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Association Between Periodontal Disease and Osteoporosis in

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Article  in  Journal of Periodontology · November 2010

DOI: 10.1902/jop.2010.100190 · Source: PubMed

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J Periodontol • November 2010

Association Between Periodontal

Disease and Osteoporosis in
Postmenopausal Women in Jordan
Rola Al Habashneh,* Haifa’a Alchalabi,† Yousef S. Khader,‡ A.M. Hazza’a,§ Ziad Odat,i
and Georgia K. Johnson¶

Background: Some studies suggest that females with oste-

oporosis are at an increased risk of periodontal attachment
loss and tooth loss; however, results have varied. The aim of
this study is to determine the relationship between periodon-
titis and osteoporosis among postmenopausal Jordanian
women.
Methods: This cross-sectional study includes 400 Jordanian

O
steoporosis is a rapidly growing
postmenopausal women with a mean age of 62.5 years (SD – health issue related to aging in
6.4 years). These subjects were recruited from patients who industrialized countries where
had received a routine dual-energy x-ray absorptiometry ex- life expectancy for women has risen.1 In
amination in the Radiology Department, King Abdullah Hospi- Jordan, a cross-sectional study2 found
tal, Jordan University of Science and Technology, between that about one-third (29.6%) of women
June 2008 and February 2009. The relationship between skel- with a mean age of 53.23 years had
etal bone mineral density (BMD) and radiographic and clinical osteoporosis as defined by World Health
parameters of periodontal status, including the loss of alveolar Organization (WHO) criteria. In a similar
crestal height (ACH), clinical attachment level, probing depth, female age group in the United States,
and percentage of sites with bleeding on probing, was evaluated 20% of non-Hispanic white and Asian
after controlling for known confounders. women aged ‡50 years had osteoporosis
Results: Bivariate analyses revealed no significant differ- compared to 5% to 10% of non-Hispanic
ences in the severity and extent of clinical attachment and black women; however, it is likely that
ACH loss among women with normal BMD, osteopenia, and os- the disease is underdiagnosed.3 Low
teoporosis. However, in the multivariate analysis, women with systemic bone density and fragility lead
osteoporosis were more likely to have severe ACH loss (odds to fractures that have a significant im-
ratio [OR]: 4.20; 95% confidence interval [CI]: 1.57 to 11.22) pact on physical, psychologic, and so-
and periodontitis (OR: 2.45; 95% CI: 1.38 to 4.34). cial activities that affect the quality of life
Conclusion: Osteoporosis was significantly associated with and are responsible for increased mor-
severe alveolar crestal bone loss and the prevalence of peri- bidity, mortality, and health-care costs.4
odontitis cases in postmenopausal Jordanian women. J Peri- Osteoporosis has been associated with
odontol 2010;81:1613-1621. increased tooth loss in various pop-
ulations.5-8 The relationships among sys-
KEY WORDS
temic bone density, alveolar bone density
Alveolar bone loss; bone density; menopause; osteoporosis; and height,9,10 and clinical attachment
periodontitis. level (CAL) were evaluated.11-15 Women
with low bone mineral density (BMD)
* Preventive Department-Periodontics, College of Dentistry, Jordan University of Science tend to have more attachment loss than
and Technology, Irbid, Jordan.
† Department of Obstetrics and Gynecology, Faculty of Medicine, Jordan University of women with normal BMD;12,13,15 how-
Science and Technology. ever, the relationship between peri-
‡ Departments of Public Health, Community Medicine, and Family Medicine, Jordan
University of Science and Technology. odontal status and osteoporosis varied
§ Department of Oral Surgery, College of Dentistry, Jordan University of Science and depending on the sample size and cor-
Technology.
i Department of Surgery, Faculty of Medicine, Jordan University of Science and Technology. rection for confounding variables.16-19
¶ Department of Periodontics, College of Dentistry, University of Iowa, Iowa City, IA. The evaluation of the relationship be-
tween osteoporosis and periodontitis is

doi: 10.1902/jop.2010.100190

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Association Between Periodontitis and Osteoporosis Volume 81 • Number 11

complicated by the fact that both diseases are multi- Table 1.

