Arch Osteoporos (2017) 12: 26

DOI 10.1007/s11657-017-0314-7

ORIGINAL ARTICLE

Use of cone beam computed tomography in identifying

postmenopausal women with osteoporosis
C. B. Brasileiro 1 & L. L. F. H. Chalub 2 & M. H. N. G. Abreu 2 & I. D Barreiros 1 & T. M. P. Amaral 1 &
A. M. Kakehasi 3 & R. A. Mesquita 1

Received: 2 December 2016 / Accepted: 6 February 2017 / Published online: 6 March 2017
# International Osteoporosis Foundation and National Osteoporosis Foundation 2017

Abstract used to compare the differences between the indices of the

Summary The aim of this study is to correlate radiometric
indices from cone beam computed tomography (CBCT) im-
ages and bone mineral density (BMD) in postmenopausal
women. Quantitative CBCT indices can be used to screen
for women with low BMD.
Purpose Osteoporosis is a disease characterized by the dete-
rioration of bone tissue and the consequent decrease in BMD
and increase in bone fragility. Several studies have been per-
formed to assess radiometric indices in panoramic images as
low-BMD predictors. The aim of this study is to correlate
radiometric indices from CBCT images and BMD in postmen-
opausal women.
Methods Sixty postmenopausal women with indications for
dental implants and CBCT evaluation were selected. Dual-
energy X-ray absorptiometry (DXA) was performed, and the
patients were divided into normal, osteopenia, and osteoporo-
sis groups, according to the World Health Organization
(WHO) criteria. Cross-sectional images were used to evaluate
the computed tomography mandibular index (CTMI), the
computed tomography index (inferior) (CTI (I)) and comput-
ed tomography index (superior) (CTI (S)). Student’s t test was
* C. B. Brasileiro
cbbrasileiro@gmail.com
1
Department of Oral Surgery and Pathology, School of Dentistry,
Federal University of Minas Gerais, Av. Antônio Carlos, 6627,
Pampulha, Belo Horizonte, Minas Gerais 31270-901, Brazil
2
Department of Community and Preventive Dentistry, School of
Dentistry, Federal University of Minas Gerais, Av. Antônio Carlos,
6627, Pampulha, Belo Horizonte, Minas Gerais 31270-901, Brazil
3
Department of Locomotor System, School of Medicine, Federal
University of Minas Gerais, Av. Alfredo Balena, 190/291, Santa
Efigênia, Belo Horizonte, Minas Gerais 30130-100, Brazil
groups’ intraclass correlation coefficient (ICC).
Results Statistical analysis showed a high degree of interob-
server and intraobserver agreement for all measurements
(ICC > 0.80). The mean values of CTMI, CTI (S), and CTI
(I) were lower in the osteoporosis group than in osteopenia
and normal patients (p < 0.05). In comparing normal patients
and women with osteopenia, there was no statistically signif-
icant difference in the mean value of CTI (I) (p = 0.075).
Conclusions Quantitative CBCT indices may help dentists to
screen for women with low spinal and femoral bone mineral
density so that they can refer postmenopausal women for bone
densitometry.
Keywords Cone beam computed tomography . Bone mineral
density . Mandibular indices . Postmenopausal women
Introduction
Osteoporosis is a systemic skeletal disease characterized by
compromised bone strength with the consequent increased
risk of fracture [1]. It is considered a public health concern
worldwide due to the high mortality rate, morbidity, and eco-
nomic impact related to osteoporotic fractures [2]. According
to the 2010 census of the Brazilian Institute of Geography and
Statistics, individuals older than 60 years were almost 20 mil-
lion people in 2010. The population of this age group is
projected to exceed 60 million in 2050 [3].
Various techniques are used in BMD evaluation, such as
dual-energy X-ray absorptiometry (DXA), quantitative com-
puted tomography (QCT), and quantitative ultrasound (QUS).
DXA is the gold standard method for BMD assessment [4].
According to international guidelines, all women over 65 years
old should perform bone densitometry, as should younger
26 Page 2 of 6
postmenopausal women with associated risk factors [5]. The
methods used to evaluate BMD are not accessible to all pa-
tients and in Brazil, and according to the last available
sociodemographic and health indicators collected in 2005
and published in 2009, there were only 1.5 instruments for
BMD evaluation per million inhabitants in the public health
system [6].
Panoramic radiography is the most frequent type of X-
ray imaging requested in dentistry, and Klemetti et al.
(1994) [7] were the first to investigate the correlation be-
tween mandibular cortical morphology and low BMD.
The index proposed by Klemetti is called the Klemetti
