967 D3000 new imprint Word template Vol 13, No 1 (2025) ISSN 2167-8677 (online) DOI 10.5195/d3000/2025.967 http://dentistry3000.pitt.edu Radiographic Study of Osteoporosis Detection in the Jaw Hussein Haleem Jasim College of Den*stry, University of Wasit, Iraq Abstract Objec0ve: To invesAgate the reliability of panoramic radiographs in detecAng osteoporosis disease. Material and Methods: Three hundred paAents, regardless of gender, were in- cluded, aged between 40 and 50 years. One hundred fiQy paAents had confirmed systemic osteoporosis by DXA scan (experimental group), while the other 150 paAents had no history of osteoporosis (Healthy control group). The study used the Ramus Index to calculate the grey mean values on panoramic images, which correlates with bone mineral density (BMD) compared with the data of dual-energy X-ray absorpAometry (DXA) as the gold standard ref- erence. Results: The findings demonstrated that panoramic images and the Ramus Index were a reliable indicator of osteoporosis (p<0.001) (80% sensiAvity, 90% specificity, and 85% accuracy). Conclusion: QuanAtaAve grey- level evaluaAon of panoramic images demonstrated diagnosAc validity. Open Access Cita%on: Jasim HH. (2025) Radiographic Study of Osteo- porosis Detec%on in the Jaw. Den%stry 3000. 1:a001 doi:10.5195/d3000.2025.967 Received: June 21, 2025 Accepted: June 26, 2025 Published: August 6, 2025 Copyright: ©2025 Jasim HH. This is an open access ar%- cle licensed under a Crea%ve Commons ARribu%on Work 4.0 United States License. Email: halmhanawi@uowasit.edu.iq Introduc)on “Osteoporosis is a metabolic-related disease marked by decreased bone mineral density (BMD)”, leading to elevated bone fragility and an elevated risk of fractures [1]. This dis- order is caused by disequilibrium between bone formation and resorption, reducing bone mineral composition in the whole body, considerably affecting bone microstructure and increasing vulnerability to fractures in the hip, femur, wrist, spine and other situa- tions [2,3] states that osteoporosis is a con- dition where the value of bone mineral den- sity is equal to 2.5 standard deviations (or more) below the mean level for young adults. The diagnosis is based on several risk fac- tors, with evaluation of the lumbar spine and femur considered the most signiKicant re- gions [3,4]. Over 200 million individuals are influenced by “osteoporosis” worldwide, with one-fifth of males and one-third of females over the age of fifty vulnerable to fractures [5]. With the continued aging of populations worldwide, the rate of osteoporosis will in- crease, creating a serious economic chal- lenge [5]. Osteoporosis reflects a classic mul- ticausal disorder where genetic tendency, exogenous effects, endogenous biological variables, and lifestyle preferences contrib- ute to differentiate individual vulnerability. [6] The normal path of bone mass follows a predictable manner, peaking about age 30, with men typically achieving greater peak bone mass than women, due to this peak, both genders facing an age-related regres- sion in bone density at a rate of 0.5 to 1% per year [7]. On the other hand, the clinical presentation of osteoporosis shows high gender predilection, with epidemiological studies suggesting the prevalence rates of 2 to 8% in men over 50 years compared to rates of 33 to 47% in women for the same age group [8]. The physiopathology of osteoporosis, espe- cially in post-menopausal women, has often been related to endocrine disturbances. The main role of estrogen insufficiency and sub- sequent secondary hyperparathyroidism has been strongly supported, with these hor- monal alterations commonly aggravated by insufficient dietary intake and the frequent prevalence of vitamin D inadequacy in aging people [6]. Estrogen exerts its protective effects on bone mainly through estrogen receptor-alpha, which keeps the critical equilibrium be- tween bone formation and resorption. De- creased signaling of estrogen receptor-alpha leads to interruption of this balance, causing inordinate bone resorption [9]. The funda- mental pathway for this process includes complicated interactions between ERα and the primary