Rev. Bras. Reumatol. vol.57 número3

r e v b r a s r e u m a t o l . 2017;57(3):270–273

ww w . r e u m a t o l o g i a . c o m . b r

REVISTA

BRASILEIRA

DE

REUMATOLOGIA

Brief

communication

Possible

links

between

osteoporosis

and

periodontal

disease

Possíveis

ligac¸ões

entre

a

osteoporose

e

a

doenc¸a

periodontal

Daniela

Cia

Penoni

_,

_Anna

_Thereza

_Thomé

_Leão

_,

_Tatiana

_Melo

_Fernandes

,

Sandra

Regina

Torres

a_{UniversidadeFederaldoRiodeJaneiro,FaculdadedeOdontologia,DepartamentodeClínicaOdontológica,RiodeJaneiro,RJ,Brazil} b_{UniversidadeFederaldoRiodeJaneiro,Servic¸odeReumatologia,RiodeJaneiro,RJ,Brazil}

c_{HospitalNavalMarcílioDias,Servic¸odeReumatologia,RiodeJaneiro,RJ,Brazil}

d_{UniversidadeFederaldoRiodeJaneiro,FaculdadedeOdontologia,DepartamentodePatologiaeDiagnósticoOral,RiodeJaneiro,RJ,}

Brazil

a

r

t

i

c

l

e

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n

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Articlehistory: Received13May2015 Accepted7December2015 Availableonline21March2016

Introduction

Osteoporosisleadstobonemassreductionwhileperiodontal diseasecausesresorptionofthealveolarbone.Bothconditions have some common risk factors like smoking, poor nutri-tionalstatus,ageandimmunedeficiency.1_{Thebonechanges} caused byosteoporosis seem toaggravate periodontal dis-ease,however,thepathogenesisofthatprocessisnotyetfully understood.2

Apossiblepathwayinwhichsystemicbonelossmaylead tomoresevere periodontaldestruction isthat thereduced bonemineraldensity (BMD),causedbyosteoporosisinthe alveolarbone,mayfacilitatelocalboneresorptioncausedby theperiodontaldisease.3_{Anotherpossibilityisthatsystemic} factorsofboneremodelingcouldmodifylocaltissueresponse to periodontal infection. Accordingly, individuals with

∗ _{Correspondingauthor.}

E-mail:[email protected](S.R.Torres).

systemic bone loss who have periodontitis may react differently to the increased production of cytokines and inflammatory mediators, therefore presenting more severe periodontaldisease.3

Periodontitisisaninfectioncausedbycomponentsofthe oralmicrobiota.Hostinflammatory-immunologicresponses totheperiodontalmicroorganismsareresponsibleformost oftheobservedtissuedamage,likeperiodontalattachment loss and alveolar bone loss.4 _{Althoughcurable at its early} stage,periodontitisremainsoneofthemostcommoncauses of tooth loss. Therefore, preventionand early detection of periodontal disease are essential toreduce the damages it implies.4

Some systemic conditions and behaviors, like poorly controlled diabetes, obesity, smoking and alcohol abuse, amongothers,maymodifyperiodontaldiseasefeatures.An inadequate dietary consumptionofcalcium and vitaminD

http://dx.doi.org/10.1016/j.rbre.2016.03.004

rev bras reumatol.2017;57(3):270–273

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mayalsorepresentamodifiableriskfactorsforthisdisease. Osteoporosishasbeenrelatedtotheseverityofperiodontal disease, but full explanation for this relationship is still lacking.1,2 _{Theaimofthis study istoreviewthe literature} on the association between osteoporosis and periodontal disease.

The

biological

plausibility

of

the

association

between

periodontal

disease

and

osteoporosis

Thepathogenesisofperiodontaldiseaseisacomplexprocess becauseitinvolveshostimmuneresponsetothesubgingival biofilm.4 _{Periodontitis is associated with increased} recep-toractivatorofnuclear factor kappa-␤ ligand(RANKL)and decreased osteoprotegerin (OPG) levels in gingival tissue and biologicalfluids, including saliva and gingival crevicu-larfluid,thusresultinginincreasedRANKL/OPGratio.5 _The involvementofRANKL andOPG systemisalso well estab-lishedinthepathogenesisofpostmenopausalosteoporosis.6 Clinicalstudieshavereportedsignificant higherserum lev-els ofRANKL inpostmenopausal women withperiodontal disease compared to matched subjects with periodontal health.6

Theincreasedproductionofproinflammatorycytokines, suchasinterleukinIL-1␤,IL-6,tumornecrosisfactor-␣ (TNF-␣)andRANKL,areimportantfactorsinthepathogenesisand progression of periodontal disease and osteoporosis.6,7 _As such,modulationoftheexpressionofthesecytokinesmay beapossiblelinkbetweeninflammationandboneresorption inosteoporosisandperiodontaldisease.6

Estrogendeficiencyhasbeenconsideredakeyfactorforthe developmentofosteoporosis.8 _{Furthermore,estrogen} influ-ences the function of human periodontal ligament cells causingan increasein theOPG expressionand adecrease inRANKL.Accordingly,thathormonemayplayanimportant protectiveroleintheantiresorptiveeffectsonhumanalveolar bone.9_{Theinfluenceofserumestrogeninperiodontalstatus} ofwomeninearlymenopausewasidentifiedinalongitudinal study.10_{Theauthorsobservedthatwomenwithnormal} estro-genlevelspresentedmorebiofilmthanthosesufferingfrom estrogendeficiency;howevertheydidnotshowincreased gin-givalinflammation.Thesefindingssuggestthatestrogenmay haveaninhibitoryeffectongingivalinflammationinpatients withperiodontits.10

