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Aging, Systemic Disease and Oral Health: Implications for Women Worldwide (Part I)

Course Number: 302

Risk Factors, Prevention, and Treatment (Osteoporosis)

Being female poses a greater risk for developing osteoporosis than male; however, the risk increases in each sex with age. Low bone mass, family history, amenorrhea, estrogen deficiency, cigarette smoking, certain medications, and Caucasian or Asian ethnicity are all risk factors (Figure 10).

Image: Osteoporosis – Risk Factors, Treatments and Connections to Oral Health.

Figure 10. Osteoporosis – Risk Factors, Treatments and Connections to Oral Health.

Weight loss and low body weight can be associated with an increased risk of fractures due to a greater loss of bone mass.63 Glucocorticoids are a type of corticosteroid hormone that are very effective at reducing inflammation and suppressing the immune system, and are effective immunosuppressants used in a wide variety of diseases.64 Glucocorticoid use results in secondary osteoporosis in about 30–50% of chronic glucocorticoid users, and the drugs can cause a rapid decline in bone strength within the first 3–6 months mostly due to increased bone resorption by osteoclasts.64 Smoking, a modifiable risk factor, has been identified in leading to lower bone density, as well as it contributes to an early death, tumors, and numerous chronic diseases.65 Alcohol consumption continues to increase globally, even though there are considerable negative health effects.66 According to animal studies, chronic alcohol consumption has been shown to affect multiple organs, body systems and molecular pathways, including the skeletal system, by disturbing vitamin D metabolism.66 Other studies showed that chronic alcohol consumption increases osteoclastogenesis and osteoclast activity in animals and humans. There is also evidence that binge or episodic excessive alcohol consumption leads to similar effects.66 A sedentary lifestyle and physical inactivity can contribute to reduced bone quality and increased risk of fractures.67 Excessive time spent in sedentary behaviors is associated with reduced physical functioning and leg blood flow, which could predispose individuals to falls, reduced bone quality, and fracture. Without proper physical activity, bones become weak and thus can fracture easily.67 In this study of over 77,000 women, regular physical activity and less sedentary time was associated with reduced risk of fracture in older women.

While there is no cure for osteoporosis, prevention and treatment is available. It is estimated that 85–90% of the adult bone mass is gained during the first two decades of life . Before age 20 is when most skeletal mass forms; therefore, preventive measures are important to implement at even young ages. Eating a diet rich in calcium, vitamins D and K, avoiding smoking or excessive use of alcohol, and exercising regularly (including weight-bearing exercises) are important preventive steps. Childhood and adolescence are critical periods of bone mineral content accumulation that may have long-term consequences for osteoporosis in adulthood, as the maximum rate of bone mass accumulation is during early adolescence. Adequate dietary calcium intake and weight-bearing physical activity are important for maximizing bone mineral content growth.68 Daily calcium enriched foods, milk, and supplementations with calcium have shown enhanced rates of bone mineral acquisition in children and adolescent studies (See Figure 11).69 While some older studies show some benefit of calcium supplementation, a 2015 systematic review showed that dietary calcium intake is not associated with risk of fracture, and there is no clinical trial evidence that increasing calcium intake from dietary sources prevents fractures. Evidence that calcium supplements prevent fractures is weak and inconsistent.70 The ageing process has been connected with physiological and psychological changes that affect the efficiency of older adults, and their health issues become more chronic and complex. Among other nutritional issues, an increased risk of malnutrition, which is associated with poor quality of life, reduced functional ability, and premature mortality occur in older adults.71 Good nutrition is an essential component for any successful rehabilitative program; however, it is critically important in the frail, elderly, and osteoporotic risk patients where poor nutritional levels can impair healing and increase further susceptibility to future fractures.71

CE302 - Images - Figure 11

Figure 11. Prevention of Osteoporosis61,63,69

Physical activity and fitness exercise programs have been shown to reduce the risk of osteoporosis,72 and epidemiological evidence has suggested that physical activity can assist in reductions of hip fractures in both women and men in so much as strengthening back muscles and improving strength and function.73 Changes in regular physical activity status were associated with the risk of hip fracture, consistent in regular physical activity was related to the maximum benefit for risk reduction in the general population.73 With therapeutic exercise assisting in maintaining or increasing bone mineral density in postmenopausal women74 studies have shown that Tai Chi may be an optional and safe exercise for improving bone mineral density (BMD) loss in postmenopausal women, and practicing Tai Chi for more than 6 months may yield greater benefits.75 In the pivotal 2004 Nurses Health Study, it was reported that women who walked at least four hours weekly experienced a 40% reduction in the risk of hip fractures.76 It is important to value daily exercise with any age group, especially during the childhood and adolescent years where bone mass, strength, and balance develop into essential elements necessary for maintaining bone density in the aging years.

Early screening with a DEXA scan measuring bone density in critical areas of the body such as the hip and spine is recommended. It is a painless, non-invasive test that takes about 20 minutes. Follow-up DEXA scans should be performed in women who develop bone mass loss. Changes in height or complaints of back pain can require consulting with a physician and healthcare professionals about x-ray and bone density measurements to determine if a fracture is present. Monitoring bone health is essential and a baseline DEXA scan can be performed for women who experience premature menopause.

Once diagnosed, treatments for osteoporosis may include oral bisphosphonates (Actonel®, Actonel® with Calcium, Fosamax® or Fosamax Plus D, Boniva®, Reclast). Intravenous bisphosphonates (Zometa®, Aredia®) are used for patients with metastatic cancer and Paget’s disease and in some cases are used by physicians for osteoporosis. Calcitonin or Fortical®, an injectable or nasal spray, Reclast, an intravenous infusion once yearly, Foreto, a daily subcutaneous injection, Prolia, an intra-muscular injection administered every 6 months, Selective Estrogen Receptor Modulators (Evista®) and Hormone Therapies (HT) have also been used. Controversial theories exist around the use of HT’s resulting in physicians prescribing treatment based on individual needs, whereas communication and patient advocacy are essential.

Table 3. Bisphosphonate Preparations by Name.

Generic NameTrade NameClinical Indication
Oral bisphosphonates
1. Alendronate
2. Risedronate
3. Etidronate
4. Ibandronate
5. Clodronate
6. Tiludronate

Bondronat, Bonviva
Bonefos, Loron, Clasteon
Treatment of osteoporosis and corticosteroid-induced osteoporosis, Paget's disease.
Intravenous bisphosphonates
1. Pamidronate
2. Zoledronate
3. Clodronate
4. Ibandronate

Zometa, Aclasta
Bonefos, Loron, Clasteon
Bondronat, Bonviva
Hypercalcaemia of malignancy, osteolytic lesions, Paget's disease, skeletal mesatases, osteoporosis (at lower frequency and dose).