factorial in etiology. Multiple systemic factors influ-
Sociodemographic and Relevant
ence the progression of osteoporosis, including age,
race, diet, gender, hormone therapy (HT), smoking, Characteristics of Participants
genetic factors, exercise, and body weight. Several
of these factors are also risk factors for severe peri- Demographic Characteristic n %
odontal disease.20 Furthermore, local factors, such Age (years)
as bacterial plaque and calculus, may also mask £60 186 46.5
the effect of osteoporosis on periodontal status.21 >60 214 53.5
To the best of our knowledge, the association be-
Years of education
tween periodontal disease and osteoporosis has not
£12 209 52.3
been evaluated in Arab women. The purpose of the >12 191 47.8
present study is to determine the relationship between
periodontal clinical and radiographic parameters and Income (JD)
systemic bone density among Jordanian postmeno- <500 174 43.5
‡500 226 56.5
pausal women aged 50 to 75 years.
BMI (kg/m2)
MATERIALS AND METHODS <25 29 7.3
Participants and Data Collection 25 to 29.9 94 23.5
This study was approved by the Institutional Review ‡30 277 69.3
Board of Jordan University of Science and Technol- Employment
ogy. Women who experienced natural menopause No 352 88.0
and who received systemic BMD assessments as an Yes 48 12.0
initial screening using dual-energy x-ray absorptiom-
Smoker 29 7.3
etry (DXA) during 2008 in the Radiology Department,
King Abdullah University Hospital, Jordan University Toothbrushing (daily) 192 48.0
of Science and Technology, were invited to participate
Number of living children
in this study. Patient BMD was measured at the lumbar <10 165 41.3
spine (anteroposterior projection at lumbar vertebrae ‡10 235 58.8
one through four) and at the femoral neck and trochan-
ter using one DXA machine.# DXA detects small Vitamin D supplementation (daily) 68 33.2
changes in bone mineral content at multiple anatomic BMD
sites with excellent precision (0.5% to 2%) and accu- Normal 94 23.5
racy (3% to 5%).22 The precision of the DXA manufac- Osteopenia 170 42.5
turer-derived BMD measurements for the machine Osteoporosis 136 34.0
used in the present study varied between 1.9% and JD = Jordanian dinar (1 JD = 1.4 United States dollars).
3.4%. Intraexaminer reproducibility was assessed be-
fore the study and showed the smallest detectable dif- health were not excluded; women with surgically in-
ference <0.05 g/cm2. Systemic BMD was classified duced menopause were excluded. Of the 900 poten-
according to the WHO criteria.23 According to this tial participants contacted, some women declined
classification, osteoporosis was defined as BMD ‡2.5 and other women did not meet the inclusion criteria.
SDs below the optimal mean BMD of young healthy in- Of the 500 women who completed a study visit, 50
dividuals of the same race and gender; osteopenia was women did not present for oral radiographs, 30 women
defined as BMD between 1.0 and 2.5 SDs below the did not complete the interview questionnaire, and 20
optimal mean BMD; and normal BMD was defined as women did not complete the oral examination. After
£1.0 SD below the optimal mean BMD. In this study, implementing all exclusions, a total of 400 women
the worst T score of all sites measured was used as were included in the study. After informed verbal
the independent variable of interest. and written consent was obtained, eligible postmeno-
Women with a history of a systemic condition or pausal women were referred to the Dental Teaching
medication intake that might influence the BMD or Center, Jordan University of Science and Technology,
periodontal disease severity were excluded (i.e., for an interview and periodontal examination. The in-
women with a history of diabetes mellitus, thyroid dis- terview questionnaire addressed sociodemographic
eases, chronic renal problems, and connective tissue information including age, age of menopause, years
diseases). Women on corticosteroids or chemother- since menopause, education level, and occupation.
apy were also excluded. Women with chronic dis-
eases that had no reported effect on periodontal # DENTSPLY, Rinn, Elgin, IL.

