Different quantitative and qualitative indices calculated on oral panoramic radiographs have been proposed as useful tools to screen for reduced skeletal bone mineral density (BMD). Our aim was to systematically review the literature on linear and qualitative panoramic measures and to assess the accuracy of these indices by performing a meta-analysis of their sensitivity and specificity. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement was followed. Fifty studies were included in the qualitative appraisal and 19 were considered for meta-analysis. The methodological quality of the retrieved studies, assessed with the QUADAS-2 tool, was on average low. Three indices were reported by most of the studies: mandibular cortical width, panoramic mandibular index, and the Klemetti index. Mandibular cortical width presented with a better accuracy in excluding osteopenia/osteoporosis (specificity), since patients with a cortical width more than 4 mm had a normal BMD in 90% of the cases. Almost all studies used a cutoff of 0.3 for the panoramic mandibular index, resulting in an estimated sensitivity and specificity in detecting reduced BMD, respectively, of 0.723 (SE 0.160; 95% confidence interval [CI], 0.352–0.926) and 0.733 (SE 0.066; 95% CI, 0.587–0.841). The presence of any kind of mandibular cortical erosion gave an estimated sensitivity and specificity in detecting reduced BMD, respectively, of 0.789 (SE 0.031; 95% CI, 0.721–0.843) and 0.562 (SE 0.047; 95% CI, 0.47–0.651) and a sensitivity and specificity in detecting osteoporosis, respectively, of 0.806 (SE 0.105; 95% CI, 0.528–0.9200) and 0.643 (SE 0.109; 95% CI, 0.417–0.820). The mandibular cortical width, panoramic mandibular index, and Klemetti index are overall useful tools that potentially could be used by dentists to screen for low BMD. Their limitations are mainly related to the experience/agreement between different operators and the different image quality and magnification of the panoramic radiographs.
Al-DamABlakeFAtacAAmlingMBlessmannMAssafAHankenHSmeetsRHeilandM. 2013. Mandibular cortical shape index in non-standardised panoramic radiographs for identifying patients with osteoporosis as defined by the German Osteology Organization. J Craniomaxillofac Surg. 41(7):e165–e169.
2.
AllenPDGrahamJFarnellDJHarrisonEJJacobsRNicopolou-KarayianniKLindhCvan der SteltPFHornerKDevlinH. 2007. Detecting reduced bone mineral density from dental radiographs using statistical shape models. IEEE Trans Inf Technol Biomed. 11(6):601–610.
3.
AlonsoMBAmbrosanoGMWatanabePCHaiter-NetoF. 2012. Assessment of panoramic mandibular index and morphological analysis of mandibular cortical bone in a Brazilian population. Osteoporos Int. 23:S484–S485.
4.
ArifinAZAsanoATaguchiANakamotoTOhtsukaMTsudaMKudoYTanimotoK. 2006. Computer-aided system for measuring the mandibular cortical width on dental panoramic radiographs in identifying postmenopausal women with low bone mineral density. Osteoporos Int. 7(5):753–759.
5.
BensonBWPrihodaTJGlassBJ. 1991. Variations in adult cortical bone mass as measured by a panoramic mandibular index. Oral Surg Oral Med Oral Pathol. 71(3):349–356.
6.
BrasJvan OoijCPAbraham-InpijnLKusenGJWilminkJM. 1982. Radiographic interpretation of the mandibular angular cortex: a diagnostic tool in metabolic bone loss. Part I. Normal state. Oral Surg Oral Med Oral Pathol. 53(5):541–545.
7.
Consensus development conference: diagnosis, prophylaxis, and treatment of osteoporosis. 1993. Am J Med. 94(6):646–650.
8.
DamilakisJVlasiadisK. 2011. Have panoramic indices the power to identify women with low BMD at the axial skeleton?Phys Med. 27(1):39–43.
9.
DevlinHAllenPDGrahamJJacobsRKarayianniKLindhCvan der SteltPFHarrisonEAdamsJEPavittS. 2007. Automated osteoporosis risk assessment by dentists: a new pathway to diagnosis. Bone. 40(4):835–842.
10.
