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Table of Contents
Year : 2015  |  Volume : 5  |  Issue : 3  |  Page : 125-130

Assessment of bone mineral density in pre- and post-menopausal women using densitometric software: A pilot study

1 Department of Prosthdontics and Oral Implantology, SDM College of Dental Sciences and Hospital, Dharwad, Karnataka, India
2 Deparmtent of Prosthodontics, SDM College of Dental Sciences and Hospital, Dharwad, Karnataka, India
3 Department of Oral Medicine and Radiology, SDM College of Dental Sciences and Hospital, Dharwad, Karnataka, India

Date of Web Publication28-Apr-2016

Correspondence Address:
Pallavi Taneja
Department of Prosthdontics and Oral Implantology, SDM College of Dental Sciences and Hospital, Dharwad, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2229-5194.181374

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Objectives: The density of available bone in the edentulous site of the patient is arguably the primary determining factors in predicting final prosthetic treatment outcome. The aim of the study was to compare and correlate the quality of mandibular bone with the help of densitometric software available in Kodak 9000C and to further substantiate the results, morphometric analysis using orthopantomograph (OPG) and quantitative ultrasound of calcaneus bone. Materials and Methods: Twenty premenopausal and twenty postmenopausal women were selected for the study with edentulous span in the mandibular second premolar and first molar region. Bone density of the edentulous span was calculated using the digital Kodak software 9000C for all the OPGs. Various radiomorphometric indices were measured on the OPG. Results were statistically analyzed. Results: The results proved that there was a statistically significant difference in the bone densitometric values for digital OPG readings, ultrasound values, mandibular cortical index, antegonial index, for pre- and post-menopausal women. Conclusion: Within the limitations of the study, the use of densitometric software yielded positive results. The results supported the fact that bone density reduces in postmenopausal women and can be used as an effective aid to quantify the bone mineral density which ultimately plays a significant role in prosthetic implant outcome.
The use of densitometric software could be used independently to measure bone density in future. An integrated team approach between the implantologist, prosthodontist, and radiologist provides a customized treatment plan, thereby, optimal patient care.

Keywords: Bone mineral density, digital orthopantomograph, implant, ultrasound

How to cite this article:
Taneja P, Meshramkar R, Guttal KS. Assessment of bone mineral density in pre- and post-menopausal women using densitometric software: A pilot study. J Interdiscip Dentistry 2015;5:125-30

How to cite this URL:
Taneja P, Meshramkar R, Guttal KS. Assessment of bone mineral density in pre- and post-menopausal women using densitometric software: A pilot study. J Interdiscip Dentistry [serial online] 2015 [cited 2023 Jun 6];5:125-30. Available from: https://www.jidonline.com/text.asp?2015/5/3/125/181374

   Introduction Top

Endosseous dental implants are currently used to retain and/or support prostheses for restoring completely or partially edentulous patients for a variety of tooth loss scenarios. A single implant is the best choice to avoid any immolation of enamel by preparation for a crown and bridge.[1]

The volume of the bone available and the quality of the bone are two factors that determine the type of surgical procedure and the type of implant to be placed. Both of these factors contribute to the successful prosthetic outcome.[2]

The earliest suggestion of an association between skeletal and oral bone loss was made in 1960.[3] Since then various studies have reported that decreased bone mineral density (BMD) affects the morphometric, densitometric, and architectural properties of mandibular bone.[4]

In 1992, the World Health Organization (WHO) developed bone density threshold criteria for the diagnosis of osteoporosis: T-score 2.5 standard deviations (SDs) below peak bone mass.[3]

Recent studies indicate that dental panoramic radiographic measures may be a useful tool in identifying low skeletal BMD, the risk of fractures.[5]

Precise determination of alveolar bone density is of paramount importance for diagnosis, treatment planning and management of conditions [6] of partial and complete edentulism, which may be rehabilitated using either implant supported prosthesis.

Various methods used to measure bone density have been documented in the literature.[3],[5] Use of densitometric software available in Kodak 9000C (Kodak 9000 three-dimensional (3D) Imaging System, October 2009), (Carestream Health Inc., Rochester, NY, USA) for evaluation of bone density can be useful if the operator gets an overview of its use without subjective error.

Thus, the purpose of this study is to quantitatively measure the bone density in the edentulous area using a densitometric software Kodak 9000C and further correlation of the quality and quantity of mandibular bone with the help of mandibular morphometric indices using orthopantomograph and quantitative ultrasound (QUS) of calcaneus bone which represents the general body density of the body.

The objectives of the study is to validate the effective use of densitometric software (available in Kodak 9000C machine) for analysis in edentulous span, and to compare the values with mandibular indices which are already proven tools for density analysis and to ascertain whether the densitometric values of OPG correlate with general body density measured by QUS.

