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Assessing Bone Health Among Your Patients
Margaret I. Scarlett, DMD
As a dental professional, you know that calcium is essential to bone and tooth health, especially during pregnancy for fetal development and later in life. But did you know that the incidence of osteoporosis is increasing in the United States, largely because of the graying of the population and lack of prevention?1
By 2020, one in two Americans aged 50 years or older will be at risk for fractures, according to a recent Surgeon General’s report.2 The cost of treating these fractures is estimated at more than $25 billion per year, with yearly increases expected after 2020. Studies show that many physicians do not detect bone density problems or treat osteoporosis with nutritional supplements or medications, even after fracture.2 In your role as an oral health provider, you can assess bone health for your patients with a few simple questions.
Proper exercise and adequate amounts of calcium during the entire lifespan are essential to maintaining good bone health. This overview article addresses ways to help your patients ensure optimal bone health throughout life, and offers some practical questions you can incorporate easily into your practice’s medical history questionnaire.
Maintaining healthy bones is important because they provide structure, protect organs, anchor muscles, and more. Over the lifespan, bone health can be difficult to maintain because the skeleton has two simultaneous and competitive functions. One is repairing damage to the skeleton or laying down new bone in response to changes in weight-bearing activity. The other is to function as a storehouse for calcium and phosphorus for the rest of the body. Maintaining constant levels in the blood and cells is critical for the function of all body organs, especially nerves and muscle. An intricate system of regulatory hormones regulates the storehouse of calcium and phosphorus in bone and other organs, such as the intestines and kidneys. These include growth hormones and cortisol, the stress hormone.
Similar to a bank account, the skeleton deposits or withdraws calcium or phosphorus as necessary. If too many withdrawals occur, bone is weakened, leading to osteoporosis. With its dual roles, bone is constantly changing. Old bone breaks down and new bone forms on a continuous basis, with the skeleton being replaced as much as 10 times during the lifespan.
Bone is composed of crystals of mineral bound to protein. The crystal phase of bone contains calcium and phosphate, called hydroxyapatite. Hydroxyapatite also is found in teeth; in bone, it is bound in a matrix with the protein, collagen. Made by osteoblasts, collagen and the crystal matrix are arranged into a hollow form. The outer shell or cortical bone comprises approximately 75% of skeletal mass, with the inside, or trabecular bone, comprising the remainder. Osteoblasts build bone, while osteoclasts resorb bone.
The sex hormones estrogen and testosterone, along with three calcium-regulating hormones, maintain bone mass. Parathyroid hormone regulates bone activity. Calcitriol, a vitamin D hormone, regulates intestinal absorption of calcium. And calcitonin, an inhibitor of bone breakdown, regulates blood calcium levels.2
Medical History Questions
There are several important questions that you as a healthcare provider can ask your patients to gain a sense of their state of bone health. These four questions also give you an opportunity to explain the importance of bone health and steps your patients can take to maintain that health.
1. Do you have adequate sources of calcium, phosphorus, and vitamin D for bone health every day?
This question helps you assess your patient for adequate sources of calcium, phosphorus, and vitamin D, which are essential to good bone health. Calcium requirements vary through life because it is not produced by the body (Table 1); rather, calcium must be obtained from nutritional sources. Absorption of calcium is assisted by vitamin D, which is why milk is fortified with it. Necessary for healthy bones and teeth, calcium also is necessary for functioning of the heart, muscles, and nerves. Common sources of calcium include:
- Dairy products—cheese, milk, yogurt, and other dairy products
- Green leafy vegetables—broccoli, kale, and others
- Calcium-fortified foods—oatmeal, cereals, bread, and soy2
2. Do you exercise every day?
This question can help you assess if your male and female patients are getting enough regular exercise to minimize bone loss. Based on genetic potential for bone density, peak bone mass occurs around age 20 in most individuals and declines with aging, making older adults more vulnerable to osteoporosis. Osteoporosis is defined as a decline in bone mass, with resulting risks of bone fractures, commonly in the hip, spine, and wrist.2
Independent of genetics, bone mass and architecture are modified by exercise. Like muscles, bones change based on mechanical and biochemical processes that maintain mass and density through life. Simple exercises like walking, jogging, running, or playing tennis, golf, or dancing help. For children, about 60 minutes of moderate physical activity is recommended; for adults at least 30 minutes of moderate physical activity is recommended.2
3. What type of medications are you taking?
This question is important because many prescription medications, including anticonvulsants, immunosuppressive drugs, and glucocorticoids, can impact bone density. With long-term use, lithium, heparin, medroxyprogesterone, and cortisone impact bone density. Moreover, endocrine disorders such as hyperparathyroidism, liver disease, intestinal disorders such as inflammatory bowel disease, Crohn’s disease, or conditions resulting in lack of physical activity can all impact bone mass. These medications and conditions affect both men and women.
4. Have you had bone density diagnostics and/or treatment for osteoporosis?
This question will alert you to those patients who have been diagnosed with a bone density condition and to those patients who may need to be referred for diagnostic testing. A patient’s panoramic radiographs may provide clues. Studies show that reduced trabecular patterns detected in the mandible could indicate bone and vascular health.3
General risk factors for osteoporosis are listed in Table 2. Lack of estrogen in postmenopausal women is a major risk for osteoporosis. Recent concerns about the safety of estrogen replacement at menopause have prompted some women to opt against hormone replacement therapy in favor of treatment for prevention of osteoporosis.2 A number of treatments for osteoporosis are available, some of which impact dental treatment. A physician can discuss and provide the treatment options to patients after initial diagnostic tests have been performed.
One class of prevention medication, biophosphonates, has been implicated in increased risks for osteonecrosis of the jaws associated with postsurgical implant placement. These medications include pamidronate, zoledronate, and alendronate. Presurgical antibiotics and chlorhexidine rinses have been shown to reduce the risk for osteonecrosis.4
While measuring bone strength directly is not possible, current measurements for bone density, which acts as a proxy for bone strength, are calculated using radiographs and absorptiometry. Bone density is measured by central diagnostic machines at the spine, hip, wrist, and humerus, using the World Health Organization’s gold standard: Reflected as a T-score, normal ranges from -1 through 0 to +1, and osteoporosis at -2.5 or higher.2
Currently, 10 million Americans over age 50 are estimated to have osteoporosis; another 34 million are at risk.2 Each year, about 1.5 million people will have an osteoporotic related fracture, resulting in a rapid decline in physical and mental health.1 About 20% of seniors with hip fracture die within 1 year, with the incidence of fractures likely to double by the year 2020.1,2 You can assist in preventing this growing problem by asking your patients these few simple questions.
1. Burge R, Dawson-Hughes B, Solomon DH, et al. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005-2025. J Bone Miner Res. 2007; 22(3):465-475.
2. Bone Health and Osteoporosis: A Report of the Surgeon General. Rockville, MD: US Dept of Health and Human Services, Office of the Surgeon General; 2004.
3. Taguchi A, Suei Y, Sanada M, et al. Detection of vascular disease risk in women by panoramic radiography. J Dent Res. 2003;82(10): 838-843.
4. Marx RE, Sawatari Y, Fortin M, et al. Bisphosphonate-Induced Exposed Bone (Osteonecrosis/Osteopetrosis) of the Jaws. J Oral Maxillofac Surg. 2005;63(11): 1567-1575.
About the Author
Margaret I. Scarlett, DMD
Scarlett Consulting International