography.

Low bone mineral density and rapid bone loss of the skeleton are associated with mortality risk from vascular diseases in post-menopausal women. Panoramic radiographic measurements are considered as indicators of skeletal bone mineral density or bone turnover. We hypothesize that such measurements may be associated with vascular disease risk in post-menopausal women. Associations of mandibular cortical shape and width on panoramic radiographs with skeletal bone mineral density and risk factors related to vascular diseases were investigated in 87 post-menopausal women. Cortical shape was associated with skeletal bone mineral density, low-density lipoprotein cholesterol, apolipoprotein B, resting heart rate, and endothelial dysfunction. Cortical width was associated with skeletal bone mineral density, low-density lipoprotein cholesterol, and apolipoprotein A1. Dentists may be able to refer women with increased risk of vascular diseases, as well as low bone mineral density, to medical professionals for further examination by panoramic findings.

Recommendation of modified classification for odontogenic carcinomas.

Primary squamous cell carcinoma (SCC) derived from odontogenic epithelium is diagnosed as primary intraosseous carcinoma (PIOC). The term "intraosseous" means the bone marrow spaces. Odontogenic cells, however, exist not only in the bone marrow space but also in the periodontal space and the subepithelial soft tissue space. In our survey for 36 SCC lesions of odontogenic origin, many lesions involved two or all of the three spaces. There was only one lesion which involved the bone marrow space alone. In some cases, the extent of the early lesions was restricted around the tooth or at a part of the alveolar crest. The possibility of a SCC of odontogenic origin arising in the periodontal and the subepithelial soft tissue spaces was suggested. We proposed the term "Odontogenic SCC" to replace "PIOC".

Radiographic evaluation of possible etiology of diffuse sclerosing osteomyelitis of the mandible.

To examine the cause and site of origin of diffuse sclerosing osteomyelitis of the mandible, we compared various radiographic findings for the mandibular lesions in 20 patients with diffuse sclerosing osteomyelitis with those in 48 patients with osteomyelitis caused by bacterial infection. In osteomyelitis of infectious origin, a typical radiographic feature was a radiolucent lesion spreading in the cancellous bone, with cortical bone perforation and lamellated periosteal reaction. In diffuse sclerosing osteomyelitis, intermingled sclerotic and osteolytic lesions with solid periosteal reaction or external bone resorption were a common finding, and in some patients the cortical bone was initially affected by the fresh or recurrent lesion. Based on these distinct differences, we suggest that the cause of diffuse sclerosing osteomyelitis is not bacterial infection and that the site of origin is not in the bone but in the periosteum.

Tooth loss and mandibular osteopenia.

The relationship between mandibular bone mass and tooth loss was studied in 269 patients who had neither metabolic disease nor local lesions affecting the mandibular cortex. In all of the subjects, the outline of the mental foramen was distinctly disclosed on unilateral or bilateral panoramic radiographs. Mandibular bone mass was evaluated by determining the mandibular cortical width in the mental region with the use of panoramic radiographs. The relationships of mandibular cortical width to patient age and sex and the number of teeth present were also investigated. In male subjects, there was no significant correlation between the number of teeth present and the mandibular cortical width. Among women in their seventh decade, those with 15 or more teeth showed significantly greater mandibular cortical width than those with fewer teeth. Decrease of mandibular bone mass was positively correlated with tooth loss in female subjects.

Oral signs as indicators of possible osteoporosis in elderly women.

The relationship between oral signs and osteoporosis was investigated to assess the possibility of using this as an indicator of postmenopausal osteoporosis. Sixty-four women between the ages of 50 and 70 years were evaluated. Osteoporotic signs consisted of thoracic spine fracture as demonstrated on lateral chest radiographs. Oral signs were the number of teeth present, mandibular cortical width, alveolar bone resorption, and the morphologic classification of the inferior cortex on panoramic radiographs. The number of teeth present (N) was highly related to the probability of thoracic spine fracture and was used to derive the probability equation for the presence of thoracic spine fracture: probability value = 1/(1 + e-z), Z = 18.68-0.29 age -0.27N. A probability value higher than 0.5 suggests the possibility of thoracic spine fracture. It was concluded that this equation could serve as a simple and useful tool for dentists to assess the possibility of latent osteoporosis.

