Coronectomy of deeply impacted lower third molar : incidence of outcomes and complications after one year follow-up

Objectives: The purpose of present study was to assess the surgical management of impacted third molar with proximity to the inferior alveolar nerve and complications associated with coronectomy in a series of patients undergoing third molar surgery. Material and Methods: The position of the mandibular canal in relation to the mandibular third molar region and mandibular foramen in the front part of the mandible (i.e., third molar in close proximity to the inferior alveolar nerve [IAN] or not) was identified on panoramic radiographs of patients scheduled for third molar extraction. Results: Close proximity to the IAN was observed in 64 patients (35 females, 29 males) with an impacted mandibular third molar. Coronectomy was performed in these patients. The most common complication was tooth migration away from the mandibular canal (n = 14), followed by root exposure (n = 5). Re-operation to remove the root was performed in cases with periapical infection and root exposure. Conclusions: The results indicate that coronectomy can be considered a reasonable and safe treatment alternative for patients who demonstrate elevated risk for injury to the inferior alveolar nerve with removal of the third molars. Coronectomy did not increase the incidence of damage to the inferior alveolar nerve and would be safer than complete extraction in situations in which the root of the mandibular third molar overlaps or is in close proximity to the mandibular canal

Total and Visceral Adiposity Are Associated With Prevalent Vertebral Fracture in Women but Not Men at Age 62 Years: The Newcastle Thousand Families Study

Low body weight is an established risk factor for osteoporosis and fracture, but the skeletal risks of higher adiposity are unclear and appear sex‐specific and site‐dependent. The aim of this study was to investigate associations of total fat mass (TFM), visceral adipose tissue (VAT), and C‐reactive protein (CRP) with bone mineral density (BMD) and prevalent vertebral fracture (VF) in men and women aged 62 years. A total of 352 men and women aged 62.5 ± 0.5 years from the Newcastle Thousand Families Study cohort received dual‐energy X‐ray absorptiometry (DXA) evaluations of femoral neck and lumbar spine BMD, of the lateral spine for vertebral fracture assessment, and of the whole body for TFM and VAT (GE Lunar CoreScan, Madison, WI, USA). Plasma CRP, FRAX scores, falls in the last 12 months, and occupation at age 50 years were also included in the analysis. Vertebral fractures were less prevalent in women than in men (odds ratio [OR] = 0.33, p < 0.001) and BMD or FRAX scores did not differ between participants with and without VF. Women with VF were heavier and had higher TFM, VAT, and CRP than women without (p < 0.001). In women, greater (+1 SD) TFM and VAT increased the odds of any grade VF (TFM: OR = 1.06, p = 0.001; VAT: OR = 2.50, p = 0.002), and greater VAT mass increased the odds of prevalent mild VF (OR = 2.60, p = 0.002). In contrast, there were no associations in men. In both sexes, after controlling for body weight, neither VAT nor CRP were associated with BMD. In conclusion, irrespective of BMD, total and visceral adiposity were associated with prevalent VF in women but not in men. High fat mass, particularly if visceral, should be considered when assessing VF risk in women. Risk factors for VF in men require further investigation, particularly given their high prevalence

Atypical femoral shaft fractures (AFF) in NHS Grampian: incidence, underlying associations and assessment of DXA scanner software designed for early identification of AFF.