DevlinCVHornerKDevlinH. 2001. Variability in measurement of radiomorphometric indices by general dental practitioners. Dentomaxillofac Radiol. 30(2):120–125.
11.
DrozdzowskaBPluskiewiczWTarnawskaB. 2002. Panoramic-based mandibular indices in relation to mandibular bone mineral density and skeletal status assessed by dual energy X-ray absorptiometry and quantitative ultrasound. Dentomaxillofac Radiol. 31(6):361–367.
12.
ErdoganOInckiKKBenlidayiMESeydaogluGKelekciS. 2009. Dental and radiographic findings as predictors of osteoporosis in postmenopausal women. Geriatr Gerontol Int. 9(2):155–164.
13.
Ezoddini ArdakaniFOwliaMHesamiSHosseiniP. 2013. Digital panoramic radiography as a useful tool for detection of bone loss: a comparative study. Acta Med Iran. 51(2):94–100.
14.
Ferreira LeiteAde Souza FigueiredoPTRamos BarraFSantos de MeloNde PaulaAP. 2011. Relationships between mandibular cortical indexes, bone mineral density, and osteoporotic fractures in Brazilian men over 60 years old. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 112(5):648–656.
15.
GaurBChaudharyAWanjariPVSunilMBasavarajP. 2013. Evaluation of panoramic radiographs as a screening tool of osteoporosis in post menopausal women: a cross sectional study. J Clin Diagn Res. 7(9):2051–2055.
16.
GluerCCJergasMHansD. 1997. Peripheral measurement techniques for the assessment of osteoporosis. Semin Nucl Med. 27(3):229–247.
17.
GulsahiAOzdenSCebeciAIKucukNOPaksoyCSGencY. 2009. The relationship between panoramic radiomorphometric indices and the femoral bone mineral density of edentulous patients. Oral Radiol. 25:47–52.
18.
GulsahiAPaksoyCSOzdenSKucukNOCebeciARGencY. 2010. Assessment of bone mineral density in the jaws and its relationship to radiomorphometric indices. Dentomaxillofac Radiol. 39(5):284–289.
19.
HallingAPerssonGRBerglundJJohanssonORenvertS. 2005. Comparison between the Klemetti index and heel DXA BMD measurements in the diagnosis of reduced skeletal bone mineral density in the elderly. Osteoporos Int. 16(8):999–1003.
20.
HernlundESvedbomAIvergårdMCompstonJCooperCStenmarkJMcCloskeyEVJönssonBKanisJA. 2013. Osteoporosis in the European Union: medical management, epidemiology and economic burden. A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA). Arch Osteoporos. 8(1–2):136.
21.
HornerKDevlinH. 1998. The relationship between mandibular bone mineral density and panoramic radiographic measurements. J Dent. 26(4):337–343.
22.
HornerKDevlinHHarveyL. 2002. Detecting patients with low skeletal bone mass. J Dent. 30(4):171–175.
23.
HornerKKarayianniKMitseaABerkasLMastorisMJacobsRLindhCvan der SteltPMarjanovicEAdamsJPavittS. 2007. The mandibular cortex on radiographs as a tool for osteoporosis risk assessment: the OSTEODENT Project. J Clin Densitom. 10(2):138–146.
24.
IshiiKTaguchiANakamotoTOhtsukaMSutthiprapapornPTsudaMKodamaIKudoYSumidaHSueiY. 2007. Diagnostic efficacy of alveolar bone loss of the mandible for identifying postmenopausal women with femoral osteoporosis. Dentomaxillofac Radiol. 36(1):28–33.
25.
JowittNMacFarlaneTDevlinHKlemettiEHornerK. 1999. The reproducibility of the mandibular cortical index. Dentomaxillofac Radiol. 28(3):141–144.
26.
KanisJABurletNCooperCDelmasPDReginsterJYBorgstromFRizzoliR; European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO). 2008. European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int. 19(4):399–428.
27.
KanisJAMcCloskeyEVJohanssonHCooperCRizzoliRReginsterJY; Scientific Advisory Board of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) and the Committee of Scientific Advisors of the International Osteoporosis Foundation (IOF). 2013. European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int. 24(1):23–57.
28.
