Efficacy of the Panoramic Radiography for Exploring Bone Mineral Density and Oral Health
Ankur Jethlia1, Honey Lunkad2,Shaista Haleem3,FazilArshad Nasyam4
1Assistant Professor, Department of Maxillofacial and Diagnostic sciences, Diagnostic Division College of Dentistry Jazan University;
2Assistant Professor, Department of Prosthetic Dental Sciences, College of Dentistry, Jazan University, Saudi Arabia;
3MSc Restorative and Aesthetic Dentistry (Manchester UK), Faculty Dental Health department Inaya Medical College Riyadh ELM University [REU];
4Assistant Professor, Department Of Oral And Maxillofacial Surgery And Diagnostic Sciences College Of Dentistry, Prince Sattam Bin Abdulaziz University, Al-Kharj, Riyadh, KSA
1Email id: [email protected]
2Email id: [email protected] ABSTRACT
Background: Established osteoporosis is not possible to return to normal condition, but in many cases, it can be prevented with early intervention. With increasing age, progressive changes occur throughout the body, including osteoporotic.This disease can be diagnosed by panoramic radiography in dental clinics.
Aim: The aim of the present study was to evaluate the diagnostic efficacy of the panoramic radiographs in the assessment of BMD and the influence of gender and dental status on the various indices.
Materials and Methods: 1000 dental panoramic radiographs of patients reporting at the Department of Oral Diagnosis and Radiology were evaluated for radio morphometric indices.
PMI and MI were calculated using 17" screen, 1024 x 768 minimum screen, resolution - 32 bits colour mode, and were calculated by a maxillofacial radiologist.The relationship between these indices among different age groups and gender were analysed using the Chi-square test, independent‘t' test, and Post Hoc Bonferroni test.
Results: Statistical analyses revealed a significant difference between the results of each group analysed in both male and female patients. Chi-square test was applied and a significant difference was found between MCI and gender and age group respectively. Correlation between age and PMI was statistically significant between group 1 and group 2; group 1 and group 3;
however the difference between group 2 and group 3 was not statistically significant. Correlation between age and MI was evaluated using the Post hoc Bonferroni test. Statistically significant differences were found between group 1 and group 2; group 1 and group 3; however the difference between group 2 and group 3 was not statistically significant.
Conclusion:MI and PMI, in the present study, present a statistically significant correlation with respect to the age of the study subjects (P<0.05). MI and PMI had a significant relationship with MCI (P<0.05).
Keywords:Bone mineral density, Osteoporosis, indices, panoramic radiography.
Keynote:Bone mineral density (BMD) refers to the amount of mineral matter per square centimetre of bones. It is used in clinical medicine as an indicator of osteoporosis and fracture
risk. Osteoporosis is a systemic skeletal disease characterized by a loss in bone mineral density and micro-architectural deterioration in bone tissue leading to enhanced bone fragility and increased risk of fracture
INTRODUCTION
Bone mineral density (BMD) refers to the amount of mineral matter per square centimetre of bones. It is used in clinical medicine as an indicator of osteoporosis and fracture risk.
Osteoporosis is asystemic skeletal disease characterized by a loss in bone mineral density and micro-architectural deterioration in bone tissue leading to enhanced bone fragility and increased risk of fracture.1 Osteopenia refers to bone density that is lower than normal peak density but not low enough to be classified as osteoporosis. It is recently acknowledged as one of the main public health issues of developed countries.2
Factors such as weight, age, functional level, nutritional state, previous fracture history, use of anticonvulsant effect the BMD in children and adults. 3 Factors affecting the BMD in jawbones are the history of extraction, denture wearing, muscular activity, drug intake, the thickness of mandibular bone, number of teeth present, etc.4There is a considerable correlation between the densities of skeletal and jawbones; therefore, the density of skeletal bones and the presence of osteoporosis or osteopenia in these bones might reflect the same state in the jaws or vice versa.5 Dual-energy X-ray Absorptiometry (DEXA) is considered to be the gold standard for the estimation of bone mineral density due to good precision of the measurements, and the availability of reliable reference ranges. 6
Panoramic radiography has been used as an excellent tool for the overview of the maxillofacial area, including many of the vital structures, such as the maxillary sinus, inferior alveolar nerve, and nasal fossa. It can also be used to predict low mineral density in patients.A numberof indices, namely the mandibular cortical index (MCI), panoramic mandibular index (PMI), and mental index (MI) have been developed to assess the quality of mandibular bone mass and to observe signs of osteopenia on panoramic radiographs.7
The aim of the present study was to evaluate the diagnostic efficacy of the panoramic radiographs in the assessment of BMD and the influence of gender and dental status on the various indices.
