March 1, 2015
by Navdeep Kaur, BDS, MSc, PhD candidate; Daniel Kandelman, Dr CD, DMD, MPH
Osteoporosis is a skeletal disorder that is characterized by decreased bone mass density and increased susceptibility to fractures. It is known as a “silent epidemic” and substantially impacts individuals as well as the health care resources. This article provides an overview of the environmental and nutritional preventive factors of osteoporosis and how dentists and oral health literacy can be instrumental in screening and preventing osteoporosis. Dentists are in a privileged position to contribute in osteoporosis screening by employing intraoral and panoramic radiography that is routinely used in dental practice. In addition, oral health literacy’s effective communication strategies should be integrated to educate patients about preventive and health promoting measures of osteoporosis. Furthermore, dentists should adopt multidisciplinary approach particularly by collaborating with physician to refer patients for further evaluations and to provide appropriate recommendations.
osteoporosis; dentist; oral health literacy; prevention; panoramic radiography
The World Health Organization refers to osteoporosis as “characterized by low bone mass and micro-architectural deterioration of bone tissue, leading to increase in fragility and a fracture risk”.1 According to National Osteoporosis Foundation, almost 54 million Americans have osteoporosis casuing substantial economical impact on healthcare resources.2 It is estimated that 1.5 million Canadians have osteoporosis that costs health care resources approximately $2.3 billion per year.3 Osteoporosis is a major public health problem worldwide that considerably impacts patient’s autonomy and health care resources therefore its early diagnosis, prevention and management are indispensable. This article provides an overview of the environmental and nutritional preventive factors of osteoporosis and how dentists and oral health literacy can play a role in the screening and prevention of osteoporosis.
Risk factors of osteoporosis
The National Osteoporosis Foundation has determined the controllable and uncontrollable risk factors that contribute in development of osteoporosis.2 The uncontrollable risk factors are the family history of osteoporosis, female gender, age factor (>50 years), menopausal stage and low body weight and framework.2 And the controllable risk factors include insufficient calcium and vitamin D intake, excessive coffee, smoking and alcohol intake.2 Although many risk factors of osteoporosis have been identified however, a large body of literature has documented estrogen deficiency in post menopausal women as the most common risk factor of osteoporosis.4 In brief, estrogen deficiency stimulates the formation of inflammatory cytokines such as interleukin 1, 2 and 6 and prostaglandin E2 that further generates osteoclasts, the bone resorptive cells and causes osteoporosis.4 Preventive treatment of osteoporosis aims to reduce bone loss by including healthy diet and physical activity.5 In this paper we have focused on the preventable factors of osteoporosis by grouping them under 1) environmental and 2) nutritional preventive factors of osteoporosis as described below:
1) Environmental preventive factors of osteoporosis
1.1 Influence of sunlight
Vitamin D is synthesized in skin when exposed to ultraviolet radiations of sunlight that facilitates the absorption of calcium. Research studies have linked reduced sunlight exposure to vitamin D deficiency that predisposes to increased risk of osteoporosis.6 Sunlight aids in conversion of vitamin D from its inactive form (7-dehydrocholesterol) to its most active form that aids in the intestinal absorption of calcium.7 As per results of a meta-analysis, 23 percent risk of vertical fractures8 and 25 percent of hip fractures could be reduced by adequate intake of calcium and vitamin D.9 In this light, in places where sunlight exposure is limited it is important to incorporate approximately, 800 IU of vitamin D in one’s daily diet to prevent osteoporosis.10
1.2 Influence of fluoridation
The American dietetic association has affirmed that the optimum levels of fluoride intake influence bone health positively.11 Due to its effects on stimulating osteoblastic activity and inhibiting bone crystal dissolution, there had been considerable interest in the use of pharmacologic doses of sodium fluoride for the treatment of osteoporosis.12 It was demonstrated that slow released sodium fluoride administered for four years prevents vertebral fractures.12 Another study explored if increased level of water fluoridation has any effects and concluded that water fluoridation level of 4ppm promotes bone formation0.13 Although few studies have linked the effects of fluoride to bone mineral density however, its role and efficacy in reducing fractures needs further clarity.11
2) Nutritional preventive factors of osteoporosis
2.1 Calcium and vitamin D