KarayianniKHornerKMitseaABerkasLMastorisMJacobsRLindhCvan der SteltPFHarrisonEAdamsJE. 2007. Accuracy in osteoporosis diagnosis of a combination of mandibular cortical width measurement on dental panoramic radiographs and a clinical risk index (OSIRIS): the OSTEODENT project. Bone. 40(1):223–239.
29.
KavithaMSAsanoATaguchiAHeoMS. 2013. The combination of a histogram-based clustering algorithm and support vector machine for the diagnosis of osteoporosis. Imaging Sci Dent. 43(3):153–161.
30.
KavithaMSAsanoATaguchiAKuritaTSanadaM. 2012a. Diagnosis of osteoporosis from dental panoramic radiographs using the support vector machine method in a computer-aided system. BMC Med Imaging. 12:1.
31.
KavithaMSSamopaFAsanoATaguchiASanadaM. 2012b. Computer-aided measurement of mandibular cortical width on dental panoramic radiographs for identifying osteoporosis. J Investig Clin Dent. 3(1):36–44.
32.
KhojastehpourLShahidiSHBarghanSAflakiE. 2009. Efficacy of panoramic mandibular index in diagnosing osteoporosis in women. J Dent Theran Univ Med Sci. 6(1):11–15.
33.
KimJNahKJungY. 2004. Comparison of panorama radiomorphometric indices of the mandible in normal and osteoporotic women. Korean J Oral Maxillofac Radiol. 34(2):69–74.
34.
KlemettiEKolmakovSKrogerH. 1994. Pantomography in assessment of the osteoporosis risk group. Scand J Dent Res. 102(1):68–72.
35.
LedgertonDHornerKDevlinHWorthingtonH. 1999. Radiomorphometric indices of the mandible in a British female population. Dentomaxillofac Radiol. 28(3):173–181.
36.
LeeKTaguchiAIshiiKSueiYFujitaMNakamotoTOhtsukaMSanadaMTsudaMOhamaK. 2005. Visual assessment of the mandibular cortex on panoramic radiographs to identify postmenopausal women with low bone mineral densities. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 100(2):226–231.
37.
LeiteAFFigueiredoPTGuiaCMMeloNSde PaulaAP. 2010. Correlations between seven panoramic radiomorphometric indices and bone mineral density in postmenopausal women. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 109(3):449–456.
38.
López-LópezJEstrugo-DevesaAJane-SalasEAyuso-MonteroRGómez-VaqueroC.2011. Early diagnosis of osteoporosis by means of orthopantomograms and oral X-rays: a systematic review. Med Oral Patol Oral Cir Bucal. 16(7):e905–e913.
39.
MacaskillPGatsonisCDeeksJJHarbordRMTakwoingiY. 2010. Analysing and presenting results. In: DeeksJJBossuytPMGatsonisC, editors. Cochrane handbook for systematic reviews of diagnostic test accuracy version 1.0. The Cochrane Collaboration [accessed 2013 Dec 13]. http://srdta.cochrane.org/.
40.
MahlCLicksRFontanellaVR. 2008. Comparação de índices morfométricos obtidos na radiografia odontológica panorâmica na identificação de indivíduos com osteoporose/osteopenia. Radiol Bras. 41(3):183–187.
41.
MansourSAlghamdiASJavedFMarzoukHKhanEA. 2013. Panoramic radiomorphometric indices as reliable parameters in predicting osteoporosis. Am J Med Sci. 346(6):473–478.
42.
MarandiSBagherpourAImanimoghaddamMHatefMHaghighiA. 2010. Panoramic-based mandibular indices and bone mineral density of femoral neck and lumbar vertebrae in women. J Dent (Tehran). 7(2):98–106.
43.
MirandaLF. 2011. Estabelecimento de um índice quantitativo e qualitativo para auxiliar no diagnóstico da osteoporose em radiografia panorâmica. São Paulo (Brazil): Faculdade de Odontologia da Universidade de São Paulo [accessed 2014 Sep 16]. http://bvsalud.org/portal/resource/en/bbo-38454.
44.
MirandaLFAritaESWatanabePACaputoBVPereiraECMarquesAP. 2012. Establishment of a quantitative and qualitative index for the diagnosis of osteoporosis in panoramic radiography. London (UK): Springer. p. S163–S164.
