Journal of Mid-life Health Journal of Mid-life Health
Home | About us | Editorial board | Search | Ahead of print | Current Issue | Past Issues | Instructions | Online submission | Subscribe | Advertise Users Online: 320  Print this pageEmail this pageSmall font sizeDefault font sizeIncrease font size 




 
 Table of Contents 
REVIEW ARTICLE
Year : 2017  |  Volume : 8  |  Issue : 4  |  Page : 151-158  

Osteoporosis and periodontitis in postmenopausal women: A systematic review


1 Department of Dentistry, All Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of Orthopedics, All Institute of Medical Sciences, Rishikesh, Uttarakhand, India
3 Department of Periodontics and Community Dentistry, Dr. Ziauddin Ahmad Dental College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

Date of Web Publication13-Dec-2017

Correspondence Address:
Dr. Lata Goyal
Department of Dentistry, All India Institute of Medical Sciences, Rishikesh - 249 201, Uttarakhand
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmh.JMH_55_17

Rights and Permissions
   Abstract 


This systematic review was done to assess the strength of association between osteoporosis and chronic periodontitis in postmenopausal women, assessed by bone mineral density (BMD) and clinical attachment loss, respectively. The Pubmed, Cochrane central, EMBASE, and Google Scholar were searched from year 1990 to 2015 for studies on association between chronic periodontitis and osteoporosis. Studies measuring osteoporosis in terms of central BMD and periodontitis in terms of clinical attachment level were studied. Data were extracted and descriptive analysis was performed. Screening of 1188 articles resulted in 24 articles for review after reading the titles and abstracts. Fifteen studies were shortlisted for inclusion in systematic review. Ten of these studies showed an association between periodontitis and osteoporosis. It implies that patients with severe periodontitis should also be evaluated for systemic bone health and vice versa.

Keywords: Bone mineral density, chronic disease, inflammation, tooth loss


How to cite this article:
Goyal L, Goyal T, Gupta N D. Osteoporosis and periodontitis in postmenopausal women: A systematic review. J Mid-life Health 2017;8:151-8

How to cite this URL:
Goyal L, Goyal T, Gupta N D. Osteoporosis and periodontitis in postmenopausal women: A systematic review. J Mid-life Health [serial online] 2017 [cited 2018 Apr 25];8:151-8. Available from: http://www.jmidlifehealth.org/text.asp?2017/8/4/151/220670




   Introduction Top


Chronic periodontitis is characterized by loss of periodontal attachment due to destruction of the periodontal ligament and loss of the adjacent supporting bone.[1] The epidemiology of periodontitis is complicated by the varying definitions of the disease and widely reported global variations in the prevalence and severity of the disease.[2],[3] Several host factors are responsible for progression of the periodontal disease such as smoking, diabetes mellitus, obesity, steroids, or cytotoxic medications.[4] Prevalence of periodontitis increases with age and is the most common cause of tooth extraction in older patients.[5] Postmenopausal status is also an important risk factor for periodontal diseases.[6],[7]

Osteoporosis is decreasing bone mass with weakening of microarchitecture of the bone. According to the World Health Organization (WHO) criteria, osteoporosis is defined as a bone mineral density (BMD) that lies 2.5 standard deviations or more below the average value for young healthy women. Normal BMD is defined as T-score of −1.0 or higher and a T-score between −1.0 and −2.5 is defined as osteopenia or low bone mass.[8] Elderly postmenopausal females are worst affected by osteoporosis.[9] Since both these conditions share common risk factors and loss of supporting periodontal bone is associated with progression of periodontitis, various researchers have looked into association between the two conditions.[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34]

Both chronic periodontitis and osteoporosis are slowly developing diseases that often come to notice only after a significant amount of damage has already taken place. Pharmacotherapy and dietary interventions are an effective means of prevention of postmenopausal osteoporosis.[35] Understanding the association between osteoporosis and chronic periodontitis could be useful if their prevention and treatment are inter-related. Although there is some evidence on the association between osteoporosis and periodontitis, no study has summarized these findings. The aim of this review was to systematically review the literature to determine if there is an association between chronic periodontitis and osteoporosis.