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J Periodontol • November 2010 Al Habashneh, Alchalabi, Khader, Hazza’a, Odat, Johnson

Table 2.
Periodontal Parameters (mean [SD]) According to Systemic BMD Classification

Parameter Normal Osteopenia Osteoporosis P

PI 2.10 (0.83) 2.25 (0.71) 2.31 (0.66) 0.232

GI 1.85 (0.68) 1.86 (0.55) 1.88 (0.36) 0.017
Sites with calculus (%) 76.95 (15.74) 77.23 (14.90) 77.73 (16.27) 0.882

Gingival recession (mm) 4.34 (1.84) 4.76 (1.72) 4.99 (1.74) 0.871
CAL (mm) 6.40 (2.16) 6.79 (1.98) 6.85 (1.90) 0.671
PD (mm) 2.15 (0.80) 2.17 (0.66) 2.03 (0.53) 0.228
BOP (%) 6.29 (21.82) 10.46 (30.55) 10.88 (30.39) 0.062

Whole-mouth ACH loss (mm) 2.02 (0.48) 2.08 (0.54) 2.17 (0.49) 0.113
Sites with ACH loss ‡2 (%) 65.59 (26.84) 67.14 (28.81) 62.97 (26.57) 0.265
Sites with ACH loss ‡3 (%) 35.09 (21.90) 39.11 (25.82) 33.75 (22.92) 0.077

Sites with ACH loss ‡4 (%) 1.51 (3.78) 1.42 (5.14) 2.05 (4.97) 0.072
Sites with PD ‡3 (%) 36.17 (23.20) 39.38 (26.17) 33.75 (22.92) 0.066
Sites with PD ‡4 (%) 6.92 (17.72) 5.57 (13.02) 6.18 (13.31) 0.292

Sites with PD ‡5 (%) 3.58 (14.27) 2.22 (7.01) 1.56 (4.02) 0.996
Sites with PD ‡6 (%) 2.25 (12.05) 1.33 (4.45) 0.08 (0.61) 0.689
Sites with CAL ‡3 (%) 88.95 (15.74) 89.23 (14.90) 89.73 (16.27) 0.883

Sites with CAL ‡4 (%) 79.66 (21.64) 81.45 (20.44) 80.49 (18.56) 0.488
Sites with CAL ‡5 (%) 68.79 (25.20) 69.96 (26.54) 72.70 (22.76) 0.794
Sites with CAL ‡6 (%) 58.05 (29.56) 64.94 (29.85) 68.37 (24.76) 0.898
PI = plaque index.

Data regarding smoking habits, reproductive history,
medical history, vitamin D supplementation (‡500 IU/
day), number of missing teeth, and oral hygiene be-
haviors were also obtained. The body mass index
(BMI) was calculated as weight in kilograms divided
by height in meters squared.
Periodontal Clinical Examination and
Radiographs
The clinical examination included a full-mouth peri-
odontal assessment. Probing depths (PD) and CALs
were measured at six sites (mesial, distal, and middle
sites of the buccal and lingual sides) on each tooth us-
ing a Williams periodontal probe. CAL was measured
as the distance from the cemento-enamel junction
(CEJ) to the base of the pocket. The percentage of
sites with BOP was calculated. Third molars were ex-
cluded from the examinations. Periodontitis was de-
fined using a modification of the criteria of Machtei
et al.24 as ‡2 interproximal sites with ‡5 mm PD, radio-
graphic bone loss, and ‡6 mm clinical attachment loss
(AL). Clinical examinations were performed by one
skilled examiner (RA). Before the beginning of the
study, the measurement reliability was determined
on the basis of examinations performed on 10 patients
with severe periodontitis. Of the replications, 98%
were within 1 mm for PDs, and 96% were within 1
mm for CALs. Additional assessments of periodontal
status included the plaque index of Silness and Löe,25
the gingival index (GI) of Löe and Silness,26 and the
calculus index (i.e., the presence or absence of calcu-
lus). These parameters were evaluated at four sites
(mesial, distal, buccal, and lingual) on each tooth.
A series of six intraoral periapical and four vertical
bitewing radiographs was taken of each subject by
the radiographer using a standardized long-cone par-
alleling technique with a film holder.** To standardize
the relationship between the image receptor and
** Lunar Prodigy Densitometer, New York, NY.