index (KI) or mandibular cortical index (MCI). Many oth-
er studies have been proposed to evaluate this radiograph-
ic index as a screening tool for osteoporosis [8–14].
Quantitative assessment of panoramic radiography as a
low-BMD predictor based on radiometric indices has been
reported, and most such studies were performed in post-
menopausal women because the lack of estrogen increases
the risk of osteoporosis. Mandibular cortical width
(MCW), also called the mental index (MI), was described
by Ledgerton et al. (1997) [15] and is the measured thick-
ness of the mandibular cortical bone at the mental fora-
men region. The panoramic mandibular index (PMI) pre-
sented by Benson et al. (1991) [16] is the ratio between
the mandibular cortical bone thickness and the distance
from the mental foramen to the lower edge of the mandi-
ble. Other linear measurements studied include the gonial
index (GI), antegonial index (AI), and antegonial depth
(AD) [17]. Angular measurements including the gonial
angle (GA), antegonial angle (AA), and mandibular angle
(MA) were also investigated [18, 19].
Cone beam computed tomography (CBCT) can be a
useful tool in identifying patients with low BMD. CBCT
provides structure images without overlapping, magnifica-
tion, or distortion and allows viewing in three dimensions
[20]. Thus, it is expected that tomographic images may
facilitate the investigation of correlations between the
quantitative and qualitative indices and low BMD
[20–22]. Koh and Kim (2011) [21] performed the first
study that evaluated CBCT and BMD in postmenopausal
women, and it was based on quantitative and qualitative
indices used in the evaluation of panoramic radiographs
as low-BMD predictors. Gungor et al. (2016) [22] also
studied radiomorphometric indices in CBCT images, but
the authors did not report whether the study was conduct-
ed only in postmenopausal women. Gomes et al. (2014)
[20] evaluated panoramic and cross-sectional CBCT im-
ages based on the Klemetti index. Thus, the aim of this
study was to correlate radiometric indices from CBCT
images and BMD in postmenopausal women and verify
if these indices may be a useful tool in detecting patients
with low BMD.
Arch Osteoporos (2017) 12: 26
Materials and methods
Subjects
This study was conducted in the Department of Oral Surgery
and Pathology, School of Dentistry, Federal University of
Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
Postmenopausal women with indications for dental implants
and CBCT evaluation were invited to participate. This study
was approved by the Ethics Committee of Federal University
of Minas Gerais (35869714.5.0000.5149). Written informed
consent was obtained from all patients, and a questionnaire
about sociodemographic aspects and health and lifestyle
habits was answered. Women with a history of oophorectomy,
metabolic bone diseases, hyperparathyroidism, hypoparathy-
roidism, diabetes, osteomalacia, renal disease, or the use of
drugs that can affect bone metabolism were excluded.
Moreover, patients in hormonal replacement therapy and pa-
tients supplemented with calcium and vitamin D for at least
6 months were excluded.
Evaluation of the bone mineral density
Bone mineral density at the femoral neck and lumbar spine
(L1–L4) was determined using the Hologic Discovery DXA
System® (Hologic Inc., Bedford, MA, USA). Patients were
classified as normal (T-score ≥ −1), osteopenia (−1 > T-
score > −2.5), and osteoporosis (T-score ≤ −2.5) according
to the WHO criteria [23].
Cone beam computed tomography
CBCT of all women was performed using the KODAK 9000C
3D® (Kodak Dental Systems, Carestream Health, USA) with
a voxel size of 0.076 mm, field of view of 50 mm diameter ×
37 mm height, tube voltage of 72 kVp, tube current of 10 mA,
and a scan time of 32.40 s. Digital Imaging and
Communications in Medicine (DICOM) files were evaluated
using the Implant Viewer software® (Anne Solutions, Brazil).
Two measurements were performed in cross-sectional images
with an interval of 15 days, bilaterally, in the region of the
mental foramen by two previously calibrated radiologists. The
indices evaluated were as follows:
CTMI: computed tomography mandibular index, which
was the inferior cortical width of the mandible (Fig. 1a)
CTI (I): computed tomography index (inferior), which was
the ratio of the inferior cortical width to the distance from the
inferior margin of the mental foramen to the inferior border of
the mandible (Fig. 1b)
CTI (S): computed tomography index (superior), which
was the ratio of the inferior cortical width to the distance from