osteogenesis pathway, including “insulin-like growth factor (IGF) and Wnt/β- Radiographic Study of Osteoporosis DetecAon in the Jaw Vol 13, No 1 (2025) DOI 10.5195/d3000/2025.967 http://dentistry3000.pitt.edu 2 catenin signaling systems”. Estrogen insuffi- ciency-induced negative regulation of ERα diminishes numerous activities of stem cells in bone marrow, decreasing their prolifera- tive efficiency, F-actin stress fiber formation and alkaline phosphatase activity. Moreover, ERα acts as a crucial controller of primary osteogenic genes such as osteocalcin, osteo- pontin and osterix [10-12]. Experimental evidence from ovariectomized rat samples has supported these findings, showing an apparent association between osteoporosis due to sex hormones insuffi- ciency and decreased mineral density of the jawbone, with major consequences for qual- ity and regenerative capability of alveolar bone [13-17]. In addition to these hormonal mechanisms, several additional risk factors promote the development of osteoporosis, long term glucocorticoid use causes bone loss through osteoblast inhibition [18,19], furthermore, smoking negatively influences bone metabolism through several pathways [20]. Insufficient calcium use disrupts bone mineralization [4], and diabetes mellitus changes bone quality due to high blood sugar, creating harmful glycated proteins. [20]. Osteoporosis of the jaw has several adverse effects on oral health, delaying healing fol- lowing tooth extraction, orthodontic treat- ment, periodontal disease progression and dental implant success [5,21,22]. Osteoporo- sis treatments such as bisphosphonates can enhance jawbone mineral density, which in turn has risks involving osteonecrosis of the jaw related to bisphosphonates [23]. The mandible, as a component of the axial skeleton, revealed exclusive properties that allow the identification of osteoporosis-re- lated alterations through radiographic anal- ysis. Studies confirm that osteoporosis causes a decline in bone mineral density, in- fluencing densitometric, morphometric and architectural qualities of the jaw. Frequent radiographic signs include extensive radio- lucency of the mandible and maxilla, reduced thickness of the mandibular inferior cortex, cortical weakening, and amplified promi- nence of anatomical landmarks like the nasal cavity and maxillary sinus [24]. Radiography is used as a diagnostic proce- dure for the assessment of dentition and jaw- bone anomalies in practical dentistry [25,26]. Dental radiographs, especially in- traoral and panoramic images, have displayed the capability of identifying early signs of bone diseases. Panoramic radiog- raphy is one of the most prevalent radio- graphic method due to its ability to get exten- sive visualization of the maxillofacial struc- ture [27,28]. Radiographic bone measure- ment indices, such as the panoramic mandib- ular index, mandibular cortical width, and cortical index have been suggested as relia- ble indices for evaluating low bone mineral density using dental panoramic radiographs [28]. The current study was designed to assess the reliability of panoramic radiographs in de- tecting “osteoporosis”. Material and Methods The study was carried out at several specialized dental centers, in Baghdad, Iraq, between April 2024 and May 2025. The study included 300 paAents of both genders aged between 40 and 50 years who were referred for panoramic im- ages. One hundred fiQy paAents had confirmed systemic osteoporosis by DXA scan (experi- mental group), while the other 150 paAents had no history of osteoporosis (healthy control group). All panoramic images were analyzed to assess bone density using ImageJ soQware [version 2.3.0, 2023; NIH, USA]. [29] The Ramus Index was used for bone density analysis of the jaws by measuring the grey values on pano- ramic images through histogram analysis of pixel intensiAes. This was achieved by calculat- ing the mean grey values (MGV) in the selected region of the mandible on panoramic images. A square (box) of 30 x 30 mm was drawn on the panoramic image in the mandibular region, and then the mean grey values within this box were analyzed. The superior side of