Long waiting time before tooth extraction may increase delayed wound healing in elderly Japanese.

In osteoporosis patients receiving antiresorptive medications, stopping the drug and delaying tooth extraction has been suggested to reduce the risk of osteonecrosis of the jaw (ONJ). However, postponing tooth extraction for ≥ 2 months was associated with an increased risk of delayed wound healing beyond 8 weeks after extraction, a risk factor for developing ONJ. INTRODUCTION: A long waiting time before tooth extraction could result from concern about a potential increased risk of osteonecrosis of the jaw (ONJ) in osteoporosis patients. We clarified whether a long waiting time before tooth extraction during the past year may be associated with an increased risk of delayed wound healing beyond 8 weeks after tooth extraction, which may be a risk factor of ONJ. METHODS: Of 5639 patients aged ≥ 60 years who visited our 20 clinics or hospitals and answered a structured questionnaire, 426 patients (151 men, 275 women) aged 60-96 years comprised the final participants in this study. Self-reported kyphosis was used as a surrogate marker of vertebral fractures. Stepwise logistic regression analysis, adjusted for covariates, was used to calculate the odds ratio (OR) and the 95% confidence interval (CI) for the presence of delayed wound healing longer than 8 weeks after tooth extraction during the past year based on the duration before extraction. RESULTS: Subjects who had waited > 2 months for tooth extraction had a significantly higher risk of delayed wound healing compared with those whose tooth was extracted within 1 month (OR = 7.23; 95% CI = 2.19-23.85, p = 0.001) regardless if antiresorptive medications for osteoporosis were used. The presence of self-reported kyphosis was significantly associated with an increased risk of delayed wound healing (OR = 5.08; 95% CI = 1.11-23.32, p = 0.036). CONCLUSIONS: A long waiting time before tooth extraction may be a risk factor for delayed wound healing beyond 8 weeks after extraction in patients aged ≥ 60 years.

Issues with the surgical treatment of antiresorptive agent-related osteonecrosis of the jaws.

Antiresorptive agent-related osteonecrosis of the jaw is a rare but significant complication in patients using antiresorptive agents such as bisphosphonates and denosumab. Although the disease is well recognized, and many studies have been performed on the management of this condition, the treatment of severe osteonecrosis is still a challenge. Most recent studies have shown an advantage of surgical treatment over conservative treatment for stage 2/3 patients, but there is no consensus on the appropriate surgical procedures for antiresorptive agent-related osteonecrosis of the jaw. Furthermore, patients with severe systemic conditions may not be appropriate for extensive surgical treatment, and the treatment protocol for such patients has not been established. In this review, issues regarding the current surgical treatment for antiresorptive agent-related osteonecrosis of the jaws are discussed, with an emphasis on the clinical aspects.

Efficacy and safety of once-yearly zoledronic acid in Japanese patients with primary osteoporosis: two-year results from a randomized placebo-controlled double-blind study (ZOledroNate treatment in Efficacy to osteoporosis; ZONE study).

In a 2-year randomized, placebo-controlled study of 665 Japanese patients with primary osteoporosis, once-yearly administration of zoledronic acid (5 mg) reduced the risk of new morphometric vertebral fractures. INTRODUCTION: The purpose of this study was to determine the efficacy and safety of once-yearly intravenous infusion of ZOL in Japanese patients with primary osteoporosis. METHODS: This was a two-year multicenter, randomized, placebo-controlled, double-blind, parallel-group comparative study (ZONE Study). Subjects were 665 Japanese patients between the ages of 65 and 89 years who had prevalent vertebral fracture. Subjects were randomly assigned to receive once-yearly intravenous infusion of 5 mg of ZOL or placebo at baseline and 12 months. RESULTS: The 2-year incidence of new morphometric vertebral fracture was 3.0 % (10/330 subjects) in the ZOL group and 8.9 % (29/327) in the placebo group (p = 0.0016). The 24-month cumulative incidence of new morphometric vertebral fracture was 3.3 % in the ZOL group versus 9.7 % in the placebo group (log-rank test: p = 0.0029; hazard ratio: 0.35; 95 % confidence interval: 0.17-0.72). The cumulative incidence of any clinical fracture, clinical vertebral fracture, and non-vertebral fracture was significantly reduced in the ZOL group by 54, 70, and 45 %, respectively, compared to the placebo group. At 24 months, ZOL administration increased bone mineral density in the lumbar spine, femoral neck, and total hip (t test: p < 0.0001). No new adverse events or osteonecrosis of the jaw were observed in this study. CONCLUSIONS: Once-yearly administration of ZOL 5 mg to Japanese patients with primary osteoporosis reduced the risk of new morphometric vertebral fractures and was found to be safe.

Panoramic radiography measurements, osteoporosis diagnoses and fractures in Japanese men and women.

