Trabecular bone patterns as a fracture risk predictor: a systematic review

Abstract

Background: The aim of this systematic review was to evaluate the assessment of trabecular bone patterns in dental radiographs, for fracture risk prediction, compared with the current diagnostic methods. Methods: The PRISMA guidelines were followed. According to predefined inclusion criteria (PICO), literature searches were focussed on published studies with analyses of trabecular bone patterns on intraoral and/or in panoramic radiographs, compared with Dual X-ray Absorptiometry (DXA) and/or Fracture Risk Assessment Tool (FRAX), with the outcomes; fracture and/or sensitivity and specificity for osteoporosis prediction. The included studies were quality-assessed using the QUADAS-2 tool and the certainties of evidence was assessed using the GRADE approach. Results: The literature searches identified 2913 articles, whereas three were found to meet the inclusion criteria. Two longitudinal cohort studies evaluated the use of trabecular bone patterns to predict bone fractures. In one of the studies, the relative risk of fracture was significantly higher for women with sparse bone pattern, identified by visual assessment of dental radiographs, and in the other study by digital software assessment. Visual assessment in the second study did not show significant results. The cross-sectional study of digital analyses of trabecular bone patterns in relation to osteoporosis reported a sensitivity of 0.70 and a specificity of 0.69. Conclusion: Based on low certainty of evidence, trabecular bone evaluation on dental radiographs may predict fractures in adults without a prior diagnosis of osteoporosis, and based on very low certainty of evidence, it is uncertain whether digital image analyses of trabecular bone can predict osteoporosis.

Patients’ thoughts about assessment of fracture risk in a dental setting using FRAX—a qualitative interview study

“…Intraoral radiographs have been used for both visual and semi-automated assessments of the trabecular pattern of the mandibular bone [ 10 – 12 ]. The visual method is operator dependent and requires careful calibration, and there is no semi- or automated method that uses intraoral radiographs with sufficient scientific evidence to justify individual risk assessment [ 13 ]. Studies using panoramic radiographs have included different aspects of the morphology of the mandible, such as the cortical width and porosity, and trabecular structure, often using different indexes, to identify patients with a higher risk of osteoporosis or fragility fracture [ 14 – 17 ].…”

“…Some Swedish private dentists have previously offered an assessment of the risk of osteoporosis by uploading intraoral radiographs on a website together with some information about gender, age, etc. The trabecular pattern of the bone on the radiograph was assessed over several years by a private company, and this resulted in a high, medium, or low risk of osteoporosis, although the scientific evidence supporting this method of assessing fracture risk on an individual level was poor [ 12 , 13 ]. Some pharmacies in Sweden offer a measurement of blood pressure or blood sugar, often in collaboration with a private primary health care provider.…”

Indices in dental image exams for bone mineral density evaluation of aromatase inhibitor users

“…Radiomorphometric indices of the lower jaw can be used to detect changes in bone mass, and this can be a useful tool for BMD screening and determining the need for referral of affected individuals for more specific exams and therapy for osteopenia/osteoporosis. [7][8][9][10] With DPR, it is also possible to analyze bone characteristics through mathematical methods, called fractal dimension analysis, which measures the complexity of irregular structures, providing further information that can help in the diagnosis of low BMD due to trabecular bone changes caused by osteoporosis. 6 In recent years, access to cone beam computed tomography (CBCT) has increased, particularly in dentistry, due to its low cost and reduced radiation dose compared to other imaging exams such as computed tomography.…”

Aspects of osteoporosis and fracture risk assessment in primary dental care: attitudes, willingness to pay and evaluation of an automated software

“…However, it is of the highest importance to keep the number of falsepositive assessments as low as possible to avoid unnecessary worry for the patients and redundant excessive workload in the medical clinics that handle possible referrals. Two recently performed systematic reviews by Pachêco-Pereira et al [2019] and Johanen et al [2021] presented a comprehensive compilation of research papers within the field of trabecular bone pattern analysis using dental radiographs for systemic disorder screening and fracture risk, respectively. Only three of the included studies (one in Pachêco-Pereira et al [2019] and two in Johanen et al [2021]) used intraoral radiographs and a software/algorithm for the purpose of trabecular pattern analysis.…”

“…Two recently performed systematic reviews by Pachêco-Pereira et al [2019] and Johanen et al [2021] presented a comprehensive compilation of research papers within the field of trabecular bone pattern analysis using dental radiographs for systemic disorder screening and fracture risk, respectively. Only three of the included studies (one in Pachêco-Pereira et al [2019] and two in Johanen et al [2021]) used intraoral radiographs and a software/algorithm for the purpose of trabecular pattern analysis. Interestingly, only used Jaw-X software, a previous generation of Boneprox software that we used in studies III and IV.…”