Wednesday, December 13, 2017

Osteoporosis: An Increasing Concern in Pediatric Dentistry

Department of Pediatric Dentistry

Lutheran Medical Center

Resident’s Name: Albert Yamoah, DDS                                                                                     Date: 12/13/2017
Article Title:  
Osteoporosis: An Increasing Concern in Pediatric Dentistry
Author(s):  Marcio A. da Fonseca
Journal: Pediatric Dentistry
Date: 2011
Major Topic: Osteoporosis, Bone Disease, Bone Mineral Density, Treatment and Management of Osteoporosis in Children
Type of Article: Literature Review
Main Purpose:
With increasing numbers of children affected by low bone density and osteoporosis, the topic has become an important issue in contemporary pediatrics.
Key points:
o   Bone fractures are the most common reason for hospitalization between 10 and 14 year olds.
o   Factors, such as lifestyle; diet; chronic illness and medications can affect bone mineral density.
o   Osteoporosis is classically defined in adults as a systemic skeletal disease characterized by:
1.     Low bone mass
2.     Alteration of ultra-structural quality of bone
3.     Deterioration in trabecular architecture
4.     Increased cortical porosity
5.     Reduced cortical thickness
6.     Decreased bone width
o   Osteoporosis is often difficult to define in children as they are constantly changing in size and shape with increases in bone mass and density.
o   Greatest bone mass acquisition tends to mirror height velocity and is greatest during puberty.  
o   Any disruption of this growth would lead to an increased risk of adult osteoporosis and fractures.
o   Excess of deficiencies in GH, TH, PTH, and sex steroids can also lead to decreased bone mineral density.

Primary Bone disorders:
Heritable Disorders of connective tissue:
o   Idiopathic juvenile osteoporosis
o   Osteogenesis imperfecta
o   Marfan syndrome
o   Ehler-Danlos syndrome
o   Bruck syndrome
o   Osteoprosis pseudoglioma syndrome
o   Homocystinuria

Secondary Bone disorders:
Inflammatory Diseases
o   Inflammatory bowel disease
o   Celiac disease
o   Juvenile idiopathic arthritis
o   Cystic Fibrosis
o   Systemic lupus erythematosus
o   Dermatomyositis

Chronic Immobalization
o   Cerebral palsy
o   Neuromuscular disorders
o   Epidermolysis bullosa
o   Spina bifida
o   Spinal cord injury
o   Head Injury

Endocrine Disturbances
o   Turner syndrome
o   Anorexia nervosa
o   Hypogonadism
o   Growth hormone deficiency
o   Juvenile Diabetes Mellitus
o   Hyperthyroidism, Hyperparathyroidism
o   Cushing syndrome
o   Delayed puberty

Hematologic-oncologic disorders
o   Childhood cancer
o   Thalassemia
o   Sickle cell disease

Inborn Errors of Metabolism
o   Protein intolerance
o   Glycogen storage diseases
o   Galactosemia
o   Gaucher disease

Iatrogenic Etiologies
o   Glucocorticoids
o   Anticonvulsants
o   Chemotherapy
o   Cyclosporine
o   Tacrolimus
o   Bone and/or cranial radiation

o    Chronic renal disease
o    Solid organ and hematopoietic stem cell therapy
o    Anorexia nervosa
o    Steroid-dependent asthma

Measuring Bone Mineral Density: 
o   DEXA (dual energy X-ray absorptiometry): Diagnostic tool in the management of adult osteoporosis.
o   DEXA doesn’t distinguish between cortical and trabecular bone
o   DEXA does not differentiate between body types for a certain age (i.e. short kids vs. tall).
o   DEXA is beneficial to use as a monitor during tx.

Treating Osteoporosis in Children:
o   Anticipatory guidance regarding healthy lifestyle  (physical activity, diet, no drugs/alcohol) is of great importance to prevent bone loss and should start from an early age.
o   In severe cases of low bone mineral density, promoting calcium and Vitamin D intake coupled with weight-bearing physical activity can provide benefits with minimal risk.

Implications of Osteoporosis in Dental Treatment: 
o   Getting a full medical history is important.
o   Dentist should be careful when using restraints with child diagnosed with osteoporosis as bone fractures may result.
o   Extractions should be done carefully as to avoid any unnecessary jaw fractures.
o   Dentists should be aware of the patient’s current therapy.
o   Bisphosphonate therapy may lead to BRONJ.
o   Elimination of all potential sources of odontogenic and mucosal infection must be done before the patient starts therapy with bisphosphonates.
o   There are no reported cases of BRONJ developing from primary tooth extraction. However, it is always important to consult with the child’s physician prior to any surgical therapy.
o   Bisphosphonates can also inhibit tooth movement: posing a problem for orthodontic therapy (reduced osteoclasts)
o   It is suggested that orthodontic treatment be avoided in patients with high risk, such as those patients receiving or have received IV Bisphosphonate.
o   Bisphosphonate has also been associated with delayed tooth eruption with OI and with ulcers when pills come in contact with oral mucosa.
Assessment of Article: Very informative
Level of Evidence/Comments: Level III

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