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Association Between Periodontitis and Osteoporosis Volume 81 • Number 11

Table 3. a ·2 magnifying lens.## The distance

from the CEJ to the alveolar crest
Characteristics of Subjects According to Overall ACH
(alveolar crestal height [ACH]) was
Severity measured at the mesial and distal in-
terproximal sites on periapical ra-
ACH Loss diographs for anterior sites and on
Moderate or bitewing radiographs for posterior
Variable Less* (n [%]) Severe† (n [%]) Total P regions by an oral radiologist (HA) using
a millimetric compass. An average ACH
Age (years) measurement over all sites was calcu-
£60 165 (88.7) 21 (11.3) 186 <0.005 lated. Subjects were categorized ac-
>60 161 (75.2) 53 (24.8) 214
cording to the average ACH as follows:
Years of education normal bone level, mild, moderate,
£12 158 (75.6) 51 (24.4) 209 0.001 and severe ACH loss. Normal bone
>12 168 (88.0) 23 (12.0) 191 levels were considered <2 mm apical
Income (JD) to the CEJ; mild ACH loss was classified
<500 137 (78.7) 37 (21.3) 174 0.212 as an average ACH ‡2 but <3 mm; mod-
‡500 189 (83.6) 37 (16.4) 226 erate ACH loss was defined as ‡3 but <4
mm; and ACH ‡4 mm was categorized
Employment
as severe bone loss. To determine the
No 282 (80.1) 70 (19.9) 352 0.053
Yes 44 (91.7) 4 (8.3) 48 intraobserver variation prior to the in-
vestigation, radiographs of 20 patients
Toothbrushing were reviewed twice by the same inves-
No 147 (70.7) 61 (29.3) 208 <0.005 tigator at different occasions separated
Yes 179 (93.2) 13 (6.8) 192
by a 2-week interval. The intraobserver
Smoking agreement in defining the ACH-loss cat-
No 303 (81.7) 68 (18.3) 371 0.753 egory between the first and second
Yes 23 (79.3) 6 (20.7) 29 measurements was high (k = 0.89). Of
BMI (kg/m2) the replications, 96% of duplicate ACH
<25 22 (75.9) 7 (24.1) 29 0.598 readings were within 1 mm.
25 to 29.9 79 (84.0) 15 (16.0) 94
‡30 225 (81.2) 52 (18.8) 277 Statistical Analyses
Statistical software*** was used for
BMD
Normal 88 (93.6) 6 (6.4) 94 <0.005 data processing and analyses. Subject
Osteopenia 143 (84.1) 27 (15.9) 170 variables were described using fre-
Osteoporosis 95 (69.9) 41 (30.1) 136 quency distributions for categoric
variables and means and SDs for con-
Current vitamin D supplementation
tinuous variables. One-way analysis of
No 269 (81.0) 63 (19.0) 332 0.588
variance was used to compare the
Yes 57 (83.3) 11 (16.2) 68
average of periodontal parameters
JD = Jordanian dinar (1 JD = 1.4 United States dollars).
* Average ACH <4 mm from the CEJ.
among study groups. Overall ACH loss
† Average ACH ‡4 mm from the CEJ. was dichotomized to severe loss or
moderate and less bone loss. Severe
teeth, a reference point where the buccal cusps of the ACH loss was analyzed using a x2 test according to
maxillary teeth should contact the film holder was pre- the systemic BMD group, the demographic informa-
determined by using a special marker. Films†† were tion of subjects, and other characteristics, such as life-
exposed for 0.3 seconds with an x-ray unit‡‡ operating style and oral hygiene. A multivariate analysis using
at 70 kVp and 7 mA. The films were processed in an binary logistic regression was conducted to determine
automatic processor§§ using processing chemicals.ii the association between severe ACH loss and osteo-
Only radiographs that met the following criteria were porosis and between periodontitis and osteoporosis.
analyzed: 1) visibility of all measurement sites, 2) ab-
sence of distortion, and 3) lack of overlapping prox- †† Kodak Insight, Eastman Kodak, Rochester, NY.
‡‡ Trophy Elitys, Beaubourg, Marne-La-Vallee Cedex2, France.
imal surfaces. Radiographic measurements were §§ XR 24, Dürr Dental, Bietigheim-Bissingen, Germany.
made under standard conditions that included the ii RP X-Omat, Eastman Kodak.
¶¶ Exal-Type F.I.D-1, Basingstone, England, U.K.
use of subdued lighting, film masking, and a conven- ## X-viewer, Malmo, Sweden.
tional viewing box¶¶ with a variable light intensity and *** SPSS v.15.0, SPSS, Chicago, IL.

