OSTEOPOROSIS: PART II

In the last issue of this e-zine, I addressed some disturbing news that has been emerging in the dental world. Cases of necrosis (death) of the jawbones that are unresponsive to treatment are currently being reported. The common denominator for the patients in all these cases was the taking of drugs used to treat osteoporosis, osteopenia and bone cancer.

Dental surgeries, such as periodontal surgery, extraction of a tooth or placement of implants resulted in open wounds that would not heal. Further treatment can often help pain, but it will not help the healing. This is a real problem.

The history and “definitions” of osteoporosis and a newly created disease, osteopenia, were also addressed in the last issue. Diagnostic testing machines and the standards and norms used by these machines were explored. Also discussed was the rise of the widely prescribed hormone replacement therapy (HRT) drugs to treat osteoporosis. Later it was noted that HRT was linked to the risk of serious diseases such as breast and ovarian cancer, and heart disease. These HRT findings opened the door for other drugs to address the “epidemic” of osteopenia and osteoporosis. These drugs,such as Didronel, Aredia, Actonel, Zometa, Boniva and Fosamax have been taken by patients for years. Thus, these latest findings on dental bone necrosis are becoming a serious concern.

(To read Osteoporosis Part 1 visit the Education & Library Section at wholebodydentistry.com)

We will continue this topic of Osteoporosis and proceed with Four Critical Questions that should be addressed.

(1) Does low BMD (Bone Mineral Density) predict future fractures? (2) Is the normal value of bone density, which is based on an approximately 30 – year- old Caucasian woman, valid for different races and ethnicity groups? (3) Are the machines being used for BMD standardized – and what are they telling us? (4) At what point are drugs, with all their potential known and unknown side effects, warranted?

Let’s look at these questions one by one.

(1) Does low BMD (Bone Mineral Density) predict future fractures?

Various studies show that low BMD is not an accurate predictor of future fracture, especially of hip fracture. The World Health Organization says osteoporosis is “a progressive systemic skeletal disease, characterized by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture.”

So osteoporosis has two components, mass or density, and strength.

Strength is a factor of the inner architecture of bone – the trabeculae. This is analogous to the steel bracing in the inside of a building. This cannot be measured.

Because the mass or density can be objectively measured by the DXA (dual x-ray absorptiometry) machine, this in fact became the definition of osteopenia and osteoporosis.

The DXA machines that are used only look at density; and tell nothing about the inside architecture of the bone and consequently the strength of the bone.

(2) Is the normal value of bone density, which is based on an approximately 30 – year- old Caucasian woman, valid for different races and ethnicity groups

Different ethnic groups have different peak bone mass. The variation can be very substantial – up to 100%.

So against whom should your bone mass be measured? (The values for defining osteoporosis and osteopenia are based on standard deviations below the young adult mean. The young adult mean is based on peak bone mass of an approximately thirty-year-old Caucasian woman.)

(3) Are the machines being used for BMD standardized – and what are they telling us?

The machines used measure the mineral content of the bones being tested – i.e., the hip, forearm, or vertebrae. Take the bone mineral content (BMC) and divide this by the surface area of the bone being tested. This gives bone mineral density (BMD). Different machines have different calibrations, and different norms, so if you do have testing always use the same machine for retesting. The BMD is then “scored” against a peak bone density “ideal”. This was established based upon a young Caucasian population. As already stated, different ethic groups have different peak bone mass. A study in Canada even showed variation in peak bone mass in different parts of the country.

Also, remember the machines only tell us about bone density not bone strength.

Your bone mass is not being compared to your peak bone mass or even to the bone mass of someone of your ethnicity or same age group. Taking your result and comparing it to a young reference population gives a T-score. When your result is measured against an average BMD for your age and gender, this is called a Z-score. However it is T scores that are used for diagnosis.

Loss of bone density is normal as we age. By using a T-score lots of people will test poorly.

Also there is no standard for the ideal peak bone mass value. One manufacturer may use a group of woman age 20-29, another 20-39. When you have a T-score that is 1.5 standard deviations below the mean, and you are told you have osteopenia, what really is this telling us? It is better to know your Z- score – how you compare to people your age and gender.

(4) At what point are drugs, with all their potential known and unknown side effects, warranted.

At what point and based upon what information are you going to take a drug to “prevent” or “treat” osteoporosis. When does the risk of the drugs outweigh the risk of hip fracture?

Bone is alive – it is constantly resorbing and replenishing.

The bone forming cells are called osteoblasts; the bone resorbing cells are osteoclasts. The bisphosphonate drugs inhibit the osteoclasts and thereby reduce the demand for osteoblasts. They fossilize the bone, making it harder. Is the necrosis of the jawbones the tip of the iceberg?But what are the long-term effects of interfering with the ballet of resorption and regeneration?

Before you decide to take a drug, I suggest you personally research this topic. I believe the fear of hip fracture that has been created is unfounded. Most of these fractures occur in people over 80 that are not in good health and are on various drugs. Just having elderly, frail people wear special hip padding has shown to substantially reduce fractures.

A book I would recommend on this topic is The Myth of Osteoporosis by Gillian Sanson.

My advice: Eat well, do aerobic, as well as weight bearing exercises, remain off drugs as much as possible, and get the toxins out of your system – do so before you get older and if you are older, it is never too late to start. Also, get enough sunlight to keep your Vitamin D level up. Vitamin D is necessary for the absorption of calcium. And most important, arm yourself with knowledge! It’s your health; let’s never forget that.

© 2006, Mark A. Breiner, DDS

The information presented is for educational purposes only. You should consult a qualified dentist or health practitioner for diagnosis and treatment.