Mandibular cortical shape index in non-standardised panoramic radiographs for identifying patients with osteoporosis as defined by the German Osteology Organization Ahmed Al-Dam * , Felix Blake, Artun Atac, Michael Amling, Marco Blessmann, Alexandre Assaf, Henning Hanken, Ralf Smeets, Max Heiland Department of Oral and Maxillofacial Surgery (Head: Prof. Dr. Dr. Max Heiland), University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany article info Article history: Paper received 13 April 2012 Accepted 28 November 2012 Keywords: Bone density Radiography panoramic Osteoporosis radiography Osteopenia Dental radiography Osteoporosis abstract The aim of this prospective controlled study was to determine the validity of the mandibular cortical shape index (CI) on panoramic radiographs in distinguishing patients with osteoporosis as defined by the German Osteology Organization (Dachverbands der Deutschsprachigen Osteologischen Fachgesell- schaften, DVO). The study group contained 50 patients (33 female, 17 male, mean age: 74.9 years), who had a high risk of osteoporosis. 50 young patients (33 female, 17 male, mean age: 37.9 years) with no anamnestic evidence of osteoporosis served as control. Three blinded observers evaluated panoramic views of the study and the control group in a mixed manner regarding the mandibular cortical shape index. The study group underwent bone mineral density measurement using dual energy X-ray ab- sorptiometry and received a diagnosis according to the Organization’s guidelines (normal, osteopenia, osteoporosis). The CI showed a high sensitivity of 72.2% and a high specificity of 93.9% with a highly significant predictive value (Chi-square ¼ 22.96, p < 0.001), while the observer’s agreement was mod- erate (kappa ¼ 0.47). We concluded that patients with a cortical shape index of the category assessed as “severe” on non-standardised panoramic radiographs have a higher risk of suffering systemic osteopo- rosis. The CI in panoramic radiographs is a good screening tool, which could be implemented in the routine assessment of panoramic radiographs in elder patients. Crown Copyright Ó 2013 Published by Elsevier Ltd on behalf of European Association for Cranio-Maxillo- Facial Surgery. All rights reserved. 1. Introduction Osteoporosis is a systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and resulting higher fracture risk (NIH Consens, 2000). The perioperative mortality rate after an osteoporotic hip fracture in Germany is about 6%, in the USA and UK the mortality rate ranges between 10 and 24% (Fisher et al., 1991; Cauley et al., 2000; Dreinhöfer and Käfer, 2004). Pa- tients with osteoporotic fractures have an increased rate of mor- tality, particularly in the first year after the fracture event, and a high risk of further fractures. Yearly,1% women aged between 50 and 79 years suffer a vertebral fracture and 1.9% experience a pe- ripheral fracture. The corresponding data in men are 0.6e0.7% (Baum and Peters, 2008). Osteoporosis is diagnosed based on the bone mineral density (BMD), which is commonly measured using the dual X-ray energy absorptiometry (DXA). According to the definition of the World Health Organization (WHO), osteoporosis is being diagnosed, when the measured BMD is 2.5 standard deviations or more below the young female adult mean bone mineral density value (T-score 2.5) (Kanis, 1994). However, the guidelines of the German Osteology Organization (Dachverbands der Deutschsprachigen Osteologischen Fachgesell- schaften, DVO) is not only based on the BMD, but also on the expected fracture risk which plays a relevant role in its definition for the initiation of specific osteoporotic diagnostic measures and for the necessity of an osteoporotic medical therapy (Pfeilschifter, 2006). The panoramic radiograph is a widely used imaging modality in dental practice. It is the second most frequently used diagnostic X-ray investigation used in general dental practice and perhaps the most frequent diagnostic X-rays in the oral and maxillofacial sur- gical practice (Horner et al., 1996; Hildebolt, 1997; Li et al., 2009). * Corresponding author. Tel.: þ49 40 7410 53259/53251; fax: þ49 40 7410 55467. E-mail addresses: a.al-dam@uke.de, ahmed.aldam@aljekte.de (A. Al-Dam). Contents lists available at SciVerse ScienceDirect Journal of Cranio-Maxillo-Facial Surgery journal homepage: www.jcmfs.com 1010-5182/$ e see front matter Crown Copyright Ó 2013 Published by Elsevier Ltd on behalf of European Association for Cranio-Maxillo-Facial Surgery. All rights reserved. http://dx.doi.org/10.1016/j.jcms.2012.11.044 Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e165ee169