Objectives: The objectives of this study were to assess the clinical utility of extended femur DXA scan software in the identification of incomplete atypical femoral fractures in a routine clinical population; to assess the short term in-vivo precision of extended femur scans; and to investigate of the incidence of atypical femoral fractures between 2008 – 2018 within NHS Grampian, to provide a context for DXA scan findings. Method: A short term precision study was undertaken using the GE Lunar extended femur DXA scanning software, with 30 participants exposed to duplicate extended femur scans. From this, analysis was undertaken to assess and compare beaking index measurements and bone mineral density measurements from the software. Audits of scan acquisition, assessment and software stability were undertaken in order to assess the scan software and staff compliance with training, the service was routinely scanning the extended femur in all patients over 20 years of age. The images acquired were used to assess the utility of the software in identifying and measuring the endosteal femoral cortex, in contrast to the visual assessment of the same areas by experienced members of staff. A retrospective review of patients within NHS Grampian identified as having femoral fractures over a ten year period was carried out in order to identify the incidence of those suffering atypical femoral fractures within this healthcare service. Results: The visual assessment of the femoral cortex was found to be more effective and efficient than the scan software alone in identifying abnormalities, in line with the findings of previous studies comparing automated analysis with visual assessment. There was no identified difference in bone mineral density precision errors at the hip precision using the extended femur scanning software compared to standard hip measurements in the 30 patients included in the study, but there were some discrepancies in duplicated beaking index measurements in part thought to be caused by slight differences in positioning for scans. Least significant change was measured as 5.68% at femoral neck and 3.96% for total hip across the study, well within the parameters of ISCD accepted figures of 6.9% for femoral neck measurements and 5% for total hip. A negative predictive value of 100% was found when using the software in a clinical setting for six months, with a positive predictive value of 0.01% and an accuracy rate of 82.07%. Around 20% of patients scanned were found to have peaks ≥1mm on extended femur DXA scan automated analysis, however these were found to have an entirely normal appearance on visual inspection of images acquired. Audits of scan positioning, analysis and assessment of extended femur scans identified several positioning anomalies which were addressed when identified. Of the 7102 patients reviewed with femoral fractures over a period of ten years, 13 (0.18%) were identified as suffering atypical femoral fracture, with one of those patients having bilateral AFF. All the patients suffering AFF were also found to have varying lengths of bisphosphonate exposure. Discussion: Measurement of bone mineral density (BMD) by DXA is routinely used to diagnose osteoporosis and monitor treatment response. When comparing scans it is important to distinguish between real changes in BMD as opposed to changes related to the measurement process itself i.e. the precision of measurements. There is no published evidence of this type of beaking index precision study having been undertaken, indeed studies performed on extended femur scanning have all utilised slightly different methodology, making direct comparison impossible. Atypical femoral fracture is a rare but recognised complication of osteoporosis treatment and the use of extended femur scan software demonstrates a promising ability to identify and assess incomplete AFF in conjunction with routine bone mineral density measurement, identifying abnormal thickening or peaks in the lateral femoral cortex aided by automated software measurements of beaking index. However, in light of the study findings, visual assessment of the femoral cortex must also be undertaken by the operator to ensure false positives are eliminated from further investigation. It would be highly unlikely in the context of current literature that 20% of a general population would exhibit signs of iAFF on extended femur scanning. Conclusion: The extended femur scan acquisition and automated analysis was found to expose the patient population to a slightly higher radiation exposure. The automated analysis was not acceptable as a stand alone assessment of the femoral cortex, visual assessment was essential in tandem to ensure software anomalies were not reported as suspicious peaks, the investigation of which would place pressures on imaging services and also un-necessary anxiety to patients. Patient positioning as per the GE Lunar scan handbook is highlighted as important in terms of reproducibility of scans and also for accurately measuring the femoral cortex. For patients and clinicians there is reassurance that although such abnormalities are rare, affecting 0.18% of the local population, abnormalities will be identified by the software and highlighted by the reporting clinician, allowing monitoring and intervention as appropriate

A study of the value of trabecular bone score in fracture risk assessment of postmenopausal women

Objective: Trabecular Bone Score (TBS) is an index of bone microarchitecture that provides additional skeletal information to areal Bone Mineral Density (aBMD). Recently TBS data has been used to optimize the Fracture Risk Assessment Tool (FRAX) predictive value. The aim of this study was to evaluate the clinical value of TBS on FRAX algorithm. Materials and Methods: Among total of 358 postmenopausal Iranian women (mean age 61.3 ± 9.5 years) tested for aBMD and TBS, 184 osteopenic women were identified. Thoracolumbar spine X-ray done in all participants revealed twenty-one vertebral fractures. For the osteopenic group, FRAX and TBS adjusted FRAX (FRAX-TBS) were calculated and compared. Results: Mean TBS of the patients was 1.31 (±0.11). A significant correlation was found between TBS and spine aBMD (r = 0.50, p < 0.001) and TBS and femoral neck aBMD (r = 0.37, p < 0.0001). A strong positive correlation was observed between aBMD adjusted FRAX and FRAX-TBS in predicting the risk of major osteoporotic fracture (r = 0.90, p < 0.0001), and hip fracture (r = 0.97, p < 0.0001). According to the area under the receiver operating characteristics curve, the predictive value of the three different models using aBMD, TBS, and combination of aBMD and TBS were similar (0.765, 0.776, and 0.781, respectively; p = 0.19). The proportion of the women needed treatment remained unchanged using FRAX or FRAX-TBS. Conclusion: This study showed no clinical benefit for TBS in postmenopausal women. Adding TBS data to aBMD or FRAX neither improved aBMD predictive value for vertebral fracture nor changed the decision on treatment based on FRAX. © 201

Does regional loss of bone density explain low trauma distal forearm fractures in men (The Mr F study)?