Radiographic findings and prognosis of simple bone cysts of the jaws.

OBJECTIVE: The aim was to evaluate the possibility of radiographic prediction of the prognosis of simple bone cysts (SBCs) of the jaws. METHODS: The relationship between the radiographic findings and treatment outcome (healing or recurrence) was investigated in 31 cases treated in the authors' hospital and 108 published cases. RESULTS: In 17 of our 31 cases, the lesions had radiographic findings of a preserved lamina dura adjacent to the lesion, with a smooth margin, and no or smooth bone expansion, and all of them healed after surgery. In the other 14 cases, there was resorption of the lamina dura, a scalloped margin, nodular bone expansion, root resorption, a sclerotic mass or multiple cavities, and nine cases of recurrence. Although there was incomplete information in the published case studies, similar results were noted. CONCLUSIONS: It was concluded that there was a relationship between the radiographic features of the lesions and prognosis. Radiographic examination should be used not only for discovering and diagnosing the lesions, but also for predicting possible prognosis.

Detection of post-menopausal women with low bone mineral density and elevated biochemical markers of bone turnover by panoramic radiographs.

OBJECTIVES: The detection of an eroded mandibular cortex on panoramic radiographs and questionnaire-based screening tools show similar diagnostic efficacies for identifying osteoporosis in post-menopausal women. We evaluated whether both tools also have similar diagnostic performances in identifying women with osteoporosis and elevated biochemical markers of bone turnover who have a high risk of fracture. METHODS: Urinary N-telopeptide cross-links of type I collagen (NTx) (corrected for creatinine) and serum levels of total non-bone-specific alkaline phosphatase (ALP) were measured in 99 post-menopausal women aged 44-70 years (mean +/- standard deviation (SD), 54.6 +/- 5.2 years) who underwent bone mineral density (BMD) assessment and panoramic radiography. BMD was measured at the lumbar spine and femoral neck using dual energy X-ray absorptiometry. The Female Osteoporosis Self-assessment Tool for Asia (FOSTA), which is based on age and weight, was used as the questionnaire-based screening tool. Osteoporosis was defined as a BMD T-score of -2.5 or less at either the lumbar spine or the femoral neck. RESULTS: Urinary NTx and serum ALP were significantly associated with cortical erosion, but not with the FOSTA. The areas under the receiver operating characteristics (ROC) curve for identifying participants with osteoporosis were 0.784 for FOSTA and 0.827 for the detection of cortical erosion, and for identifying participants with osteoporosis and elevated urinary NTx they were 0.700 for FOSTA and 0.807 for the detection of cortical erosion. CONCLUSIONS: Our results suggest that panoramic radiography is superior to questionnaire-based screening for identifying women who are at high risk of fracture.

A computer-aided diagnosis system to screen for osteoporosis using dental panoramic radiographs.

OBJECTIVES: An eroded inferior cortex of the mandible detected on dental panoramic radiographs is useful for identifying post-menopausal women with low skeletal bone mineral density (BMD) or osteoporosis. The purposes of this study were to develop a computer-aided diagnosis (CAD) system that automatically determines cortical erosion of the mandible on dental panoramic radiographs and to assess the validation of this CAD system. METHODS: A CAD system was developed based on mathematical morphology for identifying post-menopausal women with low skeletal BMD or osteoporosis, based on World Health Organization criteria, by identifying whether the endosteal margin of mandibular cortical bone was eroded. The sensitivity, specificity, predictive value, accuracy and likelihood for a positive risk result were calculated using dichotomous 2 x 2 tables using 100 panoramic radiographs. RESULTS: For identifying women with low skeletal BMD, the sensitivity and specificity were 76.8% and 61.1%, respectively, the positive and negative predictive values were 90.0% and 36.7%, accuracy was 74.0% and the likelihood for positive risk was 1.96. The respective values for identifying women with osteoporosis were 94.4% and 43.8%, the positive and negative predictive values were 48.6% and 93.3%, respectively, the accuracy was 62.0% and the likelihood for positive risk was 1.68. CONCLUSION: Our results suggest that a CAD system applied to dental panoramic radiographs may be useful for identifying post-menopausal women with low skeletal BMD or osteoporosis.