MATERIAL AND METHODS
1000 dental panoramic radiographs of patients reporting at the Department of Oral Diagnosis and Radiology were evaluated for radio morphometric indices. All panoramic radiographs were made using KODAK 8000C Digital Panoramic and Cephalometric Extraoral Imaging System (Focal Spot size: 0.5 mm (IEC 336), Tube voltage: 60-90 kV, Tube current: 2-15 mA, Exposure time:
13.9 s., Magnification: 1.27%, Grey scale: 16384 (14bits). Linear measurements were performed using KODAK Dental Imaging Software Windows v6.5.4.
Patients without any systemic diseases that would affect bone metabolism and possibly cause bone lesions and fractures were included in the study. Patients with a history of maxillofacial trauma with reconstruction were excluded from the study.
MCI was calculated by observing the inferior cortex distal to the mental foramen bilaterally, using the criteria described by Klemettiet al. (1997) 8
C 1 - The endosteal margin of the cortex is even and sharp on both sides of the mandible.
C 2 - The endosteal margin has semilunar defects (resorption cavities) with cortical residues one to three layers thick on one or both sides.
C 3 - The endosteal margin consists of thick cortical residues and is clearly porous.
PMI represents the ratio of the thickness of the mandibular cortex to the distance between the inferior margin of mental foramen and the inferior mandibular cortex.9MI is the measurement of the cortical width on the line perpendicular to the bottom of the mandible at the middle of the mental foramen.10Cortices of male and female subjects are depicted in Figure 1 and 2 respectively.
These indices were viewed using a Sony VAIO VGN-CS118E and calculated using 17" screen, 1024 x 768 minimum screen, resolution - 32 bits colour mode, and were calculated by a maxillofacial radiologist.
The relationship between these indices among different age groups and gender were analysed using the Chi-square test, independent‘t’ test, and Post Hoc Bonferroni test.
RESULTS
Out of 1000 patients, 403 were males and 597 were females. 368 were <25 years of age (group 1), 357 were 25-35 years of age (group 2) and 275 were above >35 years (group 3). The C1 category of MCI was observed in 734 patients (274 males, 460 females), whereas C2 was observed in 266 patients (129 males, 137 females) (Table 1).
Statistical analyses revealed a significant difference between the results of each group analysed in both male and female patients. Chi-square test was applied and a significant difference was found between MCI and gender and age group respectively (Table 2). Independent‘t' test was applied and a significant difference was found between PMI, MI, and gender (Table 3).
Correlation between age and PMI was evaluated using the Post hoc Bonferroni test. Statistically significant differences were found between group 1 and group 2; group 1 and group 3; however the difference between group 2 and group 3 was not statistically significant (Table 4).
Correlation between age and MI was evaluated using the Post hoc Bonferroni test. Statistically significant differences were found between group 1 and group 2; group 1 and group 3; however the difference between group 2 and group 3 was not statistically significant (Table 4)
Crosstab
MCI Total
1 2
aGEgRP < 25 Count 368 0 368
% within aGEgRP
100.0% .0% 100.0%
25 - 35
Count 220 137 357
% within aGEgRP
61.6% 38.4% 100.0%
> 35 Count 146 129 275
% within aGEgRP
53.1% 46.9% 100.0%
Total Count 734 266 1000
% within aGEgRP
73.4% 26.6% 100.0%
Table 1: MCI and age group correlation
Value df Asymp. Sig.
(2-sided) Pearson Chi-
Square
216.811a 2 <.001
Likelihood Ratio 302.867 2 .000
Linear-by-Linear Association
190.643 1 .000
N of Valid Cases 1000
Table 2: Chi-square test 0 cells (.0%) have expected count less than 5. The minimum expected count is 73.15.
Independent Samples Test
t-test for Equality of Means
T df Sig.