Nutritional factors that contribute in prevalence of osteoporosis include the insufficient intake of calcium and vitamin D. It is recommended that for optimum bone health, it is imperative that adults 40 years of age or over shall incorporate 1000 mg to 1200 mg of calcium (diet or supplements) in their daily diet.10 It is proposed that dietary foods that are rich in calcium such as calcium fortified orange juice, milk, cheese, nuts, yogurt etc are beneficial in maintaining one’s bone health.2 Additionally, adults above 40 years and those who have limited sun exposure should take 800 IU of vitamin daily either through diet or supplements.10
2.2 Coffee, alcohol and cigarette smoking
Bone is a complex tissue and requires increase intake of bone building nutrients and less consumption of substances that adversely affect bone health. A meta-analysis reported that smoking is associated with increased risk of bone fractures.14 This increased fracture susceptibility is due to deleterious systemic effects of smoking causing reduced muscle strength and affecting balance that leads to increased risk of falls.15 Furthermore, smoking is responsible for delayed fracture healing since nicotine is a vasoconstrictor and toxic effects of smoking cause tissue hypoxia inhibiting callous formation.15 That is why, it is highly recommended to stop smoking during both pre and post-operative periods of orthopedic surgeries.15 Another study reported that smoking causes reduced radial bone density in menopausal women16 and reduced femoral bone density in elderlies and decreases intestinal absorption of calcium.17 Likewise, a meta-analysis suggested that excessive alcohol intake is a risk factor for osteoporosis and hip fracture.18 Although effects of caffeine on bone health have been studied yet majority of the evidence does not support that caffeine has any significant adverse effects on the bone health.19
Along with nutritional diet, exercise routine is recommended to prevent osteoporosis particularly spinal extensor strengthening program as well as balance and low impact strength training are considered beneficial in reducing rapid bone loss in postmenopausal women.20 In a nutshell, it is recommended that healthy diet intake, no smoking and limited consumption of alcohol and physician approved exercise routine are essential in optimizing the quality of one’s bone health.5
Role of dentists in screening of osteoporosis
Dentists can contribute in osteoporosis screening by integrating few simple screening steps in their routine dental practice. First step is to ask in detail patient’s medical history to ascertain any osteoporosis risk factors such as hereditary risk
factor, smoking, calcium and vitamin D deficiency, excessive caffeine or alcohol intake, etc.2 Osteoporosis causes reduced bone mass density throughout one’s body including maxillary and mandibular bones leading to resorption of alveolar ridges and reduced cortical width.21
Although, bone scan tests such as DXA (Dual Energy X-ray Absorptiometry) are considered as “gold standard” to diagnose osteoporosis however, research shows that intraoral and panoramic radiographs used by dentists in their routine dental practice are also functional in examining mandibular bone density.22-25 Thus, the second step is that dentists can employ intraoral and panoramic images to examine the bone mass density of mandibular cortical bone. Several studies have reported that the panoramic and intraoral images of patients showing reduced mandibular bone mass density and thinner cortex in mental foramen area28 indicate systemic risk of osteoporosis.22-27 Horner et al. demonstrated that the reduced cortex (< 3 mm) at the mandibular foramen is correlated with low bone mass density at the forearm, femoral neck and spine.29 Results of a study conducted by Taguchi et al. indicated that 60 percent of their patients who had mandibular cortical width<3mm when referred for DXA evaluations were confirmed having osteoporosis.30 Thus dentists should refer patients with reduced cortex (< 3 mm) to physician for further evaluation for systemic osteoporosis.24 Recent research reported that the bone mineral density of maxillary sites such as maxillary midline and tuberosity has strong correlation with bone mineral density of spine.31
As a third step, dental professionals should adopt multidisciplinary approach by collaborating particularly with physician to refer patients for further evaluation of systemic osteoporosis. In addition, collaborating with various specialists such as nutritionist, rehabilitation can be useful to provide adequate referrals and recommendations for preventive measures.32 Following figure provides a stepwise procedure that should be followed by dentist for osteoporosis screening:
Role of oral health literacy in preventing osteoporosis
Patient compliance to prevention and treatment is associated with effective communications between health care provider and patients.33 Several studies have proved that key element to improve health outcomes is that provided information should enhance patient’s knowledge and understanding so that they can effectively use this information to improve their health.34,35 Thus, dentists can integrate the oral health literacy’s effective communication strategies during osteoporosis screenings to create awareness related to osteoporosis amongst their patients.