   Materials and Methods Top


This systematic review was conducted in accordance with the 2009 PRISMA statement.[36]

Focused Question: Is there an association between osteoporosis and periodontitis in postmenopausal women, as assessed by BMD and clinical attachment loss, respectively?

Search strategy

Comprehensive search of literature was carried out using PubMed (http://www.ncbi.nlm.nih. gov/pubmed), EMBASE (http://www.elsevier.com/online-tools/embase), Google Scholar, and the Cochrane database (http://www.cochrane.org) for all studies published in the English language before 24th December 2015. The following search terms were used: (“osteoporosis” [MeSH] OR “bone density' [MeSH]) AND (“periodontitis” [MeSH] OR “periodontal attachment loss” [MeSH] OR “periodontal”). The eligible studies were selected by going through the title and abstracts. Full text was extracted for the studies found eligible after study of abstracts. The references of the studies shortlisted for review and articles found in this search were hand searched.

Screening and selection

Inclusion criteria

  1. Studies on human subjects published in English language were included for the review
  2. Studies that were of case–control or cohort or cross-sectional designs. Studies were included if they directly compared the association between osteoporosis (expressed in terms of BMD) and chronic periodontitis measured in terms of clinical attachment level (CAL) or CAL and pocket probing depth (PPD)
  3. Diagnosis of osteoporosis made using dual energy X-ray absorptiometry (DEXA) test performed on hip or spine
  4. Postmenopausal females were included for study.


Exclusion criteria

  1. Review articles and case series were excluded
  2. DEXA on peripheral bones or diagnosis of osteoporosis using ultrasonography or X-rays was excluded as these do not give as accurate diagnosis of osteoporosis as DEXA of axial skeleton
  3. Studies where diagnosis of chronic periodontitis was made using tooth loss, oral hygiene, gingival appearance, or use of a dental prosthesis were excluded
  4. Studies based on self-reported diagnosis of osteoporosis/periodontal conditions were also excluded
  5. Studies that did not report any estimates for the association between osteoporosis and periodontitis were excluded.


Definition of osteoporosis and periodontitis

The WHO definition of osteoporosis, where osteoporosis is defined in terms of T-score of the BMD was taken.[8] Osteoporosis is diagnosed when the T-score is 2.5 standard deviations or more below the mean BMD value of a young sex-matched reference population. Studies which had calculated BMD on both the lumbar spine and hip, we took the values of the worst affected site. Periodontitis was defined by criteria given by American Academy of Periodontology, patients having ≥3 mm of clinical attachment loss and more than 30% of sites involved.[1] Periodontitis was expressed in terms of measured values of CAL or CAL and PPD.

Data collection

From each eligible study, following information was extracted:First author, year of publication, study design, country, ethnicity of population, mean age, gender, sample size, BMD site, T-scores, CAL, PPD, and relevant effect sizes (mean difference, odds ratios or relative risks, or correlation coefficients). Screening of abstracts and full texts and data extraction were performed independently by two different reviewers (LG and TG). If there was any discrepancy between the reviewers it was resolved by mutual consensus.

Statistical methods

The studies were heterogeneous in terms of cutoff values of CAL used for diagnosis of severe periodontitis. There were differences in the statistical analysis and reporting of results so that data from these studies could not be pooled together for a meta-analysis.


