Nutrition and Oral Medicine (Nutrition and Health)

Chapter 15 / Osteoporosis 2634. EFFECTS OF OSTEOPENIAAND OSTEOPOROSIS ON THE ORAL CAVITYPeriodontal disease and tooth loss become more prevalent with increased age (7,8), soit may be expected that a large proportion of the elderly population will exhibit these oralconditions concurrently with signs of osteoporosis or osteopenia. However, many epidemiologicstudies find that individuals with poor bone status at systemic skeletal sites tendto have more oral bone loss, periodontal disease, and tooth loss than similarly agedindividuals with good skeletal bone status (1,9–14), which suggests that the relationshipis more than coincidental. Other studies report no associations (15–18). Each study haslimitations. The strength of the evidence must be evaluated in the context of subjectselection, sample size, and study design.Given the complex causes of oral and systemic bone loss, associations between thetwo are likely to be moderate or weak, and large sample sizes are needed to ensureadequate statistical power. Randomized clinical trials offer the best evidence for acausal relationship, but none are available to date. The next best level of evidenceconsists of prospective studies that simultaneously follow changes in systemic bone andoral status over time. Finally, cross-sectional studies offer weak evidence for or againsta causal relationship. Findings should be controlled for potential confounders such asage or years since menopause, smoking status, and hormone replacement status. Thecurrent state of the knowledge is such that most of the human studies of associationsbetween systemic bone status and oral outcomes are cross-sectional and do not alwayscontrol for multiple confounders. The prospective studies and more comprehensivecross-sectional studies are described in more detail below.4.1. Periodontal Diseases: Alveolar Bone LossPeriodontal disease involves the destruction of alveolar bone tissue by bacteriainducedinflammation. Although bacteria are necessary to initiate and continue theinflammatory response, osteopenia and osteoporosis might act as host characteristicsthat influence the initial bone quantity and quality. Few studies have included directmeasurements of oral bone loss. Payne et al. (9) assessed changes in alveolar bone heightover a period of 2 yr in 17 postmenopausal women with osteoporosis at the spine and21 women with normal BMD. The osteoporotic women exhibited significantly moresites with alveolar bone loss than women with normal spine BMD. Moderate correlationsbetween alveolar bone height and BMD of the hip, spine, and forearm have beenreported in several small cross-sectional studies of women comprising a wide age range(1,19–22). In contrast, Elders et al. (15)reported no association between spine BMD andloss of alveolar bone height on molars and premolars in healthy women between the agesof 46 and 55. Subjects in this latter study were all early postmenopausal with goodperiodontal health on average.4.2. Clinical Measures of Periodontal DiseaseOther studies (10,15–17) examined the relationship of systemic bone status to clinicalmeasures of periodontal disease such as clinical attachment loss (CAL) and periodontalpocket depth (PPD). In a cross-sectional analysis of data from 11,655 participants in thethird National Health and Nutrition Examination Survey (NHANES III), BMD of the