this square was drawn to be tangent to the mandibular sig- moid notch, the anterior side extended toward the anterior edge of the ramus, the posterior side extended toward the posterior margin of the ramus, and the inferior side of the square reached close to the mid-ramus region. Radio- graphic data from panoramic images were an- alyzed to compare localized bone density with systemic DXA results (Figure 1). The parameters of the DXA scan used in the study as the gold standard reference are DXA sensiAvity: 90%, specificity: 95%, and accuracy: 93%. [30, 31] All parameters of the panoramic X-ray system were adjusted to be similar to all panoramic images (kVp: 80 kV, mA: 10 mA and exposure Ame: 15 seconds). Bone Density Evalua0on A- Parameters of localized bone density on panoramic images: • Normal bone density (High Density - Radio- paque): Mean grey values range between 160- 255. • Osteopenia (Moderate Density - Less radio- paque): Mean grey values range between 100- 159. • Osteoporosis: Low Density (More Radiolu- cent): Mean grey values range between 0–99. B- “Dual-Energy X-ray AbsorpAometry (DXA)” [32]: The diagnosis of osteoporosis via “DXA (Dual- Energy X-ray Absorptiometry)” was based on T-scores, according to criteria of The World Health Organization (WHO) as follows: • Normal: T-score ≥ -1.0. Bone density is within 1 standard deviation (SD) of the young adult mean. • Osteopenia or early osteoporosis (Low Bone Mass): T-score between -1.0 and -2.5. Bone density is 1 to 2.5 SD below the young adult mean. Indicates increased fracture risk. • Osteoporosis: T-score ≤ -2.5 Bone density is 2.5 SDs or more below the young adult mean. High fracture risk. Figure 1. Ramus index (RI) applied in the study. Inclusion Criteria o PaAents of both genders aged between 40 and 50 years. o PaAents had confirmed systemic osteoporosis by DXA test, included in the experimental group. o PaAents had no history of osteoporosis in the healthy control group. Exclusion Criteria o PaAents with metabolic bone disorders other than osteoporosis (e.g., Paget’s disease, oste- omalacia). Radiographic Study of Osteoporosis DetecAon in the Jaw Vol 13, No 1 (2025) DOI 10.5195/d3000/2025.967 http://dentistry3000.pitt.edu 3 PaAents with systemic diseases that may af- fect bone metabolism or turnover (e.g., diabe- tes mellitus and chronic kidney disease). Menopausal women. Pregnant or lactaAng women. PaAents on corAcosteroids or other medica- Aons known to alter bone metabolism within the past 6 months. PaAents treated with osteoporosis medica- Aons within the past 6 months. PaAents with periodonAAs, trauma, malig- nancy or pathology affecAng the maxilla or mandible. PaAents with dental implants, prostheses, or restoraAons interfering with bone evaluaAon. Alcoholic paAents and heavy smokers. PaAents on chemotherapy or radiotherapy. Sta0s0cal Analysis Chi-square test: used to assess the reliability of panoramic images in detecAng osteoporo- sis compared to DXA (gold standard). Cramér’s V Test: to measure the strength of associaAon. ROC Curve Analysis – Determine the sensiAv- ity and specificity of using grey values to clas- sify osteoporosis by plorng a Receiver Oper- aAng CharacterisAc (ROC) curve. Confidence Intervals (95%): To quanAfy the precision of diagnosAc performance metrics (sensiAvity, specificity, and accuracy). Results The findings demonstrated a strong correlaAon between the mean grey values (MGV) on pan- oramic radiographs and the actual bone den- sity status measured by DXA (The gold stand- ard). [Chi-square staAsAc (χ²) =169.28, p-value < 0.001]. The Cramér’s V test = 0.75, confirming the high reliability for bone density measure- ments on panoramic images for the detecAon of osteoporosis. In the osteoporoAc group, 80% of paAents had low grey mean values (more radiolucent), consistent with the ex- pected low bone density in osteoporosis. This means that panoramic images correctly idenA- fied a large number of osteoporoAc paAents. In addiAon, 16.7% of osteoporoAc paAents had moderate grey mean values (less radiolucent), suggesAng osteopenia or expected future oste- oporosis, and only 3.3% of osteoporoAc pa- Aents had high grey