   Results Top


Initial search showed 1188 articles, of which 723 were in English language and on human subjects. Of these, 24 articles were selected for further review after reading the titles and abstracts.[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32] Full texts of these articles were extracted, and on the basis of inclusion criteria mentioned before, 15 studies were shortlisted for inclusion in systematic review.[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25] The details of the study selection process are shown in [Figure 1]. All included studies were case–control or cross-sectional in nature, with level IV evidence.[37]
Figure 1: PRISMA flowchart describing the process of study selection and exclusion

Click here to view


A total number of patients in these studies were 4210. Demographic details and chief conclusion from the studies are summarized in [Table 1]. Most of the included studies had expressed the results in different statistical terms such as mean values of CAL in different groups, correlation or regression coefficients, and odds ratio [Table 2], [Table 3], [Table 4]. Cutoff values for CAL and PPD were different in different studies [Table 1]. Among the 15 studies included in the systematic review, ten showed a significant association between chronic periodontitis and osteoporosis.
Table 1: Summary of studies included, their main finding, and conclusion

Click here to view
Table 2: Summary of relation between bone mineral density and clinical attachment loss in included studies (correlation coefficients)

Click here to view
Table 3: Summary of relation between bone mineral density and clinical attachment loss (odds ratio)

Click here to view
Table 4: Summary of relation between bone mineral density and clinical attachment loss

Click here to view


Brennan et al.[11] had used the highest sample size of 1329 patients. They found significant correlation for worst site T-score (r = −0.069, P = 0.01) and BMD of total forearm (−0.092, P = 0.001), anteroposterior spine (r = −0.058, P = 0.05), and whole body (r = −0.056, P = 0.048).


   Discussion Top


This systematic review favors a strong association between the central BMD and CAL. Periodontitis is infection-induced inflammation of the structures around the tooth resulting in loss of its soft tissue attachment and surrounding bone mass, finally resulting in tooth loss. Not only local factors such as hygiene are associated with periodontitis, systemic factors such as diabetes, smoking, and poor general health but also affect periodontal status. A relation between osteoporosis and periodontitis has also been postulated in literature, which is also supported by this systematic review. Osteoporosis being a systemic disease, leads to loss of bone stock not only from spine and appendicular skeleton but also from the alveolar bone.[38] Thus, osteoporosis is expected to hasten the process of bone loss in chronic periodontitis.[39]

Osteoporosis is well known in postmenopausal women with maximum bone loss occurs in the first 5 years following menopause.[40] Both osteoporosis and chronic periodontitis are slowly progressive diseases sharing many features together. Osteoporosis is well known in postmenopausal women with prevalence as high as 50%.[41],[42] Postmenopausal status is also associated with increased severity of periodontitis with prevalence as high as 30%.[43],[44] Osteoporosis is a silent killer and osteoporosis-related fractures contribute to significant amount of morbidity and mortality in older population.[45] Chronic periodontitis has also been associated with increased mortality in older patients, as it may be an indicator of several associated chronic illnesses and ill health.[46]

Periodontitis is chronic inflammatory disease of supporting structures of teeth which is measured in terms of CAL, PPD, and alveolar bone loss. We selected the studies which includes CAL or CAL and PPD both. CAL is a better indicator of chronic periodontitis compared to other indicators such as number of missing teeth, PPD, and alveolar crestal height (ACH). PPD is most commonly used indicator for periodontitis, but it also measures gingiva coronal to cementoenamel junction. ACH has to be measured using oral radiographs and thus may depend on the quality and angle of X-ray projection. CAL can be measured clinically and will appear earlier compared to radiographic changes. Further generalized loss of bone density with osteoporosis may directly affect the alveolar bone.

Studies which had calculated BMD on both the lumbar spine and hip were included. Central or axial BMD, measured at spine or hip, is the most sensitive marker of osteoporosis, compared to peripheral BMD measurement at sites such as wrist or calcaneum. There is poor association between peripheral BMD and future fracture risk and the definition of osteoporosis based on peripheral BMD values are unreliable.[47] Brennan et al.[11] studied 1329 participants and found significant correlation between CAL and BMD of total forearm, worst site T-score, anteroposterior spine, and whole body. Unadjusted results of regression analysis showed consistent inverse association between BMD and CAL. However, after adjustment for age, cigarette smoking, and education, last dental cleaning results were not significant. Presence or absence of subgingival calculus was strong effect modifier. They found strongest association between BMD and clinical attachment loss in women without subgingival calculus. In the study by Tejal et al.,[24] there was a weak correlation between the CAL and systemic osteoporosis (r = 0.10–0.17), which did not reach statistical significance. Four studies did not find any association between periodontitis and osteoporosis.[18],[19],[22],[25] Marjanovic et al.[18] could not establish any association between osteoporosis and chronic periodontitis. Adjusted odds ratio for association between osteoporosis and severe periodontal disease was 0.99 (95% Confidence interval 0.61–1.61). This was a relatively larger study involving 380 participants. This was the strongest evidence against possible association between CAL and osteoporosis in this systematic review. One limitation of this study was that it measured CAL in one or two sextants only and not in the whole mouth. Furthermore, the study did not clearly mention whether premenopausal women were excluded from the study.