Summary The pathogenesis of low trauma wrist fractures in men is not fully understood. This study found that these men have lower bone mineral density at the forearm itself, as well as the hip and spine, and has shown that forearm bone mineral density is the best predictor of wrist fracture. Introduction Men with distal forearm fractures have reduced bone density at the lumbar spine and hip sites, an increased risk of osteoporosis and a higher incidence of further fractures. The aim of this case-control study was to investigate whether or not there is a regional loss of bone mineral density (BMD) at the forearm between men with and without distal forearm fractures. Methods Sixty-one men with low trauma distal forearm fracture and 59 age-matched bone healthy control subjects were recruited. All subjects underwent a DXA scan of forearm, hip and spine, biochemical investigations, health questionnaires, SF-36v2 and Fracture Risk Assessment Tool (FRAX). The non-fractured arm was investigated in subjects with fracture and both forearms in control subjects. Results BMD was significantly lower at the ultradistal forearm in men with fracture compared to control subjects, in both the dominant (mean (SD) 0.386 g/cm2 (0.049) versus 0.436 g/cm2 (0.054), p < 0.001) and non-dominant arm (mean (SD) 0.387 g/cm2 (0.060) versus 0.432 g/cm2 (0.061), p = 0.001). Fracture subjects also had a significantly lower BMD at hip and spine sites compared with control subjects. Logistic regression analysis showed that the best predictor of forearm fracture was ultradistal forearm BMD (OR = 0.871 (0.805–0.943), p = 0.001), with the likelihood of fracture decreasing by 12.9% for every 0.01 g/cm2 increase in ultradistal forearm BMD. Conclusions Men with low trauma distal forearm fracture have significantly lower regional BMD at the ultradistal forearm, which contributes to an increased forearm fracture risk. They also have generalised reduction in BMD, so that low trauma forearm fractures in men should be considered as indicator fractures for osteoporosis

Serum markers of bone fragility in type-2 diabetes mellitus

Patients with type-2 diabetes mellitus (T2DM) have normal or increased bone mineral density (BMD) but despite that, they are characterized by an increased hip and vertebral fracture risk that involves the alteration of bone quality and not the reduction in bone mass. BMD is utilized for the diagnosis and evaluation of osteoporosis, but BMD itself cannot provide an accurate diagnosis of the individuals at increased risk of fracture and, therefore, studies have focused on identifying other risk factors that are partially or fully independent of BMD. The fracture risk score tool-FRAX® models provide information about a 10-year probability of osteoporotic fractures, but do not include risk factors specific to illness such as diabetes duration, diabetes drug therapy, glycemic control, or the presence of micro-vascular complications. Multiple markers have been investigated to provide information on the risk of fractures in patients with T2DM such as: advanced glycation end products (AGEs), insulin-like growth factor-I (IGF-I), osteocalcin (OC), adiponectin, and sclerostin, but epidemiological studies did not provide homogeneous information regarding the link between these markers and bone fragility in T2DM subjects. Markers that increase the accuracy of fracture risk estimation in patients with T2DM need to be identified and employed in current medical practice

Relationship between Weight, Body Mass Index, and Bone Mineral Density in Men Referred for Dual-Energy X-Ray Absorptiometry Scan in Isfahan, Iran

Objective. Although several studies have investigated the association between body mass index (BMI) and bone mineral density (BMD), the results are inconsistent. The aim of this study was to further investigate the relation between BMI, weight and BMD in an Iranian men population. Methods. A total of 230 men 50-79 years old were examined. All men underwent a standard BMD scans of hip (total hip, femoral neck, trochanter, and femoral shaft) and lumbar vertebrae (L2-L4) using a Dual-Energy X-ray Absorptiometry (DXA) scan and examination of body size. Participants were categorised in two BMI group: normal weight <25.0 kg/m2 and overweight and obese, BMI ≥ 25 kg/m2. Results. Compared to men with BMI ≥ 25, the age-adjusted odds ratio of osteopenia was 2.2 (95% CI 0.85, 5.93) and for osteoporosis was 4.4 (1.51, 12.87) for men with BMI < 25. It was noted that BMI and weight was associated with a high BMD, compatible with a diagnosis of osteoporosis. Conclusions. These data indicate that both BMI and weight are associated with BMD of hip and vertebrae and overweight and obesity decreased the risk for osteoporosis. The results of this study highlight the need for osteoporosis prevention strategies in elderly men as well as postmenopausal women

Guidelines for the diagnosis, prevention and management of osteoporosis

Osteoporosis poses a significant public health issue. National Societies have developed Guidelines for the diagnosis and treatment of this disorder with an effort of adapting specific tools for risk assessment on the peculiar characteristics of a given population. The Italian Society for Osteoporosis, Mineral Metabolism and Bone Diseases (SIOMMMS) has recently revised the previously published Guidelines on the diagnosis, riskassessment, prevention and management of primary and secondary osteoporosis. The guidelines were first drafted by a working group and then approved by the board of SIOMMMS. Subsequently they received also the endorsement of other major Scientific Societies that deal with bone metabolic disease. These recommendations are based on systematic reviews of the best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on leading experts' experience and opinion, and on good clinical practice. The osteoporosis prevention should be based on the elimination of specific risk factors. The use of drugs registered for the treatment of osteoporosis are recommended when the benefits overcome the risk, and this is the case only when the risk of fracture is rather high as measured with variables susceptible to pharmacological effect. DeFRA (FRAX® derived fracture risk assessment) is recognized as a useful tool for easily estimate the long-term fracture risk. Several secondary forms of osteoporosis require a specific diagnostic and therapeutic management