OBJECTIVES: The purpose of this study was to investigate the association of the shape of the mandibular cortex on panoramic radiographs with the risk of an osteoporosis diagnosis without prevalent fractures and with the risk of osteoporotic fractures in Japanese men and women. SUBJECTS AND METHODS: One thousand and twenty-one subjects aged 40-89 years, who visited our university hospital and underwent panoramic radiography between 2007 and 2013, participated in this study. Eighty-eight patients received a diagnosis of osteoporosis without prevalent fractures, and 55 were diagnosed with osteoporotic fractures. Blinded to the groupings, we classified the shape of the mandibular cortex on panoramic radiographs as normal, moderately eroded or severely eroded. RESULTS: After adjustment for confounding factors, the odds ratios for an osteoporosis diagnosis associated with moderately eroded and severely eroded mandibular cortices were 1.4 (95% CI, 0.8-2.6) and 2.6 (95% CI, 1.4-5.0), respectively. The odds ratios for an osteoporotic fracture associated with moderately eroded and severely eroded cortices were 0.8 (95% CI, 0.4-1.7) and 1.1 (95% CI, 0.5-2.5), respectively. CONCLUSIONS: Subjects in Japan with eroded mandibular cortices tended to be at increased risk of osteoporosis diagnoses but not of fractures.

Triage screening for osteoporosis in dental clinics using panoramic radiographs.

Many patients with osteoporosis go undiagnosed because typically no symptoms are present before a fracture. Triage screening to refer patients to appropriate medical professionals for further investigation would be useful to address the increase in the incidence of osteoporotic fractures. Dental clinics may offer a new triage screening pathway because dentists frequently take radiographs of bones in the course of dental treatment. A major premise for such triage screening in dental clinics is that dentists can readily use a screening tool in their dental practice. For example, cortical width and shape of the mandible detected on panoramic radiographs may be appropriate indices for triaging individuals with osteoporosis. To date, several investigators have demonstrated significant associations between cortical indices on panoramic radiographs and bone mineral density of the skeleton generally, such as the spine and femur, biochemical markers of bone turnover and risk of osteoporotic fractures. Further, in two recent Japanese clinical trials, approximately 95% of women who were identified by trained dentists in their clinics using cortical shape findings did have osteopenia or osteoporosis. These findings support the possibility that dental clinics may offer a new triage platform to identify individuals with otherwise undetected osteoporosis.

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.

Case-control study on self-reported osteoporotic fractures and mandibular cortical bone.

OBJECTIVES: The purpose of this case-control study was to determine whether the radiographic appearance of the mandibular cortical bone in patients who were elderly and noninstitutionalized was related to a self-reported history of osteoporotic fractures. STUDY DESIGN: Patients who had a billing statement at the School of Dentistry dated between 1993 and 1996, who were older than 60, and who had a panoramic radiograph were invited to be interviewed regarding fracture history (circumstances and year of fracture) and risk factors for osteoporosis. Cases (n = 93) were individuals reporting osteoporotic fractures (fractures occurring after minor impact). Controls (n = 394) were individuals reporting traumatic fractures (n = 105) or no fractures (n = 289). Blinded to case-control status, we evaluated the mandibular cortex on a panoramic radiograph and classified them as normal (even and sharp endosteal margin), moderately eroded (evidence of lacunar resorption or endosteal cortical residues), or severely eroded (unequivocal porosity). In addition, cortical thickness was measured below the mental foramen. RESULTS: After adjustment for potentially confounding factors, the odds ratio for an osteoporotic fracture associated with moderately eroded and severely eroded mandibular cortices was 2.0 (95% CI, 1.2 to 3.3) and 8.0 (95% CI, 2.0 to 28.9), respectively. After adjusting for all potentially confounding factors, we found that the cortex was 0.54 mm (or 12%) thinner in subjects with an osteoporotic fracture compared with controls (95% CI, 0.25 to 0.84 mm). CONCLUSIONS: Subjects with a self-reported history of osteoporotic fractures tend to have increased resorption and thinning of the mandibular lower cortex.

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.

Detecting young Japanese adults with undetected low skeletal bone density using panoramic radiographs.

OBJECTIVE: The cortical width below the mental foramen of the mandible determined from panoramic radiographs is a useful screening tool for identifying elderly individuals with a low skeletal bone mineral density (BMD). However, whether the mandible cortical width (MCW) is useful for identifying a low skeletal BMD in men and women of 40 years or younger is not known. METHODS: The BMD of the calcaneus was measured by ultrasonography bone densitometry in 158 men and 76 women aged 18-36 years. A logistic regression analysis adjusted for age was used to calculate the odds ratios and 95% confidence interval (CI) of having a low calcaneal BMD, according to the quartiles of the MCW. The areas under the receiver operator characteristic curve (AUC) for identifying participants with a low calcaneal BMD using the MCW were assessed to evaluate the diagnostic efficacy of the MCW. RESULTS: In men, the adjusted odds ratios of a low calcaneal BMD associated with the second, third and lowest quartiles of MCW were 5.66 (95% CI, 0.61-52.23), 5.43 (95% CI, 0.59-50.18) and 33.22 (95% CI, 3.97-276.94), respectively, compared with the highest quartile, while no significant trend in the adjusted odds ratios was observed in women. The AUC for identifying participants with a low calcaneal BMD based on the MCW was 0.796 (95% CI, 0.702-0.890) in men and 0.593 (95% CI, 0.398-0.788) in women. CONCLUSION: MCW determined from panoramic radiographs can be used to identify undetected low calcaneus BMD in young adult men, but not in young adult women.

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.

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.