Pilgram et al.[22] found a weak positive correlation between the periodontal status and BMD in longitudinal follow-up of 3 years though no correlation could be seen at cross-sectional level in 135 participants. However, this study had some limitations. The primary objective was to study the effect of hormone replacement therapy on bone density and periodontal status. The number of patients suffering from osteoporosis or periodontitis was not revealed. Although Weyant et al.[25] found no statistically significant association between periodontal indicators and BMD in 292 participants, a trend toward a more severe periodontal disease was seen in all their measurements with decreasing BMD, indication of a possible association. Moeintaghavi et al.[19] also did not find any statistically significant association between osteoporosis and periodontitis, but the sample size was very small.

There has been a strong association in literature between loss of ACH and osteoporosis,[48] but conclusion on correlation between CAL and osteoporosis is lacking. A significant association between CAL and osteoporosis should imply that mechanisms other than systemic bone loss and reduction in alveolar bone density with osteoporosis play an important role in the development and progression of chronic periodontitis. There is an increasing evidence that osteoporosis may be a result of systemic inflammation.[49],[50],[51] This paves way for a common mechanism for osteoporosis and chronic periodontitis: chronic low-grade inflammation.

Limitations

There are several limitations of this review. Studies included were cross-sectional or case–control in nature. Since all the included studies were of level IV evidence, no further risk of bias assessment was done.

Prospective studies are needed in the future for better quality evidence on this topic. Meta-analysis could not be carried out due to marked heterogeneity between the studies. Definition of periodontitis and cutoff values of CAL varied across studies. The studies included in the review were not homogenous with regard to the use of anti-resorptive therapy, with some studies excluding patients taking such treatment.

A strong association between CAL and osteoporosis was confirmed. Further community-based studies prospective are required to justify the strength of this association. More information is needed on improvement of CAL and other clinical and laboratory markers of chronic periodontitis with improvement of BMD with medical treatment with antiresorptive agents. This may be difficult as any significant improvement in BMD with treatment will need several years of follow-up.


   Conclusion Top


Chronic periodontitis is strongly associated with osteoporosis in postmenopausal women.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Parameter on chronic periodontitis with slight to moderate loss of periodontal support. American Academy of Periodontology. J Periodontol 2000;71 5 Suppl:853-5.  Back to cited text no. 1
    
2.
Demmer RT, Papapanou PN. Epidemiologic patterns of chronic and aggressive periodontitis. Periodontol 2000 2010;53:28-44.  Back to cited text no. 2
    
3.
Albandar JM. Epidemiology and risk factors of periodontal diseases. Dent Clin North Am 2005;49:517-32, v-vi.  Back to cited text no. 3
[PUBMED]    
4.
Seymour GJ, Ford PJ, Cullinan MP, Leishman S, Yamazaki K. Relationship between periodontal infections and systemic disease. Clin Microbiol Infect 2007;13 Suppl 4:3-10.  Back to cited text no. 4
    
5.
Reich E. Trends in caries and periodontal health epidemiology in Europe. Int Dent J 2001;51 6 Suppl 1:392-8.  Back to cited text no. 5
    
6.
Wactawski-Wende J. Periodontal diseases and osteoporosis: Association and mechanisms. Ann Periodontol 2001;6:197-208.  Back to cited text no. 6
    