mean values, suggesAng a normal density despite having osteoporosis ac- cording to DXA. In the control group, 66.7% % of individuals had high grey mean values, con- firming their normal bone density. Only 23.3% showed moderate grey mean values, and 10% demonstrated low grey mean values, suggest- ing a small rate of false posiAves where the panoramic images suggested bone loss, even though the DXA did not. The staAsAcs test revealed that the diagnosAc efficiency of the procedure has moderate sen- siAvity, high specificity, and good accuracy, but it is staAsAcally less effecAve than DXA in all pa- rameters (p < 0.05). SensiAvity for panoramic imaging (80%) is significantly lower than DXA (90%) [Z = −3.16, p < 0.00], Specificity for pan- oramic imaging (90%) is lower compared to DXA (95%) [Z = −2.24, p = 0.025], confirming re- duced specificity. In the same way, accuracy for panoramic images (85%) is staAsAcally lower than DXA’s (93%) [Z = −2.89, p = 0.004]. Confi- dence intervals 95% enhanced confirmaAon of these findings. SensiAvity for panoramic im- ages (73.6–86.4%) does not reach DXA’s stand- ard sensiAvity (~ 90%), proving its inferiority. Specificity (85.2–94.8%) minimally overlaps with DXA’s specificity (~ 95%), indicaAng possi- ble similarity in an ideal situaAon, although sAll mostly lower. Accuracy (81.0–89.0%) is sAll less than DXA’s accuracy (~ 93%), supporAng that panoramic imaging is less accurate. In addiAon, AUC = 0.95% indicated excellent diagnosAc performance. Discussion “Osteoporosis” is a systemic disorder idenA- fied by reduced bone mineral density and dis- turbance of bone architecture. Systemic osteo- porosis affects the radial, spinal, femoral, cra- niofacial bones and oral structures, directly in- fluencing various oral condiAons and dental procedures [33,34]. Osteoporosis is primarily associated with in- creased risk of complicaAons in dental pracAce due to advanced alveolar bone resorpAon, causing delayed healing aQer tooth extracAons and a greater risk of pathological fractures dur- ing dental procedures, in addiAon to the pro- gression of the periodontal disease much faster. OrthodonAc treatments encounter diffi- culAes in tooth movement, and denture wear- ers oQen exhibit an improper fit resulAng from jawbone reducAon. AnAresorpAve medica- Aons such as bisphosphonates also have a marked risk of bisphosphonate-related jaw os- teonecrosis aQer aggressive dental surgery. In dental implants, the osteoporoAc bones of the jaw mostly lead to impaired osseointegraAon, raising the danger of implant failure too early. Osteoporosis also alters the mechanobiology through the bone-implant integraAon, causing more challenges, as the bone may struggle to withstand normal masAcaAon forces, possibly leading to peri-implant bone loss and implant overload with Ame. Therefore, comprehensive pre-surgical evaluaAon is criAcal, involving bone density assessments to invesAgate the quality of the jawbone, and denAsts should consider less invasive techniques. The associaAon between oral health status and osteoporosis is sAll controversial. The denAst can monitor paAents for osteoporosis, aims to examine people at osteoporosis risk and sup- port their urgent referral [35]. Some studies re- ported the associaAon between the mandibu- lar bone mineral content and many skeletal lo- caAons frequently uAlized for bone densitom- etry indicators in the idenAficaAon of osteopo- rosis [36]. The assessment of dental radio- graphs might contribute to the idenAficaAon of osteoporosis [37]. Many studies have reported that panoramic radiography may act as a de- pendable screening method for osteoporosis detecAon [38,39]. Various radio-morphometric indices have been suggested to evaluate the associaAon of bone loss in the mandible, such as Panoramic Mandibular Index (PMI), Mandib- ular CorAcal Index (MCI), Mental Index (MI), Mandibular CorAcal Width (MCW) and Ante- gonial Index (AI) [35,40-42]. Many researchers suggested using the Mandibular CorAcal Index (MCI), the Mental Index (MI), and a visual esA- maAon index on panoramic images for bone mineral density evaluaAon, and they con- cluded that these three indices