Healthy People 2010 has defined oral health literacy as, “the degree to which individuals have the capacity to obtain, process, and understand the basic health information and services needed to make oral health related decisions”.36 Recent research has proved that people with limited oral health literacy use less preventive services, have poorer treatment compliance and have higher rates of hospitalization.37 Oral health literacy is critical in empowering patients to build the knowledge and skills to self-manage chronic disease and to make informed health promoting or preventive decisions.38
Dentists can integrate the communication strategies of oral health literacy to create awareness and understanding about osteoporosis among their patients so that they could use this information to make appropriate health promoting and preventive decisions. The basic information to provide should include the nature of osteoporosis and its consequences, what options of treatment are available, preventive dietary and exercise routine and prevention of falls and fractures. Particularly, dentists must collaborate with their patient’s physician to prevent any oral complications related to certain osteoporosis medications such as bisphosphonate that may cause bisphosphonated osteonecrosis.39 A consultation with patient’s physician can educate patient if and when to discontinue bisphosphonate therapy to prevent any oral complications during dental therapy.39
Recognizing and by being sensitive to patient’ diverse communication needs dentist should present information in small sentences to transmit the knowledge related to preventive measures of osteoporosis.40 Another effective way is to use the ‘teach back technique’ in which dentists can ask patient to repeat the given instructions to confirm if the patient has well understood the provided information.40 It is recommended that the dentist must give full attention to their patients by maintaining eye contact and by encouraging patients to discuss and ask any questions related to their health concerns.40 In addition, verbal information can be supplemented by written information without any medical/ dental jargons and acronyms.41 Furthermore, teaching by using visual means such as line drawings, pictograms, illustrations, videos etc. can be beneficial in explaining details of preventive measures of osteoporosis.42 Additionally, a telephone extension number to call and clarify any further questions related to prevention, evaluations, treatment options available or medications can be provided. Following is a summary of the effective oral health literacy communication strategies that should be used to help patients understand better.
Oral health literacy’s effective communication strategies:
• Recognize and be sensitive to patient’ diverse communication needs
• Present preventive information in small sentences
• Provide full attention to patient through eye contact
• Use “teach back technique” to confirm if patient has understood the provided information
• Supplement verbal information with written information with no medical/ dental jargons and acronyms
• Use pictograms/ illustrations/ videos for better understanding of patients
• Provide a telephone extension number to call and clarify any further questions
• Include the basic preventive information for example nature of disease and its consequences, what options of treatment are available, preventive dietary and exercise routine and methods of preventing falls and fractures
Although panoramic radiographs cannot be used to diagnose systemic osteoporosis but it is functional in prescreening of osteoporosis and the cases having less than 3 mm of bone density should be referred to physician for further diagnosis of systemic osteoporosis. In addition, oral health literacy’s effective communication strategies should be used to educate patients about health promoting and preventive measures to maintain and promote their bone health. Furthermore, dental professionals should adopt multidisciplinary approach and collaborate with various specialists to provide their patients with adequate diagnostic, preventive and therapeutic options related to osteoporosis. In conclusion, by integrating osteoporosis screenings, oral health literacy effective communication strategies and consultations in a forum of multidisciplinary team members, dentists can play a significant role in screening osteoporotic patients who might benefit from timely diagnosis and treatment.OH
Conflict of interest
No conflict of
interest is declared
Navdeep Kaur is a doctoral student in the department of biomedical sciences, Faculty of medicine, Université de Montréal; Daniel Kandelman is full professor and director of the international center of prevention of oral diseases for specific needs population, Faculty of dental medicine, Université de Montréal.