(2- tailed)
Mean Difference
Std. Error Difference
95% Confidence Interval of the Difference
Lower Upper PMI Equal
variances assumed
5.173 998 <.001 .03428 .00663 .02128 .04728
Equal variances not assumed
5.256 907.934 .000 .03428 .00652 .02148 .04708
MI Equal variances assumed
6.569 998 < .001 .41921 .06381 .29398 .54443
Equal variances not assumed
6.809 956.381 .000 .41921 .06157 .29838 .54004
Table 3: Independent t test for MI and PMI
Depe ndent Varia ble
(I) aGEg RP
(J) aGEg RP
Mean Difference
(I-J)
Std. Error Sig. 95% Confidence Interval Lower Bound Upper Bound
PMI < 25 25 - 35
-.03481* .00766 <.001 -.0532 -.0164
> 35 -.02361* .00822 .012 -.0433 -.0039
25 - 35
< 25 .03481* .00766 <.001 .0164 .0532
> 35 .01120 .00827 .528 -.0086 .0310
> 35 < 25 .02361* .00822 .012 .0039 .0433
25 - 35
-.01120 .00827 .528 -.0310 .0086
MI < 25 25 - 35
-.39742* .07372 <.001 -.5742 -.2206
> 35 .02273 .07910 1.000 -.1670 .2124
25 - 35
< 25 .39742* .07372 <.001 .2206 .5742
> 35 .42014* .07962 <.001 .2292 .6111
> 35 < 25 -.02273 .07910 1.000 -.2124 .1670 25 -
35
-.42014* .07962 <.001 -.6111 -.2292 Table 4: Post Hoc Tests Multiple Comparisons *. The mean difference is significant at the 0.05 level.
Figure 1: Normal and Eroded Cortex in a male subject
Figure 2: Normal and Eroded Cortex in a Female subject
DISCUSSION
The present study was carried out to evaluate the diagnostic efficacy of the panoramic radiographs in the assessment of BMD and the influence of gender and dental status on the various indices. In the present clinical trial, 1000 dental panoramic radiographs of patients reporting at the Department of Oral Diagnosis and Radiology were evaluated for radio morphometric indices. Out of 1000 patients, 403 were males and 597 were females. 368 were
<25 years of age (group 1), 357 were 25-35 years of age (group 2) and 275 were above >35 years (group 3). The C1 category of MCI was observed in 734 patients (274 males, 460 females), whereas C2 was observed in 266 patients (129 males, 137 females).
Statistical analyses revealed a significant difference between the results of each group analysed in both male and female patients. Chi-square test was applied and a significant difference was found between MCI and gender and age group respectively. Independent‘t' test was applied and a significant difference was found between PMI, MI, and gender with the p-values of.02128 and.29398 respectively. These findings from the present study were in accordance with the various previous other studies in the literature by Knezovic et al11 in 2002, Raghdaa et al12 in 2011, and Govindraju et al13 in 2016 where authors reported that MI and age were related to each other in a negative fashion, where the reduction in MI was observed with an increase in age.
Another study by Musa et al14 in 2002, showed contradictory findings in relation to the present study where no significant correlation between age and MI was observed.
Correlation between age and PMI was evaluated using the Post hoc Bonferroni test. Statistically significant differences were found between group 1 and group 2; group 1 and group 3; however the difference between group 2 and group 3 was not statistically significant with respective p- values of <.001, <.001, and .012. These findings were in agreement with the studies by Taguchi15 and Bensen BW et al16 in where authors also reported PMI values are directly proportional to the age of the subjects, whereas, another study by Yǜzǜgǜllǜ et al17 in 2009 had a disagreement with the findings of the present study where no relationship between two was reported.
PMI showeda statistically significant difference between males and females (P<0.05) so that females had higher amounts of PMI. Similar results were also published by Haster and colleagues18 in 2011and by Ledgerton et al19 where higher PMI was seen in females compared to male subjects.
CONCLUSION
MI and PMI, in the present study, present a statistically significant correlation with respect to the age of the study subjects (P<0.05). MI and PMI had a significant relationship with MCI (P<0.05). The study had few biases in regard to sample size and all the radiographs were captured at a single diagnostic centre. Also, the single geographical area was focused on in the present study. More longitudinal studies with a larger sample size and longer monitoring periods are needed to reach a definitive conclusion.
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