   Materials and Methods Top

A total of forty female patients were selected particularly to two different groups. The two groups were classified as Group I (premenopausal women with the age range of 25–35 years) and Group II (postmenopausal women with the age range of 45–65 years). The selected patients were partially edentulous with the mandibular arch with either second premolar or first molar/or both missing. The selected patients who had received OPG as part of their dental treatment were randomly selected. All patients were informed about the study, and informed consent was signed by each patient. The ethics committee reviewed and approved the study protocol. A detailed medical history and menstrual history was recorded for each patient.

The inclusion criteria for pre- and post-menopausal women

  • Women not receiving hormone replacement therapy
  • No history of any metabolic bone diseases, diabetes, significant renal impairment, and bone destructive lesions
  • Edentulous area in the premolar and molar area of the mandible.

The inclusion criteria for postmenopausal women in specific

  • Patients who had not undergone hysterectomy or oophorectomy
  • Natural history of menopause (minimum of 3 years).

Patients on medication, affecting the BMD (steroids, anticonvulsants, excessive thyroxine doses), were excluded from the study.

Bone densitometric assessment on OPG

Bone density in the region of interest (mandibular second premolar/ first molar region/edentulous span) was calculated using the digital densitometric Kodak software 9000C (Kodak 9000 three-dimensional (3D) Imaging System, October 2009), (Carestream Health Inc., Rochester, NY, USA) for all the dental panoramic radiographs. The tool allows the measurement between two different points as a linear distance measurement and the readings reveal average value at any given point [Figure 1].
Figure 1: Densitometric analysis in Kodak 9000C extra oral imaging

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All the measurements were carried out by a single observer. To check the reliability, the measurements were repeated after an interval of 2 weeks.

Calculation of radiomorphometric indices

Digital panoramic radiographs were made for all the patients employing Kodak 9000C 3D Extraoral Imaging System at 110 Kv and 100 mA. The position of the head was standardized.

Linear measurements were made using a digital caliper and a clear plastic acetate sheet superimposed on panoramic radiographs [Figure 2].
Figure 2: Bone density examination using ultrasound scan

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Following indices were measured on dental panoramic radiographs:

  1. Mandibular cortical index (MCI) refers to the inferior mandibular cortical thickness and is categorized into three groups according to the criteria described by Klemetti et al[7]

    • C1-the endosteal margin of the cortex is even and sharp on both sides;
    • C2-the endosteal margin shows semilunar defects (lacunar resorption) and/or seems to form endosteal cortical residues on one or both sides; and
    • C3-the cortical layer forms heavy endosteal cortical residues and is clearly porous.

  2. Mental index (MI) is the measurement of the cortical width at the mental foramen region and is assessed according to the technique described by Ledgerton et al[8]Accordingly, the mental foramen was identified and a line was traced that passed perpendicular to the tangent of the lower border of the mandible and through the center of the mental foramen. The cortical width was measured at this point

  3. The inferior panoramic mandibular index (PMI) as described by Benson et al.[9] is the ratio of the thickness of mandibular cortex to the distance between the mental foramen and the inferior mandibular cortex
  4. Antegonial index (AI) is the depth of the antegonial notch. A tangent was drawn to the lower border of the mandible and the two lines joining the tangent to the deepest point on the antegonial notch was drawn. The distance between the tangent and a line perpendicular to the intersection of the two lines was measured.

Measurement of bone density using ultrasound

Since the bone densitometric values had to be validated, all the patients were subjected to QUS (QUS; CM-200, Furono, Kobe, Japan) of calcaneus bone to assess the general skeletal bone mass. BMD at the right calcaneus as a percentage of the speed of sound was determined. Furthermore, the T-score according to the WHO criteria was noted [Figure 3].
Figure 3: OPG showing tracings for different morphometric indices

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All the readings were tabulated and subjected to statistical analysis.

Statistical analysis

The results were expressed as arithmetic means, considering the SD. Pearson linear correlation and Student's t-test was used to evaluate the interdependence between examined parameters (digital OPG readings, QUS values, MI, PMI). A nonparametric test - Mann–Whitney test was also conducted for both groups to examine the relationship between the two variables (AI, MCI) that were not normally distributed. Correlation was considered to be significant at the values of P < 0.05. All the statistical methods were carried out using a software program (Statistical package 17, SPSS).