7.
Mascarenhas P, Gapski R, Al-Shammari K, Wang HL. Influence of sex hormones on the periodontium. J Clin Periodontol 2003;30:671-81.  Back to cited text no. 7
    
8.
WHO. Assessment of Fracture Risks and Its Applications to Screening for Postmenopausal Osteoporosis. WHO Technical Report Series. Geneva: WHO; 1994.  Back to cited text no. 8
    
9.
International Osteoporosis Foundation. Foundation IO the Facts about Osteoporosis and Its Impact. Lyon, France: International Osteoporosis Foundation; 2004.  Back to cited text no. 9
    
10.
Geurs NC. Osteoporosis and periodontal disease. Periodontol 2000 2007;44:29-43.  Back to cited text no. 10
    
11.
Brennan RM, Genco RJ, Hovey KM, Trevisan M, Wactawski-Wende J. Clinical attachment loss, systemic bone density, and subgingival calculus in postmenopausal women. J Periodontol 2007;78:2104-11.  Back to cited text no. 11
    
12.
Gomes-Filho IS, Passos Jde S, Cruz SS, Vianna MI, Cerqueira Ede M, Oliveira DC, et al. The association between postmenopausal osteoporosis and periodontal disease. J Periodontol 2007;78:1731-40.  Back to cited text no. 12
    
13.
Gondim V, Aun J, Fukuda CT, Takayama L, Latorre Mdo R, Pannuti CM, et al. Severe loss of clinical attachment level: An independent association with low hip bone mineral density in postmenopausal females. J Periodontol 2013;84:352-9.  Back to cited text no. 13
    
14.
Grocholewicz K, Bohatyrewicz A. Oral health and bone mineral density in postmenopausal women. Arch Oral Biol 2012;57:245-51.  Back to cited text no. 14
    
15.
Al Habashneh R, Alchalabi H, Khader YS, Hazza'a AM, Odat Z, Johnson GK. Association between periodontal disease and osteoporosis in postmenopausal women in Jordan. J Periodontol 2010;81:1613-21.  Back to cited text no. 15
    
16.
Iwasaki M, Taylor GW, Nakamura K, Yoshihara A, Miyazaki H. Association between low bone mineral density and clinical attachment loss in Japanese postmenopausal females. J Periodontol 2013;84:1708-16.  Back to cited text no. 16
    
17.
Juluri R, Prashanth E, Gopalakrishnan D, Kathariya R, Devanoorkar A, Viswanathan V, et al. Association of postmenopausal osteoporosis and periodontal disease: A double-blind case-control study. J Int Oral Health 2015;7:119-23.  Back to cited text no. 17
    
18.
Marjanovic EJ, Southern HN, Coates P, Adams JE, Walsh T, Horner K, et al. Do patients with osteoporosis have an increased prevalence of periodontal disease? A cross-sectional study. Osteoporos Int 2013;24:1973-9.  Back to cited text no. 18
    
19.
Moeintaghavi A, Pourjavad M, Dadgar S, Tabbakh NS. Evaluation of the association between periodontal parameters, osteoporosis and osteopenia in post menopausal women. J Dent (Tehran) 2013;10:443-8.  Back to cited text no. 19
    
20.
Passos JS, Vianna MI, Gomes-Filho IS, Cruz SS, Barreto ML, Adan L, et al. Osteoporosis/osteopenia as an independent factor associated with periodontitis in postmenopausal women: A case-control study. Osteoporos Int 2013;24:1275-83.  Back to cited text no. 20
    
21.
Penoni DC, Torres SR, Farias ML, Fernandes TM, Luiz RR, Leão AT, et al. Association of osteoporosis and bone medication with the periodontal condition in elderly women. Osteoporos Int 2016;27:1887-96.  Back to cited text no. 21
    