1616
J Periodontol • November 2010
Table 4.
Univariate and Multivariate Analysis of Factors Associated With
Severe ACH Loss*
Variable Crude OR (95% CI)
Age (years) 1.15 (1.09 to 1.20)
BMD
Normal 1.00
Osteopenia 2.77 (1.10 to 6.97)
Osteoporosis 6.33 (2.56 to 15.64)
Years of education
>12 1.00
£12 2.36 (1.38 to 4.04)
Income (JD)
‡500 1.00
<500 1.38 (0.83 to 2.29)
JD = Jordanian dinar (1 JD = 1.4 United States dollars).
* ACH ‡4 mm from CEJ.
† Adjusted for age, years of education, and income.
The statistical significance of the two-way interactions
between BMD and other variables in the main effects
model was assessed with the use of forward stepwise
regression to test whether other variables modified the
effect of BMD on severe ACH loss and periodontitis.
The variables that formed interaction terms with
BMD were age, education, and income when the de-
pendent variable was severe ACH loss. The variables
were income and vitamin D supplementation when
the dependent variable was periodontitis. The two-
way interaction terms, one at a time, were added in
the model that contained all main effects and were as-
sessed for their significance using the likelihood ratio
test. Because none of the interaction terms were found
to be significant, a stratified analysis was not con-
ducted. P £0.05 was considered statistically signifi-
cant.
RESULTS
This study included 400 postmenopausal women (age
range: 50 to 75 years; mean [SD]: 62.5 [6.4] years). The
sociodemographic and relevant characteristics of
the participants are shown in Table 1. The majority of
the women were either overweight or obese. About
one-third (33.2%) of the subjects reported taking
vitamin D supplementation. Based on DXA results,
42.5% of the group was classified as osteopenic, and
34.0% of the group had osteoporosis. Alveolar bone
levels were within the normal range (ACH <2 mm from
the CEJ) in 13.3% of the women; 68.3% of the women
had mild to moderate ACH loss (ACH ‡2 to 4 mm from
the CEJ), and 18.5% of the women had severe ACH
loss (ACH ‡4 mm from the CEJ). Of the total group,
178 (44.5%) subjects had periodontitis as defined by
the modified criteria of Machtei et al.24
Al Habashneh, Alchalabi, Khader, Hazza’a, Odat, Johnson
With the exception of GI,
there were no significant differ-
ences in the clinical and radio-
graphic parameters among
women with normal BMD,
P Adjusted OR (95% CI) P osteopenia, and osteoporo-
0.000 1.13 (1.07 to 1.19) 0.000 sis (Table 2). The prevalence
of severe ACH loss accord-
ing to sociodemographic
1.00
and relevant characteristics
0.031 1.79 (0.67 to 4.80) 0.248
0.000 4.20 (1.57 to 11.22) †
0.004 is shown in Table 3. Although
only 6.4% of women with nor-
mal bone density had severe
ACH loss, 15.9% of women
0.002 1.86 (1.03 to 3.36) 0.040
with osteopenia and 30.1%
of women with osteopo-
rosis had severe ACH loss
0.213 2.01 (1.12 to 3.61) 0.020 (P <0.005). The prevalence
of severe ACH loss was signif-
icantly higher among women
>60 years (P <0.005), women
with fewer years of education (P = 0.001), and
women who did not brush their teeth (P <0.005). In
the multivariate analysis, only age, years of educa-
tion, income, and systemic BMD were significantly
associated with severe ACH loss (Table 4). After ad-
justing for these variables, osteoporosis was signifi-
cantly associated with increased odds of severe
ACH loss (odds ratio [OR]: 4.20; 95% confidence in-
terval [CI]: 1.57 to 11.22).
The prevalence of periodontitis according to the
modified criteria of Machtei et al.24 in relation to socio-
demographic and relevant characteristics is shown
in Table 5. Results from the bivariate analysis show
a statistically significant association between peri-
odontitis and systemic bone density, income level,
BMI, and vitamin D supplementation. The prevalence
of periodontitis among women who had osteoporosis
(54.4%) was significantly higher than that among
women with normal BMD (39.4%) and women with
osteopenia (39.4%) (P = 0.017). As shown in Table
6, osteoporosis remained a strong predictor of peri-
odontitis in the multivariate model. Postmenopausal
women with osteoporosis were more likely to have
periodontitis (OR: 2.45; 95% CI: 1.38 to 4.34).
DISCUSSION
Understanding the association between periodontal
disease and osteoporosis and the mechanisms under-
lying this association in postmenopausal women may
aid health professionals in the prevention, early detec-
tion, and treatment of these common diseases.27 To
the best of our knowledge, this is the first study to in-
vestigate the relationship between periodontal dis-
ease and osteoporosis in the Eastern Mediterranean
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Association Between Periodontitis and Osteoporosis Volume 81 • Number 11