   Results Top

This study included 20 premenopausal and 20 postmenopausal women with the mean age of 30 and 55.5 years respectively. Mean and SD of measured variables are shown in [Table 1] and [Table 2].
Table 1: Mean values of Groups I and II using Student's t-test (for normally distributed variables)

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Table 2: Comparison of Groups I and II using for two variables that were not normally distributed, the antegonial index and mandibular cortical index, using the Mann–Whitney U-test

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Correlation of the parameters

For digital OPG readings, the mean value for Group I was found to be 97.13 ± 2.77 and for Group II was 106.26 ± 15.27 which was statistically significant. For T-score, the mean value for Group I was 0.1531 ± 1.12 and Group II was − 2.3850 ± 0.79. For MI, the mean value for Group I was 4.9375 ± 1.30 and for Group II was 4.1250 ± 0.83. Hence, it was concluded that the values from the densitometric software showed a negative correlation with the QUS values and MI, with the results being significant.

   Discussion Top

For osseointegration of endosteal implants to occur, not only adequate bone quantity is required, but adequate density is also needed. The initial bone density not only provides mechanical immobilization of the implant during healing but after healing also permits distribution and transmission of stresses from the prosthesis to the implant-bone interface.[10]

The increasing demand for implant treatment has also raised interest in the available imaging techniques to perform a proper preoperative planning before oral implant placement. Various methods to assess jaw bone density include quantitative computerized tomography; quantitative cone beam computerized tomography; dual energy X-ray absorptiometry (DEXA); magnetic resonance imaging; QUS; panoramic; and cephalometric radiographs.[11]

The DEXA technique is used frequently, but cost viability, and limited trained personnel limits its use.

Various parameters have been used to measure bone density. Drozdzowska et al.[3] in their study have compared the MCI, PMI to correlate with BMD of the mandible and with QUS of calcaneus. Mandibular BMD (m-BMD) was performed in the body of the mandible measured as g/cm 2. The results state that of all the parameters assessed, only m-BMD correlated significantly with DEXA and QUS.

Bozic and Ihan Hren [5] in their study compared whether OPGs differ between osteoporotic and nonosteoporotic women. Mandibular atrophy signifying osteoporosis was assessed by six anatomic indices. Relative bone density (RBD) was assessed using color histogram. They concluded that mandibular bone tissues between osteoporotic and nonosteoporotic women differed significantly on OPGs and RBD was also lower in osteoporotic women.

Nackaerts et al.[12] assessed the precision and accuracy of a digital densitometric tool, osteop for the analysis of mandibular bone density. Forty-seven bone samples derived from premolar region were obtained from adult cadavers. DEXA, digital radiography was performed on all specimens. They found out it offers potential for clinical evaluation of bone density and minute bone density changes in the jaw bone.

Oliveira et al.[13] did a study to evaluate the relative efficacy of the trabecular bone in the mandibular angle and body, which were analyzed for fractal dimension (FD) and pixel intensity (PI) on the digital OPG images. The results showed that FD and PI values were significantly different between normal and osteoporotic patients for the right and left mandibular angle and for the left mandibular body.

Thus, very often OPGs have been employed in the assessment of osteoporosis either to evaluate indices or in comparison with DEXA and QUS. The present study employs the OPG with densitometric software for bone density assessment.

Digital OPG scans were performed in Kodak 9000C 3D extraoral imaging system. All the assessments were performed by the same observer in a Trophy Digital Imaging and Communications in Medicine format. The display details are selected via the inspection window placed in the mandibular second premolar and first molar of the panoramic view. The test showed a significant difference between pre- (mean = 97.12) and post-menopausal group (mean = 106.25). Furthermore, digital OPG readings correlated with MI at P = 0.000 <0.01 level.

Radiomorphometric indices are predominantly based on measurements of cortical bone because it is more easily visualized on radiographic film than is trabecular bone.[2] A standardized site of investigation in many of the studies has been in the mental region of the mandible because it is not usually associated with attachment sites of the major masticatory muscles.

Cortical width and porosity on dental panoramic radiographs have been shown to be potentially useful assessment methods.[14] Therefore, this study used various panoramic indices.

Measurement of the thickness of the mandibular cortical width in the mental foramen region on panoramic radiographs has been suggested as a way to predict patients with low bone mineral density. Previous studies [15] have shown significant relationships between the MI and bone mineral density. In our study, the cortical bone in the mental region was significantly thinner in Group II of postmenopausal women as compared to premenopausal group.

Ultrasound measurements (QUS) of the calcaneus using FURONO CM-200 were performed at the right (dominant) heel to assess the general bone density. All measurements were done by the same operator. In Group II of postmenopausal women, there was a significant correlation between QUS measurements and MI. Whereas in Group I of premenopausal women, there was positive correlation between QUS measurements and MI and AI. Also, there was a significant difference between QUS measurement values of pre- (mean = 0.15) and postmenopausal (mean = −2.39) groups.