A comparative study of simple bone cysts of the jaw and extracranial bones.

OBJECTIVES: To improve the interpretation of simple bone cyst (SBC) lesions of the jaw. METHODS: A comparative study of SBC lesions of the jaw and extracranial bones was performed through a literature survey. RESULTS: In extracranial SBC, the cavities were always filled with fluid, and a high recurrence rate was shown through extensive research. Aneurysmal bone cyst (ABC) was included in the differential diagnosis owing to some clinicopathologic similarities. Fluid, gas and blood were found in the cavity in jawbone SBC, and recurrence was believed to be rare. Differential diagnosis was rarely discussed in the literature. CONCLUSIONS: Based on reports, the cavity did not normally contain gas because no air-fluid level was observed on panoramic radiographs and no density/intensity area indicating gas was seen on CT or MRI. A blood-filled cavity should be examined carefully, and the possibility of an ABC should be considered. The recurrence rate needs to be re-estimated because an extensive survey has not been performed to clarify the treatment outcomes of jawbone SBC.

Diagnostic efficacy of alveolar bone loss of the mandible for identifying postmenopausal women with femoral osteoporosis.

OBJECTIVES: Mandibular cortical width (MCW) detected on panoramic radiographs may be useful for identifying postmenopausal women with osteoporosis. There is little known regarding whether alveolar bone loss (ABL) of the mandible detected on panoramic radiographs is a potentially accurate screening tool for osteoporosis in comparison with MCW. The purpose of this study was to evaluate whether ABL of the mandible on panoramic radiographs is useful for identifying femoral osteoporosis in postmenopausal women in comparison with MCW. METHODS: Three hundred and fifty-four Japanese postmenopausal women (mean age+/-SD, 56.8+/-7.7 years) were recruited for this study. Femoral BMD was measured by dual energy X-ray absorptiometry. Panoramic radiographs were obtained to estimate ABL of the mandible and MCW. RESULTS: A multiple regression analysis revealed that femoral BMD was significantly associated with MCW (P<0.001), weight (P<0.001), age (P<0.001) and ABL of the mandible (P=0.029; adjusted r(2)=0.380). The area under the ROC curve (AUC) for identifying femoral osteoporosis was 0.609 [95% confidence interval (CI), 0.523-0.696] for ABL of the mandible and 0.779 (95% CI, 0.713-0.844) for MCW, respectively. AUC for ABL of the mandible indicated less accuracy. CONCLUSIONS: Our results suggest that ABL of the mandible on panoramic radiographs may not be useful for identifying postmenopausal women with femoral osteoporosis in comparison with MCW.

Risk of vertebral osteoporosis in post-menopausal women with alterations of the mandible.

BACKGROUND: Previous studies have suggested that a thin or eroded cortex of the mandible detected on dental panoramic radiographs is associated with low vertebral bone mineral density (BMD) or osteoporosis. However, those studies did not estimate the multivariate-adjusted risk for low vertebral BMD or osteoporosis associated with alterations of the mandible. METHODS: BMD of the lumbar vertebrae (L2-L4) was compared among quartiles of cortical width and among three cortical shape categories in 450 post-menopausal women (mean age, 57.2 years), adjusted for potential confounders. The odds ratios for low BMD or osteoporosis according to cortical width and shape were also calculated. RESULTS: Significant associations were found between cortical width and shape, and vertebral BMD. The odds ratios for low vertebral BMD associated with the second, third and lowermost quartiles of cortical width were 1.71 (95% confidence interval (CI), 0.96-3.05), 2.30 (95% CI, 1.29-4.11) and 5.43 (95% CI, 2.16-10.71), respectively, compared with the uppermost quartile. The odds ratios for osteoporosis according to cortical width category were similar to those for low BMD. The odds ratios for low BMD associated with mildly to moderately and severely eroded cortices were 3.85 (95% CI, 2.37-6.25) and 7.84 (95% CI, 2.57-23.90), respectively, compared with normal cortex. The odds ratios for osteoporosis associated with mildly to moderately and severely eroded cortices were 4.73 (95% CI, 2.54-8.80) and 14.73 (95% CI, 6.14-35.47), respectively. CONCLUSIONS: Post-menopausal women with alterations of the mandible may have an increased risk for low vertebral BMD or osteoporosis.