Table 5. of alveolar bone and attachment loss

were not significantly different among
Periodontitis According to Sociodemographic and
women with different systemic bone
Relevant Characteristics densities. This may be related to the
averaging of data in whole-mouth
Periodontitis values for these parameters. For bone
Variable Yes* (n [%]) No (n [%]) Total P loss, the percentage of sites with ‡3
and ‡4 mm ACH approached signifi-
Age (years) cance (P = 0.077 and P = 0.072, re-
£60 87 (46.8) 99 (53.2) 186 0.420
spectively) (Table 2). Age was not a
>60 91 (42.5) 123 (57.5) 214
significant factor for the prevalence
Years of education of periodontitis in our study (P = 0.420)
£12 101 (48.3) 108 (51.7) 209 0.131 (Table 5), whereas it was for ACH loss
>12 77 (40.3) 114 (59.7) 191 (Table 3). This may be related to the
Income (JD) fact that the periodontitis definitions
<500 91 (52.3) 83 (47.7) 174 0.006 were categorical parameters defined
‡500 87 (38.5) 139 (61.5) 226 by at least two sites with severe de-
struction, whereas severe ACH loss
Employment
No 154 (43.8) 198 (56.3) 352 0.414 represented a whole-mouth mean of
Yes 24 (50.0) 24 (50.0) 48 interproximal sites with ACH ‡4 mm
from the CEJ. Our findings support
Toothbrushing those of a large cross-sectional study19
No 94 (45.2) 114 (54.8) 208 0.840
that found >3 times the likelihood of
Yes 84 (43.8) 108 (56.3) 192
crestal bone height in postmenopausal
Smoking women with osteoporosis. These inves-
No 165 (44.5) 206 (55.5) 371 0.971 tigators noted a stronger association
Yes 13 (44.8) 16 (55.2) 29 between osteoporosis and crestal bone
BMI (kg/m2) loss in subjects 70 to 85 years of age
<25 20 (69.0) 9 (31.0) 29 0.001 compared to subjects <70 years of age.
25 to 29.9 50 (53.2) 44 (46.8) 94 The same large cross-sectional
‡30 108 (39.0) 169 (61.0) 277 study21 observed that the relationship
BMD between ACH and systemic bone den-
Normal 37 (39.4) 57 (60.6) 94 sity was more consistent than that CAL
Osteopenia 67 (39.4) 103 (60.6) 170 and osteoporosis, which was similar to
Osteoporosis 74 (54.4) 62 (45.6) 136 0.017 our study. The study21 also showed
that the presence or absence of sub-
Current vitamin D supplementation
gingival calculus affected the associa-
No 199 (59.9) 133 (40.1) 332 0.005
Yes 23 (33.8) 45 (66.2) 68 tion between systemic bone density
and CAL. In the absence of calculus,
JD = Jordanian dinar (1 JD = 1.4 United States dollars).
* According to modified criteria of Machtei et al.,24 periodontitis was defined as at least two women with lower bone densities had
interproximal sites with PD ‡5 mm, radiographic bone loss, and CAL ‡6 mm. more AL. Among the women in our
study, the presence or absence of cal-
region. This cross-sectional study resulted in several culus was not a factor in the relationship between peri-
important insights. odontitis and osteoporosis. Calculus was extensive in
Among the 400 postmenopausal women in the our population, which made it difficult to differentiate
study, 34% of them were identified as having osteopo- its role. Furthermore, our study did not discriminate
rosis, which is slightly higher than the 29.6% of sub- between supra- and subgingival deposits.
jects reported by Shilbayeh2 in a study in Jordanian Women who took vitamin D supplementation in our
women of a slightly younger age group but with study were less likely to be periodontitis cases than
similar parity and BMI to those of the present study. women who did not take vitamin D (P = 0.001). A lim-
In the multivariate analysis, after adjusting for in- itation of the present study is that calcium supplemen-
come and vitamin D supplementation, osteoporosis tation was not assessed. Data suggests that calcium
was significantly associated with periodontitis (OR: and vitamin D intake by adult periodontal mainte-
2.45). When adjusted for age, income, and education, nance patients is associated with better periodontal
osteoporosis was associated with severe ACH loss health.28 Because of the low prevalence of smoking
(OR: 4.20). However, the overall extent and severity among Arab women, we did not find any association