This is the first study done on Indian population which uses the above-mentioned software to correlate BMD with the other parameters. Based on the literature search, this software has been used for the 1st time to measure bone density. To further substantiate the validity of the results obtained from this method, additional proven methods like the use of radio-morphometric indices was also employed in this study.

DEXA is considered the most reliable tool for measuring the skeletal bone mass. However, because of economic constraints and other practical reasons could not be used. Therefore, QUS was considered as an alternative standard in this study.

This is one of the few studies in which the groups were divided based on the menopausal status where the premenopausal group included patients ranging from 25 to 35 years, and postmenopausal group included patients from 45 to 65 years. Patients in our study groups were not selected on the basis of any radiographic or medical criteria, which would define an individual as normal or osteoporotic. Based on the medical history, patients on medications or suffering from systemic diseases affecting BMD were excluded from the study. The study group, therefore, represents patients undergoing normal physiologic bone changes with age, who had undergone OPG examination as a part of their routine dental treatment.

This software once proven can be used in daily practice and can help a dentist to further refer their patients for appropriate treatment.

   Conclusion Top

Within the limitations of the study, the use of densitometric software yielded positive results. The results correlated with other proven methods and could be used independently to measure bone density in future. Further, the software can be used for the detection of osteoporosis, which has a direct influence on the prosthetic outcome of a patient.


The authors express their gratitude to Dr. Lekha K (Professor and Head, Department of Prosthodontics), Dr. Krishna Burde (Professor and Head, Department of Oral Medicine and Diagnosis) and Dr. Muddapur for statistical help. Special thanks to NOVARTIS India limited, Pharmaceuticals Division, Mumbai, India for their support in providing the facility of ultrasound.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Mack F, Samietz SA, Mundt T, Proff P, Gedrange T, Kocher T, et al. Prevalence of single-tooth gaps in a population-based study and the potential for dental implants – Data from the Study of Health in Pomerania (SHIP-0). J Craniomaxillofac Surg 2006;34 Suppl 2:82-5.  Back to cited text no. 1
Homolka P, Beer A, Birkfellner W, Nowotny R, Gahleitner A, Tschabitscher M, et al. Bone mineral density measurement with dental quantitative CT prior to dental implant placement in cadaver mandibles: Pilot study. Radiology 2002;224:247-52.  Back to cited text no. 2
Drozdzowska B, Pluskiewicz W, Tarnawska B. Panoramic-based mandibular indices in relation to mandibular bone mineral density and skeletal status assessed by dual energy x-ray absorptiometry and quantitative ultrasound. Dentomaxillofac Radiol 2002;31:361-7.  Back to cited text no. 3
Bergkvist G, Koh KJ, Sahlholm S, Klintström E, Lindh C. Bone density at implant sites and its relationship to assessment of bone quality and treatment outcome. Int J Oral Maxillofac Implants 2010;25:321-8.  Back to cited text no. 4
Bozic M, Ihan Hren N. Osteoporosis and mandibles. Dentomaxillofac Radiol 2006;35:178-84.  Back to cited text no. 5
Taguchi A, Suei Y, Sanada M, Higashi Y, Ohtsuka M, Nakamoto T, et al. Detection of vascular disease risk in women by panoramic radiography. J Dent Res 2003;82:838-43.  Back to cited text no. 6
Klemetti E, Kolmakov S, Kröger H. Pantomography in assessment of the osteoporosis risk group. Scand J Dent Res 1994;102:68-72.  Back to cited text no. 7
Ledgerton D, Horner K, Devlin H, Worthington H. Radiomorphometric indices of the mandible in a British female population. Dentomaxillofac Radiol 1999;28:173-81.  Back to cited text no. 8
Benson BW, Prihoda TJ, Glass BJ. Variations in adult cortical bone mass as measured by a panoramic mandibular index. Oral Surg Oral Med Oral Pathol 1991;71:349-56.  Back to cited text no. 9
Budtz-Jörgensen E. Restoration of the partially edentulous mouth – A comparison of overdentures, removable partial dentures, fixed partial dentures and implant treatment. J Dent 1996;24:237-44.  Back to cited text no. 10
Adell R, Lekholm U, Rockler B, Brånemark PI. A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg 1981;10:387-416.  Back to cited text no. 11
Nackaerts O, Jacobs R, Pillen M, Engelen L, Gijbels F, Devlin H, et al. Accuracy and precision of a densitometric tool for jaw bone. Dentomaxillofac Radiol 2006;35:244-8.  Back to cited text no. 12
Oliveira ML, Pedrosa EF, Cruz AD, Haiter-Neto F, Paula FJ, Watanabe PC. Relationship between bone mineral density and trabecular bone pattern in postmenopausal osteoporotic Brazilian women. Clin Oral Investig 2013;17:1847-53.  Back to cited text no. 13
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