Oral Health welcomes this original article.
1. World Health Organization Prevention and Managemnet of Osteoporosis- A Report of WHO Scientific group. http://apps.who.int/iris/bitstream/10665/42841/1/WHO_TRS_921.pdf?ua=1, 2003.
2. National Osteoporosis Foundation. What is osteoporosis? Available from: http://nof.org/learn/basics.
3. Osteoporosis Canada. Facts and statistics Available from: http://www.osteoporosis.ca/osteoporosis-and-you/osteoporosis-facts-and-statistics/
4. Kanis, J.A., et al., The diagnosis of osteoporosis. J Bone Miner Res, 1994. 9 (8): p. 1137-41.
5. Bonura, F., Prevention, screening, and management of osteoporosis: an overview of the current Postgrad Med, 2009. 121(4): p. 5-17.
6. Brock, K.E., et al., Vitamin D status is associated with sun exposure, vitamin D and calcium intake, acculturation and attitudes in immigrant East Asian women living in Sydney. J Steroid Biochem Mol Biol, 2013. 136: p. 214-7.
7. Bouillon, R., et al., Vitamin D metabolism and action. Osteoporos Int, 1998. 8 Suppl 2: p. S13-9.
8. Shea, B., et al., Calcium supplementation on bone loss in postmenopausal women. Cochrane Database Syst Rev, 2004(1): p. CD004526.
9. Tang, B.M., et al., Use of calcium or calcium in combination with vitamin D supplementation to prevent fractures and bone loss in people aged 50 years and older: a meta-analysis. Lancet, 2007. 370(9588): p. 657-66.
10. Boonen, S., et al., Need for additional calcium to reduce the risk of hip fracture with vitamin D supplementation: evidence from a comparative metaanalysis of randomized controlled trials. J Clin Endocrinol Metab, 2007. 92(4): p. 1415-23.
11. Palmer, C.A. and J.A. Gilbert, Position of the Academy of Nutrition and Dietetics: the impact of on health. J Acad Nutr Diet, 2012. 112(9): p. 1443-53.
12. Pak, C.Y., et al., Treatment of postmenopausal osteoporosis with slow-release sodium fluoride. Final report of a randomized controlled trial. Ann Intern Med, 1995. 123(6): p. 401-8.
13. Hillier, S., et al., Fluoride in drinking water and risk of hip fracture in the UK: a case-control study. Lancet, 2000. 355(9200): p. 265-9.
14. Kanis, J.A., et al., Smoking and fracture risk: a meta-analysis. Osteoporos Int, 2005. 16(2): p. 155-62
15. Abate, M., et al., Cigarette smoking and musculoskeletal disorders. Muscles Ligaments Tendons J, 2013. 3(2): p. 63-9.
16. Krall, E.A. and B. Dawson-Hughes, Smoking and bone loss among postmenopausal women. J Bone Miner Res, 1991. 6(4): p. 331-8.
17. Krall, E.A. and B. Dawson-Hughes, Smoking increases bone loss and decreases intestinal calcium absorption. J Bone Miner Res, 1999. 14(2): p. 215-20.
18. Kanis, J.A., et al., Alcohol intake as a risk factor for fracture. Osteoporos Int, 2005. 16(7): p. 737-42.
19. Plauto Christopher Aranha Watanabe, M.G.a.d.C.W.a.R.T., How Dentistry Can Help Osteoporosis 2012. Yannis Dionyssiotis (Ed.), ISBN: 978-953-51-0026-3, InTech.Available from: http://www.intechopen.com/books/osteoporosis/how-dentistry-can-help-fight-osteoporosis.
20. Sinaki, M., Exercise for patients with osteoporosis: management of vertebral compression fractures and trunk strengthening for fall prevention. PM R, 2012. 4(11): p. 882-8.
21. Wactawski-Wende, J., et al., The association between osteoporosis and alveolar crestal height in postmenopausal women. J Periodontol, 2005. 76(11 Suppl): p. 2116-24.