1618
J Periodontol • November 2010
Table 6.
Univariate and Multivariate Analysis of Factors Associated With make it difficult to establish
Periodontitis
Variable Crude OR (95% CI)
BMD
Normal 1.0
Osteopenia 1.002 (0.60 to 1.68)
Osteoporosis 1.84 (1.08 to 3.14)
Income (JD)
<500 1.75 (1.17 to 2.61)
‡500 1.0
Vitamin D supplementation
No 2.92 (1.69 to 5.06) <0.005
Yes 1.0
JD = Jordanian dinar (1 JD = 1.4 United States dollars).
between smoking and periodontal destruction or sys-
temic bone density.
Until recently, HT was used in the prevention and
treatment of osteoporosis. A recent study29 reported
a higher likelihood of periodontitis among postmeno-
pausal women who were not taking HR compared to
premenopausal women (64.4% versus 46.3%; P =
0.005). The alveolar bone density and crestal height
increased among women who took HT and/or cal-
cium supplements, which correlated with changes
in systemic BMD.30,31 This was not a factor in the
present study because women who took HT were ex-
cluded from the study.
Intraoral radiographs are susceptible to angulation
errors.32 The projection geometry of serial radiographs
should be standardized to minimize measurement er-
rors33,34 and maintain the validity of interpretation.35,36
Furthermore, conventional intraoral radiographs are
limited to a two-dimensional representation of a
three-dimensional anatomic structure, and several in-
vestigations37-39 showed that radiographic assess-
ment tends to underestimate the amount of bone
loss compared to surgical inspection. The present
study used conventional radiographic techniques,
and to minimize measurement variability, one skilled
radiologist (HA) performed the measurements with
a high degree of reliability.
Proposed mechanisms to explain a potential rela-
tionship between periodontitis and osteoporosis were
20
summarized by Geurs. Perhaps more alveolar bone
loss occurs simply because the bone surrounding the
teeth is less dense and, therefore, more susceptible to
resorption. Predisposing factors common to these two
diseases include age, genetic predisposition, and
environmental or lifestyle factors. Confounding fac-
tors, such as socioeconomic status, oral hygiene, hor-
Al Habashneh, Alchalabi, Khader, Hazza’a, Odat, Johnson
mone intake, and race also
whether there is a causal re-
lationship between osteo-
porosis and periodontitis.
P Adjusted OR (95% CI) P Perhaps it is more useful to
continue to study the mecha-
1.0 nisms by which osteoporosis
0.994 1.35 (0.78 to 2.35) 0.281 may be associated with oral
0.025 2.45 (1.38 to 4.34) 0.002 bone loss.
Our study was designed to
0.006 1.80 (1.17 to 2.75) 0.007 assess the associations be-