22.
Pilgram TK, Hildebolt CF, Dotson M, Cohen SC, Hauser JF, Kardaris E, et al. Relationships between clinical attachment level and spine and hip bone mineral density: Data from healthy postmenopausal women. J Periodontol 2002;73:298-301.  Back to cited text no. 22
    
23.
Singh A, Sharma RK, Siwach RC, Tewari S, Narula SC. Association of bone mineral density with periodontal status in postmenopausal women. J Investig Clin Dent 2014;5:275-82.  Back to cited text no. 23
    
24.
Tezal M, Wactawski-Wende J, Grossi SG, Ho AW, Dunford R, Genco RJ. The relationship between bone mineral density and periodontitis in postmenopausal women. J Periodontol 2000;71:1492-8.  Back to cited text no. 24
    
25.
Weyant RJ, Pearlstein ME, Churak AP, Forrest K, Famili P, Cauley JA. The association between osteopenia and periodontal attachment loss in older women. J Periodontol 1999;70:982-91.  Back to cited text no. 25
    
26.
Aspalli SS, Shetty VS, Parab PG, Nagappa G, Devnoorkar A, Devarathnamma MV. Osteoporosis and periodontitis: Is there a possible link? Indian J Dent Res 2014;25:316-20.  Back to cited text no. 26
[PUBMED]  [Full text]  
27.
Bullon P, Goberna B, Guerrero JM, Segura JJ, Perez-Cano R, Martinez-Sahuquillo A. Serum, saliva, and gingival crevicular fluid osteocalcin: Their relation to periodontal status and bone mineral density in postmenopausal women. J Periodontol 2005;76:513-9.  Back to cited text no. 27
    
28.
Kim BJ, Ahn SH, Bae SJ, Kim EH, Kim TH, Lee SH, et al. Association between metabolic syndrome and bone loss at various skeletal sites in postmenopausal women: A 3-year retrospective longitudinal study. Osteoporos Int 2013;24:2243-52.  Back to cited text no. 28
    
29.
Lohana M, Suragimath G, Abbayya K, Varma S, Zope S, Kale V. A study to assess and correlate osteoporosis and periodontitis in selected population of Maharashtra. J Clin Diagn Res 2015;9:ZC46-50.  Back to cited text no. 29
    
30.
Darcey J, Devlin H, Lai D, Walsh T, Southern H, Marjanovic E, et al. An observational study to assess the association between osteoporosis and periodontal disease. Br Dent J 2013;215:617-21.  Back to cited text no. 30
    
31.
Hernández-Vigueras S, Martínez-Garriga B, Sánchez MC, Sanz M, Estrugo-Devesa A, Vinuesa TT. Oral microbiota, periodontal status and osteoporosis in postmenopausal women. J Periodontol 2015;15:1-15.  Back to cited text no. 31
    
32.
von Wowern N, Westergaard J, Kollerup G. Bone mineral content and bone metabolism in young adults with severe periodontitis. J Clin Periodontol 2001;28:583-8.  Back to cited text no. 32
    
33.
Takaishi Y, Okamoto Y, Ikeo T, Morii H, Takeda M, Hide K, et al. Correlations between periodontitis and loss of mandibular bone in relation to systemic bone changes in postmenopausal Japanese women. Osteoporos Int 2005;16:1875-82.  Back to cited text no. 33
    
34.
Tak IH, Shin MH, Kweon SS, Nam HS, Cauley JA, Kim OJ, et al. The association between periodontal disease, tooth loss and bone mineral density in a Korean population. J Clin Periodontol 2014;41:1139-44.  Back to cited text no. 34
    
35.
Cosman F, de Beur SJ, LeBoff MS, Lewiecki EM, Tanner B, Randall S, et al. Clinician's guide to prevention and treatment of osteoporosis. Osteoporos Int 2014;25:2359-81.  Back to cited text no. 35
    
36.
Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: Explanation and elaboration. BMJ 2009;339:b2700.  Back to cited text no. 36
    