22. Devlin, H., et al., Diagnosing osteoporosis by using dental panoramic radiographs: the OSTEODENT project. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 2007. 104(6): p. 821-8.
23. Taguchi, A., et al., Use of dental panoramic radiographs in identifying younger postmenopausal women with osteoporosis. Osteoporos Int, 2006. 17(3): p. 387-94.
24. Parlani S, N.P., Agrawal S, Chitumalla R, Beohar G et al. , Role of Panoramic Radiographs in the Detection of Osteoporosis. Oral Hyg Health, 2014. 2(121).
25. Lopez-Lopez, J., et al., Early diagnosis of osteoporosis by means of orthopantomograms and oral x-rays: a systematic review. Med Oral Patol Oral Cir Bucal, 2011. 16(7): p. e905-13.
26. A Taguchi, M.O., T Nakamoto, K Naito, M Tsuda, Y Kudo, E Motoyama, Y Suei1 and K Tanimoto, Identification of post-menopausal women at risk of osteoporosis by trained general dental practitioners using panoramic radiographs. Dentomaxillofac Radiol, 2007. 36: p. 149-54.
27. Nackaerts, O., et al., Osteoporosis detection using intraoral densitometry. Dentomaxillofac Radiol, 2008. 37(5): p. 282-7.
28. Kribbs, P.J., Comparison of mandibular bone in normal and osteoporotic women. J Prosthet Dent, 1990. 63(2): p. 218-22.
29. Horner, K., H. Devlin, and L. Harvey, Detecting patients with low skeletal bone mass. J Dent, 2002. 30(4): p. 171-5.
30. Taguchi, A., et al., [Screening for osteoporosis by dental panoramic radiographs]. Clin Calcium, 2006. 16(2): p. 291-97.
31. Merheb, J., et al., Relation between Spongy Bone Density in the Maxilla and Skeletal Bone Density.Clin Implant Dent Relat Res, 2014.
32. Dragoi, D., et al., A multidisciplinary approach in patients with femoral neck fracture on an osteoporotic basis. Rom J Morphol Embryol, 2010. 51(4): p. 707-11.
33. Hall, J.A., D.L. Roter, and N.R. Katz, Meta-analysis of correlates of provider behavior in medical encounters. Med Care, 1988.
26(7): p. 657-75.
34. Rozier, R.G., A.M. Horowitz, and G. Podschun, Dentist-patient communication techniques used in the United States: the results of a national survey. J Am Dent Assoc, 2011. 142(5): p. 518-30.
35. Horowitz, A.M., et al., Use of recommended communication techniques by Maryland dental hygienists. J Dent Hyg, 2013. 87(4): p. 212-23.
36. Healthy people 2010.2nd ed.,Vol.II : Oral Health.Washington,DC:US Government Printing Office 2000.
37. Baker, D.W., et al., Functional health literacy and the risk of hospital admission among Medicar managed care enrollees. Am J Public Health, 2002. 92(8): p. 1278-83.
38. Wehmeyer, M.M., et al., The impact of oral health literacy on periodontal health status. J Public Health Dent. 2012 Nov 2
39. Migliorati, C.A., K. Mattos, and M.J. Palazzolo, How patients’ lack of knowledge about oral bisphosphonates can interfere with medical and dental care. J Am Dent Assoc, 2010. 141(5): p. 562-6.
40. Helen Osborne, M.E., OTR/L, Health Literacy From A to Z, Second Edition: Practical Ways to Communicate your Health Message. October 7, 2011. Jones & Bartlett Learning, Burlington, MA.
41. Arora, A., et al., ‘English leaflets are not meant for me’: a qualitative approach to explore oral health literacy in Chinese mothers in Southwestern Sydney, Australia. Community Dent Oral Epidemiol, 2012. 40(6): p. 532-41.
42. In Other Words…Using Visuals and Other Creative Tools to Make Health Messages Clear,Available from: http://www.healthliteracy.com/article.asp?PageID=7409 .