45.
MoherDLiberatiATetzlaffJAltmanDG; PRISMA Group. 2009. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg. 8(5):336–341.
46.
MuramatsuCMatsumotoTHayashiTHaraTKatsumataAZhouXIidaYMatsuokaMWakisakaTFujitaH. 2013. Automated measurement of mandibular cortical width on dental panoramic radiographs. Int J Comput Assist Radiol Surg. 8(6):877–885.
47.
NakamotoTTaguchiAOhtsukaMSueiYFujitaMTanimotoKTsudaMSanadaMOhamaKTakahashiJ. 2003. Dental panoramic radiograph as a tool to detect postmenopausal women with low bone mineral density: untrained general dental practitioners’ diagnostic performance. Osteoporos Int. 14(8):659–664.
PassosJSGomes FilhoISSarmentoVASampaioDSGonçalvesFPCoelhoJMCruzSSTrindadeSCCerqueiraEM. 2012. Women with low bone mineral density and dental panoramic radiography. Menopause. 19(6):704–709.
50.
PfeifferPBewersdorfSSchmageP. 2012. The effect of changes in head position on enlargement of structures during panoramic radiography. Int J Oral Maxillofac Implants. 27(1):55–63.
51.
ReitsmaJBRutjesAWSWhitingPVlassovVVLeeflangMMGDeeksJJ. 2009. Assessing methodological quality. In: DeeksJJBossuytPMGatsonisC, editors. Cochrane handbook for systematic reviews of diagnostic test accuracy version 1.0.0. The Cochrane Collaboration [accessed 2009 Oct 27]. http://srdta.cochrane.org/.
52.
RenvertSBerglundJPerssonREPerssonGR. 2011. Osteoporosis and periodontitis in older subjects participating in the Swedish National Survey on Aging and Care (SNAC-Blekinge). Acta Odontol Scand. 69(4):201–207.
53.
RobertsMGrahamJDevlinH. 2010. Improving the detection of osteoporosis from dental radiographs using active appearance models. In: Proceedings of the 2010 IEEE International Conference on Biomedical Imaging: From nano to macro. Piscataway (NJ): IEEE Press. p. 440–443.
54.
RobertsMGGrahamJDevlinH. 2013. Image texture in dental panoramic radiographs as a potential biomarker of osteoporosis. IEEE Trans Biomed Eng. 60(9):2384–2392.
55.
SchulzeRKrummenauerFSchalldachFd’HoedtB. 2000. Precision and accuracy of measurements in digital panoramic radiography. Dentomaxillofac Radiol. 29(1):52–56.
56.
SedrineWBChevallierTZegelsBKvaszAMichelettiMCGelasBReginsterJY. 2002. Development and assessment of the Osteoporosis Index of Risk (OSIRIS) to facilitate selection of women for bone densitometry. Gynecol Endocrinol. 16(3):245–250.
57.
SutthiprapapornPTaguchiANakamotoTOhtsukaMMallickPCTsudaMKodamaIKudoYSueiYTanimotoK.2006. Diagnostic performance of general dental practitioners after lecture in identifying post-menopausal women with low bone mineral density by panoramic radiographs. Dentomaxillofac Radiol. 35(4):249–252.
58.
TaguchiAAsanoAOhtsukaMNakamotoTSueiYTsudaMKudoYInagakiKNoguchiTTanimotoK, and others. 2008. Observer performance in diagnosing osteoporosis by dental panoramic radiographs: results from the Osteoporosis Screening Project in Dentistry (OSPD). Bone. 43(1):209–213.
59.
TugnaitAClerehughVHirschmannPN. 2003. Radiographic equipment and techniques used in general dental practice: a survey of general dental practitioners in England and Wales. J Dent. 31(3):197–203.
60.
WhitingPFRutjesAWWestwoodMEMallettSDeeksJJReitsmaJBLeeflangMMSterneJABossuytPM; QUADAS-2 Group. 2011. QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med. 155(8):529–536.
61.
YasarFSenerSYesilovaEAkgünlüF. 2009. Mandibular cortical index evaluation in masked and unmasked panoramic radiographs. Dentomaxillofac Radiol. 38(2):86–91.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