Identification of post-menopausal women at risk of osteoporosis by trained general dental practitioners using panoramic radiographs.

BACKGROUND: An eroded inferior cortex of the mandible on panoramic radiographs may be useful for identifying post-menopausal women with low bone mineral density (BMD), or osteoporosis. The purpose of this study was to assess whether trained general dental practitioners (GDPs) can identify post-menopausal women with undetected low skeletal BMD as well as spinal fractures by panoramic radiographs in their clinics. METHODS: Out of 455 women aged 50 years and older who visited the dental clinics of 22 trained GDPs and had panoramic radiographic assessment for the examination of dental diseases between June and December 2004, 168 post-menopausal women were diagnosed as having low skeletal BMD based on cortical erosion findings. Of these women, 39 women aged 50-84 years (mean age (SD, standard deviation), 64.8 (7.4) years) with no previous diagnosis of osteoporosis participated in this study. BMD at the lumbar spine and femoral neck was measured using dual energy X-ray absorptiometry (DXA). Spine fractures were assessed on lateral radiographs obtained at the time of the DXA assessment. RESULTS: Two women (5.1%) had normal BMD (BMD T-score>-1.0), 21 women (53.9%) had osteopenia (BMD T-score of -2.5 to -1.0) and 16 women (41.0%) had osteoporosis (BMD T-score<-2.5). Eight women (20.5%) had fractures at the thoracic spine, lumbar spine, or both. CONCLUSIONS: Our results suggest that a high percentage of post-menopausal women with undetected low skeletal BMD as well as spinal fractures may be identified based on trained GDPs' analyses of their panoramic radiographs.

Diagnostic performance of general dental practitioners after lecture in identifying post-menopausal women with low bone mineral density by panoramic radiographs.

OBJECTIVES: Mandibular cortical erosion detected on panoramic radiographs may be useful for identifying post-menopausal women with low skeletal bone mineral density (BMD). The purposes of this study were to calculate the diagnostic performance of general dental practitioners (GDPs) who attended a lecture on identifying post-menopausal women with low BMD from findings on panoramic radiographs and to evaluate the influence of GDPs' age on diagnostic performance. METHODS: After a 1 h lecture, 111 GDPs were asked to classify the mandibular cortex (normal or eroded) on panoramic radiographs obtained from 100 post-menopausal women who have had skeletal BMD assessment. Low BMD was defined as a BMD T score of -1.0 or less. Diagnostic performance was analysed by comparing two groups classified by mandibular cortex (women with normal cortex and women with any eroded cortex) with those classified by BMD (women with normal BMD and women with low BMD). RESULTS: The mean sensitivity, specificity, positive predictive value, negative predictive value, accuracy and likelihood ratio for a positive risk result were 73.0% (95% confidence interval [CI]; 71.3 to 74.7%), 49.0% (95% CI; 46.4 to 51.5%), 66.9% (95% CI; 66.0 to 67.8%), 57.0% (95% CI; 55.8 to 58.2%), 62.9% (95% CI; 62.1 to 63.7%) and 1.51 (95% CI; 1.44 to 1.58), respectively. GDPs' age did not influence diagnostic performance. CONCLUSIONS: Our results suggest that 73.0% of women who had low skeletal BMD can be identified by GDPs after a lecture on the use of panoramic radiographs as an aid in diagnosing low BMD; however, the diagnostic performance may not be influenced by GDPs' age.

Metastatic retinoblastoma of the maxilla and mandible.

Metastatic retinoblastoma of the jaws is very rare. We present a 4-year-old boy with metastatic retinoblastoma that involved both the maxilla and mandible simultaneously. Enhanced CT indicated bone-destructive masses with partially non-enhanced area and enhanced margin in the right maxilla and left mandible. MRI showed well-delineated masses that were isointense on T(1) weighted images and hyperintense on T(2) weighted images. Four weeks after chemotherapy and bone marrow transplantation, the size of lesions remarkably decreased. The patient died 19 months later with extensive tumour metastases despite additional chemotherapy. In this case, the dental crypt of a permanent tooth was considered the potential target through which retinoblastoma metastasized to the jaws.

Diffuse sclerosing osteomyelitis of the mandible: its characteristics and possible relationship to synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome.