37.
Howick J, Chalmers I, Glasziou P, Greenhalgh T, Heneghan C, Liberati A, et al. Introduction to the 2011 Oxford Centre for Evidence-Based Medicine (OCEBM) Table of Evidence Oxford, Oxford Centre for Evidence-Based Medicine; 2011.  Back to cited text no. 37
    
38.
Indrasari M, Kusdhany LS, Koesmaningati H. Resorption level of edentulous alveolar bone in normal, osteopenia and osteoporosis Postmenopausal women. Int J Clin Prev Dent 2012;8:141-6.  Back to cited text no. 38
    
39.
Groen JJ, Menczel J, Shapiro S. Chronic destructive periodontal disease in patients with presenile osteoporosis. J Periodontol 1968;39:19-23.  Back to cited text no. 39
    
40.
Ahlborg HG, Johnell O, Nilsson BE, Jeppsson S, Rannevik G, Karlsson MK. Bone loss in relation to menopause: A prospective study during 16 years. Bone 2001;28:327-31.  Back to cited text no. 40
    
41.
Paul TV, Thomas N, Seshadri MS, Oommen R, Jose A, Mahendri NV. Prevalence of osteoporosis in ambulatory postmenopausal women from a semiurban region in Southern India: Relationship to calcium nutrition and Vitamin D status. Endocr Pract 2008;14:665-71.  Back to cited text no. 41
    
42.
Kanis JA, Burlet N, Cooper C, Delmas PD, Reginster JY, Borgstrom F, et al. European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int 2008;19:399-428.  Back to cited text no. 42
    
43.
Albandar JM, Rams TE. Global epidemiology of periodontal diseases: An overview. Periodontol 2000 2002;29:7-10.  Back to cited text no. 43
    
44.
Locker D, Slade GD, Murray H. Epidemiology of periodontal disease among older adults: A review. Periodontol 2000 1998;16:16-33.  Back to cited text no. 44
    
45.
WHO Scientific Group on the Assessment of Osteoporosis at Primary Care Level, Summary Meeting Report: Brussels, Belgium, 5-7 May 2004, Geneva, Switzerland: World Health Organization; 2007.  Back to cited text no. 45
    
46.
Linden GJ, Linden K, Yarnell J, Evans A, Kee F, Patterson CC. All-cause mortality and periodontitis in 60-70-year-old men: A prospective cohort study. J Clin Periodontol 2012;39:940-6.  Back to cited text no. 46
    
47.
Payne JB, Reinhardt RA, Nummikoski PV, Patil KD. Longitudinal alveolar bone loss in postmenopausal osteoporotic/osteopenic women. Osteoporos Int 1999;10:34-40.  Back to cited text no. 47
    
48.
Stanojkovic I, Kotur-Stevuljevic J, Spasic S, Milenkovic B, Vujic T, Stefanovic A, et al. Relationship between bone resorption, oxidative stress and inflammation in severe COPD exacerbation. Clin Biochem 2013;46:1678-82.  Back to cited text no. 48
    
49.
Management of Osteoporosis and the Prevention of Fragility Fractures - A National Clinical Guideline; Scottish Intercollegiate Guidelines Network – SIGN; March, 2015.  Back to cited text no. 49
    
50.
de Pablo P, Cooper MS, Buckley CD. Association between bone mineral density and C-reactive protein in a large population-based sample. Arthritis Rheum 2012;64:2624-31.  Back to cited text no. 50
    
51.
Eriksson AL, Movérare-Skrtic S, Ljunggren Ö, Karlsson M, Mellström D, Ohlsson C. High-sensitivity CRP is an independent risk factor for all fractures and vertebral fractures in elderly men: The MrOS Sweden study. J Bone Miner Res 2014;29:418-23.  Back to cited text no. 51
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

Top
  
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
   Introduction
    Materials and Me...
   Results
   Discussion
   Conclusion
    References
    Article Figures
    Article Tables

 Article Access Statistics
    Viewed1115    
    Printed61    
    Emailed0    
    PDF Downloaded204    
    Comments [Add]    

Recommend this journal