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

Course Number: 302

Risk Factors, Prevention, and Treatment

Being female poses a greater risk for developing osteoporosis than male; however, the risk increases in each gender with age. Low bone mass, family history, amenorrhea, estrogen deficiency, cigarette smoking, certain medications, and Caucasian or Asian ethnicity are all risk factors (Figure 9).

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

Figure 9. 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.55 The prolonged use of corticosteroids is a common cause witnessed in osteoporosis. It has been estimated that 30-50% of long-term users of corticosteroids will experience an incidence of fracture.56 Smoking, a modifiable factor, has been identified in leading to lower bone density.57 There are different mechanisms by which alcohol intake may decrease bone mass and strength. The effects of alcohol on bone hypothesized to be direct and indirect. The decrease in bone mass and strength following alcohol consumption is primarily due to a bone remodeling imbalance, with a major decrease in bone formation. Fairly recent studies, have described new mechanisms by which alcohol may act on bone remodeling, including osteocyte apoptosis, oxidative stress, and Wnt signaling pathway modulation.58 A sedentary lifestyle and/or physical inactivity contribute to reduced muscle strength and impaired balance and gait, each impairing neuromuscular function contributing to fragility and fractures. Maintaining physical strength is a vital approach that leads to healthy ageing. Impairments in skeletal muscle leads to reductions in muscle mass and strength, factors directly associated with mortality rates in the elderly.59

While there is no cure for osteoporosis, prevention and treatment is available. 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. Adequate dietary calcium intake and weight-bearing physical activity are important for maximizing bone mineral content growth.60 Daily calcium enriched foods, milk, and supplementations with calcium have shown enhanced rates of bone mineral acquisition in children and adolescent studies.61 It has been further noted the positive effects on bone mineral density in postmenopausal women taking calcium supplementations.62 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.63

Physical activity and fitness exercise programs have been shown to reduce the risk of osteoporosis,64 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.65 With therapeutic exercise assisting in maintaining or increasing bone mineral density in postmenopausal women66 studies have shown those early postmenopausal women practicing Tai Chi Chun to have a 47% decrease in falls.67 In the 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.68 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).