Estrogenimportancetomaintainofosteogenic differenti-ationthroughestrogenreceptorsintheperiodontalligament cells has been reported.11 _{Animal studies have analyzed} the influence of estrogen deficiency on the alveolar bone mass.12,13_{Adecreaseinthealveolarbonemineraldensitywas} observedinsheep,sixmonthsafterovariectomy.12_Ithasbeen suggestedthatthereductionofalveolarcrestheightobserved inestrogen-deficient animalscouldresultfromhigher con-centrationsofIl-6withinthegingivaandtheadjacentbone.12 Furthermore,increasedbonelosswasdetectedinthefemur andthe alveolarboneofovariectomizedrats whenan ani-malmodelinducedbyacombinationofbothperiodontitisand osteoporosiswasused.13_{Asaresult,ithasbeenconjectured} thatpostmenopausalosteoporosismayactasariskfactorfor periodontaldisease.13

Evidences

of

the

effects

of

osteoporosis

in

periodontal

condition

Indeed moststudies that evaluated the association oflow systemic BMD with alveolar bone loss showed significant positiveresults.1,3 _{Systemicboneloss,forinstance,showed} a strong relationship with interproximal alveolar bone loss in postmenopausal women with osteopenia, thus showing that it may be a risk indicator for periodontal destruction.3

Cross-sectionalstudieswithlargesamplesizesfrom the Women’sHealthInitiativeObservationalStudy(WHIOS) indi-catedthatthelossofalveolarcrestalheightis230%higher forwomenwithosteoporosisascomparedwithwomenwith normalT-score,withincreasedlossforwomenagedover70. Overall,therewasmorethan3-foldincreaseinthe oddsof worsealveolarcrestalheightinsubjectswithT-scores con-sistentwithosteoporosis.14_{Forpostmenopausalwomenaged} lessthan70years,systemicBMDandoralinfection indepen-dentlyinfluencedoralboneloss.15

Astudycomparingtheperiodontalstatusofwomenwith and without osteoporotic fractures revealed that fractured postmenopausalwomenhavelostmoreteethandpresented moreadvancedattachmentloss.16

Studies assessing the association between osteoporosis and periodontal disease differ widely in their methodol-ogy, using samples with different selection criteria, social anddemographiccharacteristics,techniquesforperiodontal examinationandBMDassess.Dataanalysisalsovariesanddo notalwayscontrolforconfoundingfactors.Thelackof stan-dardizationforthesestudiesmayexplainthediscrepancies observedamongtheresultstheypresented.1,2 _Studieswith largersamplesandstandardizeddiagnosesforosteoporosis andperiodontaldiseaseareneededtoclarifywhether osteo-porosisisariskfactortoperiodontaldiseaseand,ifso,towhat extent.2

The

influence

of

treatment

of

osteoporosis

in

periodontal

condition

Systemicosteoporosis,lowdietarycalciumandlowvitaminD levelsmayinfluenceperiodontalstatusandmaybeassociated withtoothloss.2_{Ithasbeenreportedthatperiodontaldisease} ismorecommoninwomenwithosteoporosisandis associ-atedwithlowervitaminDlevel.6_{Accordingly,awarenessofthe} systemicboneconditionofadentalpatienttogetherwiththe knowledgeofpatient’sintakeofcalciumandvitaminD,may beimportanttounderstandperiodontalstatusandimprove oralhealth.2

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inverselyassociatedwithvitaminDlevels,gingivalbleeding andchronicperiodontaldisease.19

Severaloptionsareavailableforpharmacological preven-tionand treatmentofosteoporosis, combinedwiththeuse of calcium and vitamin D. Among them,bisphosphonates wasshown tobe veryeffective.20 _{Additionally, it hasbeen} observed that the use of bisphosphonates in conjunction with conventional periodontal therapy looks promising.21 In particular, alendronate treatment improved periodontal diseaseandboneturnoverinpostmenopausalwomen.22_The significant reduction in RANKL/OPG in gingival fibroblasts is on par with effects on osteoblasts.23 _{Accordingly, that} may playakey rolein favoringinhibitionofalveolar bone resorption.23

Theassociationofosteonecrosisofthejawswiththeuse ofbisphosphonateshasbeenconcerningdentists.However, antiresorptivetherapyforlowbonemassrepresentsalowrisk fordevelopingantiresorptiveagent-inducedosteonecrosisof thejaw.24_{Ontheotherhand,osteoporosisisresponsiblefor} considerablemorbidityandmortality.Accordingly,the bene-fitsprovidedbyantiresorptivetherapyoutweighthelowriskit bringsofdevelopingosteonecrosisofthejaw.24_Furthermore, untreatedperiodontaldiseaseinpatientsundergoing bisphos-phonatestherapymayleadtoahigherriskofosteonecrosisof thejaws.Assuch,monitoreddentalcareisrecommendedin ordertomaintainahealthyperiodontalstatus.25

Conclusion

Healthcareprofessionalsand patientsalikemust bemade aware that prevention of osteoporosis may be beneficial not only for maintaining bone health alone, but also for periodontalhealth.Accordingly,ithighlightstheroleof multi-disciplinaryteamsinsupportinghealth.Dentistsshouldrefer patientstoadoctortoenforcethetreatmentofosteoporosis. Likewise,doctorsshouldfeelcomfortabletoreferpatientsto adentistforpreventionand evaluationofperiodontal con-dition.Bydoingso,theriskfordevelopingosteoporosisand severeperiodontaldiseasecouldbeminimized.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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