the superior margin of the mental foramen to the inferior bor-
der of the mandible (Fig. 1c)
Arch Osteoporos (2017) 12: 26
Fig. 1 Radiometric index. a CTMI: inferior cortical width of the
mandible (W). b CTI (I): ratio of the inferior cortical width to the
distance from the inferior margin of the mental foramen to the inferior
The mean values were calculated for each index.
The indices evaluated in this study were in accordance with
Koh and Kim (2011) [21]. CTMI is related to the MCW, also
called the MI, described by Ledgerton et al. (1997) [15].
MCW or MI represents the measured thickness of the man-
dibular cortical bone at the mental foramen region. A line
parallel to the long axis of the mandible and tangential to the
inferior border of the mental foramen is drawn. A line perpen-
dicular to this tangent intersecting the inferior border of the
mental foramen is then drawn, along which the mandibular
cortical width is measured. CTI (S) and CTI (I) are related to
the PMI. The PMI is a radiometric measurement introduced
by Benson et al. (1991) [16] and is the ratio between the
mandibular cortical bone thickness and the distance from the
superior or inferior margin of the mental foramen to the infe-
rior border of the mandible.
Data analyses
Interobserver and intraobserver agreement was calculated by
the intraclass correlation coefficient (ICC). Statistical analysis
showed a high degree of interobserver and intraobserver
agreement for all measurements (ICC > 0.80). The mean and
confidence interval of the indices were determined for the
three groups. The statistical analyses were performed using
the SAEG System for Statistical Analysis 9.1® (Federal
University of Viçosa, Viçosa, Minas Gerais, Brazil) and
SPSS® for Windows 17.0 (Statistical Package for the Social
Sciences, Chicago, IL, USA). The Kolmogorov-Smirnov and
Lilliefors tests were used to verify the normal distribution of
the values. Statistical analysis showed a normal distribution,
and Student’s t test was used to compare the differences be-
tween the indices of the groups.
Results
The characteristics of the study subjects by age are shown in
Table 1. The mean age of the normal group was 55.6, ranging
between 47 and 78 years. For the osteopenia and osteoporosis
Page 3 of 6 26
border of the mandible (W/I). c CTI (S): ratio of the inferior cortical width
to the distance from the superior margin of the mental foramen to the
inferior border of the mandible (W/S)
groups, the mean age was 57.5, ranging between 50 and
66 years, and 62.4, ranging between 52 and 80 years, respec-
tively. The results showed a higher average age of groups with
low BMD (osteopenia and osteoporosis) compared to the nor-
mal group. The low-BMD groups had equivalent ages.
Table 2 presents the mean values of the computed tomog-
raphy indices evaluated. The results showed that the mean
values of CTMI, CTI (S), and CTI (I) were lower in the oste-
oporosis group than in the osteopenia and normal patients.
The CTMI mean values in osteoporosis patients were signif-
icantly lower than those in the osteopenia and normal groups
(p = 0.000). For CTI (S), the mean values in the osteoporosis
group were also lower than those in the osteopenia and normal
patients, and the differences were statistically significant
(p = 0.017 and p = 0.000, respectively). Similarly, for CTI
(I), the mean values in the osteoporosis group were lower than
those in the osteopenia group (p = 0.021) and the normal
group (p = 0.002). Considering normal patients and women
with osteopenia, the mean values of CTI (S) (p = 0.022) and
CTMI (p = 0.015) were significantly lower in the osteopenia
group. However, there was no statistically significant differ-
ence in the mean value of CTI (I) (p = 0.075) when comparing
these groups.
Discussion
Panoramic radiography is an imaging method routinely used
in dental practice, and most studies evaluating quantitative
radiometric indices in panoramic radiographs, such as
MCW, have demonstrated statistically significant correlations
between these indices and low BMD in postmenopausal wom-
en [14, 19, 24]. The mean cortical thickness of the osteopenia/
osteoporotic groups was lower than that of the normal group
[8, 25, 26]. Previous studies reported that a mandibular corti-
cal width below 3 mm at the mental foramen region may be
considered a threshold value when predicting low BMD and is
a cutoff for referring patients for densitometric evaluation [27,
28]. However, the measurement of the thickness of the lower
mandible cortical bone in panoramic radiography is limited by
26 Page 4 of 6 Arch Osteoporos (2017) 12: 26