1.0 tween systemic bone density
and periodontal disease
measures after adjustment
2.76 (1.55 to 4.93) 0.001
for several confounding fac-
1.0
tors. Despite the fact that
we tried to address known
factors associated with BMD
and periodontitis, there still
may be unknown factors. The great majority of women
had a low socioeconomic status and they may not ac-
curately represent the greater population of postmen-
opausal, Jordanian women. Moreover, the present
study included women who were referred to King
Abdullah Hospital. Therefore, the ability to generalize
the study findings to other populations is limited. Fu-
ture studies that include women from the general pop-
ulation are warranted.
Given the cross-sectional design used in the pres-
ent study, our findings reflect the cumulative effects
of disease processes and prevent the establishment
of causal relationships; longitudinal studies would
be valuable to establish the temporal association be-
tween systemic and oral bone loss. Therefore, future
research should continue to evaluate specific associ-
ations between osteoporosis and periodontitis, the
temporality of these factors, and include subpopula-
tions that are at increased risk. This knowledge may
form the basis for targeting preventive and therapeu-
tic measures to individuals who are at the greatest risk
for both diseases. Dental professionals should under-
stand the potential relationship between systemic
BMD and periodontal status, educate patients on their
oral disease risk factors, and reinforce the benefits of
a healthy lifestyle.20
CONCLUSION
Although the severity and extent of attachment and
bone loss did not vary across different systemic BMDs
in the postmenopausal Arab women in this study, af-
ter adjusting for known confounders, women with os-
teoporosis had increased odds of having periodontitis
and severe ACH loss compared to women with normal
BMD.
1619
Association Between Periodontitis and Osteoporosis
ACKNOWLEDGMENTS
This study was supported by the Jordan University of
Science and Technology/Deanship of Research
Fund. The authors thank the staff of King Abdullah
Hospital and Dental Teaching Center, Jordan Univer-
sity of Science and Technology, for their help and sup-
port. The authors report no conflicts of interests
related to this study.
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Correspondence: Dr. Rola Al Habashneh, Preventive De-
partment-Periodontics, College of Dentistry, Jordan Uni-
versity of Science and Technology, P.O. Box: 3030, Irbid
22110, Jordan. E-mail: rolaperio@yahoo.com.
Submitted April 3, 2010; accepted for publication May 24,
2010.
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