PURPOSE: This article reports on the possible relationship of diffuse sclerosing osteomyelitis (DSO) of the mandible to synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome. PATIENTS AND METHODS: The pathologic features in 12 new DSO patients and those in previously reported cases were reviewed and compared with those of SAPHO syndrome. RESULTS: Many similarities were noted between the two entities in terms of the clinical, radiographic, and histologic features. Furthermore, multiple bone lesions and skin lesions (palmoplantar pustulosis and psoriasis) were observed not only in SAPHO syndrome but also in DSO patients. CONCLUSION: DSO is concluded to be one manifestation of SAPHO syndrome.

Diagnostic points and possible origin of osteomyelitis in synovitis, acne, pustulosis, hyperostosis and osteitis (SAPHO) syndrome: a radiographic study of 77 mandibular osteomyelitis cases.

OBJECTIVES: To find diagnostic points and to identify the origin of osteomyelitis in synovitis, acne, pustulosis, hyperostosis and osteitis (SAPHO) syndrome. METHODS: Fifty-two patients with mandibular suppurative osteomyelitis and 25 patients with mandibular osteomyelitis in SAPHO syndrome were included in the study. Radiographic patterns of the lesion, types of periosteal reaction and the presence of external bone resorption and bone enlargement were investigated in each case and compared between the two entities. RESULTS: Suppurative osteomyelitis demonstrated an osteolytic pattern and a lamellated type of periosteal reaction, whereas SAPHO syndrome revealed a mixed-pattern, solid-type periosteal reaction, external bone resorption and bone enlargement. CONCLUSIONS: Radiographic examination is suggested to be convenient and a useful diagnostic method of differentiating osteomyelitis in SAPHO syndrome from suppurative osteomyelitis. The periosteum is suspected to be the original site of osteomyelitic lesions in SAPHO syndrome.

Simple bone cyst. Evaluation of contents with conventional radiography and computed tomography.

To evaluate whether gas is present in the cavity of simple bone cysts, the clinical and histologic findings of 53 patients with simple bone cysts were examined and compared with an experimental model. The model consisted of a dry mandible with the medullary bone removed and the resulting cavity injected with water. Although an air-liquid level was observed on all radiographs for the experimental model, none was observed in the clinical cases of simple bone cysts. When the experimental cavity was completely filled with water, the density in the cavity was similar to that of the surrounding water on computed tomography, but when it was filled with air, the density was lower than that of the surrounding water. In contrast, in simple bone cysts said to contain air at surgery, the cavity contents were not consistent with the density for gas on computed tomography. These results indicate that the operative finding of air in the cavity of simple bone cysts may have been in error at least in some cases.

Mucosal condition of the oral cavity and sites of origin of squamous cell carcinoma.

PURPOSE: This study investigated the clinical appearance of the affected mucosa in patients with squamous cell carcinoma (SCC) in the oral and oropharyngeal region. PATIENTS AND METHODS: The mucosal conditions of 396 patients was classified into two types. Type A, showing ulcer formation and/or tumor formation, and type B, showing only mucosal enlargement without any other abnormality. RESULTS: Type A was detected in the oral cavity and oropharynx, and type B was observed only in the upper and lower alveolus and gingiva. Of 14 type B patients histologically evaluated for the relationship between the tumor cells and surface oral epithelium, 10 showed a disconnection between the epithelium and the tumor cells, whereas in two the tumor cells extended into the epithelium. CONCLUSION: It was concluded that SCC of type B is not of oral epithelial origin, but is of maxillary sinus epithelium or odontogenic cell origin. In the mandible, type B SCC originates from odontogenic epithelium (odontogenic carcinoma).

Formation of double contour in the human mandibular condyle. A case report.

This is the first report of double contour formation in the human mandibular condyle that includes both radiographic and histologic confirmation. Panoramic radiographs showed an additional cortical layer formation on the posterior of the condyle during follow-up after displacement of the condyle. Two cortical layers on the posterior portion of the condyle were demonstrated on the histologic specimen. The outer layer consisted of a few lamellated bone layers and included many osteocytes. However, minimal fibroconnective tissue was seen, and there was no cartilage layer. We concluded that the double contour formation was not caused by endochondral ossification but by periosteal bone formation.