Table 1 Characterization of the

sample by age Groups Number Lower Upper Mean Confidence interval (95%)

Lower Upper

Normal 20 47 78 55.6 52.00 59.20

Osteopenia 20 50 66 57.5 55.20 59.81
Osteoporosis 20 52 80 62.4 58.66 66.14

the difficulty of precisely locating the mental foramen and
determining the upper border of the mandibular cortical bone
[14]. Thus, these limitations may be overcome by CBCT,
because the tomographic images make it possible to precisely
locate and view the mental foramen.
The study of Koh and Kim (2011) [21] was the first to
evaluate CBCT as a low-BMD predictor, and the authors
found that the mean value of the CTMI in the osteoporo-
sis group (2.33 mm) was lower than that in the normal
patients (3.22 mm), but there was no significant correla-
tion between the groups. In this study, the patients with
low BMD were divided into osteopenia and osteoporosis
patients, and the mean values of CTMI in the osteopenia
and osteoporosis groups (3.68 and 2.93 mm, respectively)
were lower than those in the normal group (4.24 mm). In
contrast to Koh and Kim (2011) [21], the results were
statistically significant. The difference in sample size
and how the groups were divided may explain the dis-
crepancy in the results of the studies. Gungor et al.
(2016) [22] also used cross-sectional CBCT images, such
as this study, to evaluate CTMI, CTI (I), and CTI (S) and
demonstrated that the CTMI measurements in the osteo-
porosis group (2.76 mm) were lower than those in the
osteopenia (3.42 mm) and normal groups (3.62 mm).
However, in contrast with the results of this study, these
differences were not significant when comparing
osteopenia with the control patients. The differences in
the results may be explained by the fact that Gungor
et al. (2016) [22] did not evaluate postmenopausal women
and the normal group age range was considerably less
than the age range of the patients evaluated in this study.
The influence of age in the mandibular cortical width has
previously been reported in studies with panoramic
radiographs. Khojastehpour et al. (2011) [8] and Kim
et al. (2014) [14] showed that age was significantly cor-
related with mandibular thickness and that as age in-
creased, MCW decreased. Although differences were ob-
served in the results of the three studies that investigated
CBCT as a low-BMD predictor, it can be inferred that a
CTMI thinner than 3 mm at the mental foramen region
may be considered a threshold value when predicting low
spinal and femoral BMD, as well as many panoramic
radiographic studies [14, 19, 24, 27–29].
In relation to CTI (I) and CTI (S), Koh and Kim (2011)
[21] found statistically significant differences between os-
teoporosis and normal groups. Gungor et al. (2016) [22]
demonstrated similar results considering low-BMD and
control groups, but the comparison between the
osteopenia and normal groups revealed no significant dif-
ferences. In this study, the mean values of CTI (I) and
CTI (S) were significantly lower in the osteoporosis group
than in the osteopenia and normal groups. However, we
did not find any significant difference between the
osteopenia and normal groups in the CTI (I) mean values.
These differences can be explained by the sample size.
Studies that evaluated the correlation between PMI and
BMD in panoramic radiography also showed controver-
sial results. Some authors found a significant correlation
between PMI and BMD [19, 30], but others do not show
this correlation [10, 25, 31].
A limitation of the study is that it was conducted by the
analysis of cross-sectional images in CBCT, while most stud-
ies were performed using panoramic radiography.
Considering that only three studies evaluated radiometric in-
dices in CBCT images, further studies should be conducted to
confirm the reliability of the results.

Table 2 Radiometric index (mean ± standard deviation) of the groups according to bone mineral density: normal, osteopenia, and osteoporosis

Group Normal Osteopenia Osteoporosis Normal × Normal × Osteopenia ×

mean (mm) ± SD mean (mm) ± SD mean (mm) ± SD osteopenia (p) osteoporose (p) osteoporose (p)

CTMI 4.27 ± 0.88 3.68 ± 0.55 2.93 ± 0.67 0.015 0.000 0.000
CTI (I) 0.33 ± 0.91 0.29 ± 0.47 0.24 ± 0.69 0.075* 0.002 0.021
CTI (S) 0.27 ± 0.81 0.22 ± 0.37 0.18 ± 0.56 0.022 0.000 0.017

*Mean that there was no statistically significant difference considering p < 0.05, when comparing groups
Arch Osteoporos (2017) 12: 26
Conclusions
The results of this study suggest that quantitative CBCT indi-
ces may be useful in identifying postmenopausal women with
low BMD and as a screening tool for osteoporosis. These
indices are able to help dentists screen women with low spinal
and femoral bone mineral density so that they can refer post-
menopausal women for bone densitometry.
Acknowledgments This study was supported by the Research Support
Foundation of the State of Minas Gerais (FAPEMIG, #CDS-BPD-00178-
14) and the National Council of Technological and Scientific
Development (CNPq, # 309322/2015-4), Brazil.
Compliance with ethical standards This study was approved by the
Ethics Committee of Federal University of Minas Gerais
(35869714.5.0000.5149). Written informed consent was obtained from
all patients.
Conflicts of interest None.
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