presented as helpful tools for the detecAon of osteoporosis [43]. Many studies used panoramic images to detect osteoporosis and have proven their efficiency in that regard. Therefore, the current study re- lied on panoramic imaging to evaluate the reli- ability of panoramic images using grey values for detecAng osteoporosis compared to the measurements of dual-energy X-ray absorp- Aometry (DXA), which was used as the gold standard reference. The study evolved the Ra- mus Index (RI) to calculate the grey mean val- ues on panoramic images, which correlate with bone mineral density (BMD) using ImageJ soQ- ware. The study showed an evident relaAonship be- tween osteoporosis idenAfied through pano- ramic images (using grey mean values) and the diagnosis, which relied on DXA. The study found that the vast majority of individuals in the control health group (93.3%) showed high grey mean values consistent with normal bone density. A minor proporAon of them (4%) re- vealed moderate mean grey values; in addi- Aon, a diminished percentage (2.7%) showed low mean grey values, which could propose Radiographic Study of Osteoporosis DetecAon in the Jaw Vol 13, No 1 (2025) DOI 10.5195/d3000/2025.967 http://dentistry3000.pitt.edu 4 signs of early or exisAng osteoporosis. In con- trast, most paAents (80%) in osteoporoAc pa- Aents showed low mean grey values, a sugges- Ave result of decreased bone mineral density or osteoporosis. A small percentage of them (16.7%) revealed moderate mean grey values, proposing osteopenia, while only a few cases (3.3%) had high mean grey values, which could be due to human variaAon. These results reported that panoramic images (based on grey mean value analysis) have a good sensiAvity (80%), high specificity (90%), and good accuracy (85%). Therefore, on pano- ramic images, most osteoporoAc paAents were correctly idenAfied by low mean grey values, and most healthy control individuals were cor- rectly idenAfied by high mean grey values. On the opposite side, the current study showed some misclassificaAons (false negaAves and false posiAves), suggesAng that although pan- oramic imaging showed great potenAal as a screening tool, it should not replace DXA for definiAve diagnosis. However, the sensiAvity of radiographic im- ages in idenAfying early bone loss is sAll re- stricted, and bone density reducAon may not be observable unAl marked bone loss. In addi- Aon, the radiographic findings of osteoporosis can interfere with other condiAons, like perio- donAAs or other metabolic bone disorders, causing it difficult to differenAate from osteo- porosis, On the other hand, populaAons at higher risk for osteoporosis (like post-meno- pausal women), dental radiographs can serve as a helpful adjunct in the early detecAon for paAents. DenAsts must be trained to idenAfy minimal alteraAons in bone density and refer paAents for addiAonal assessment if necessary. So, integraAon of radiographic features with clinical predisposing factors such as a history of fractures, gender, and age can enhance diag- nosAc accuracy. Conclusions Panoramic image analysis using grey values can be considered a reliable adjuncAve tool for dis- Anguishing osteoporoAc paAents from healthy controls, parAcularly in situaAons where DXA scans are not readily available. Although useful as a screening method, its performance in sen- siAvity, specificity, and accuracy is staAsAcally less effecAve than DXA. Therefore, it should not replace the DXA method for definiAve di- agnosis, and it should be used as part of a mul- Amodal approach rather than a standalone di- agnosAc criterion. In addiAon, denAsts must remain careful and analyze panoramic findings within the wider clinical serng. Factors such as anatomical var- iaAons, paAent posiAoning and image quality can affect grey values evaluaAon and may cause misclassificaAon. However, because of its common availability in dental and maxillofa- cial pracAces, panoramic radiography presents a cost-efficient and accessible iniAal screening tool. This is parAcularly valuable in areas with limited services or access to advanced imaging technologies. 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