Klemetti Index Research Articles

Direct-Acting Oral Anticoagulant/Vitamin K Antagonists: Do They Affect the Trabecular and Cortical Structure of the Mandible?

Background: This study aimed to evaluate the mandibular bone structure of patients using oral anticoagulants (OACs) vitamin K antagonist drugs (warfarin) and other OACs including direct oral anticoagulants [(DOACs) apixaban, rivaroxaban, dabigatran, edoxaban]. Analyses were based upon the fractal dimension (FD), the panoramic mandibular index (PMI) and the Klemetti index (KI), which is also known as the mandibular cortical index (MCI).Methodology: Ninety participants were divided into three groups: group 1: 30 systemically healthy individuals who had not used any anticoagulants before, group 2: 30 individuals using warfarin, and group 3: 30 individuals using DOACs. FD was used to analyze trabecular bone architecture in the condyle, angle, and two sites in the alveolar bone. PMI was used to evaluate the quantity of cortical bone and KI was used to evaluate the cortical bone quality.Results: There was no difference between the groups regarding FD analysis and KI; however, a difference was found between groups 1, 2, and 3 in the PMI (P≤ 0.001). The PMI in group 1 was higher than in groups 2 and 3.Conclusion: Mandibular radiomorphometric indices can be used on panoramic radiographs to evaluate the quantity of mandibular cortical bone in patients using oral anticoagulants.

Role of ortho-pantho-graphic X-ray in the diagnosis of osteoporosis

Background: Osteoporosis affects people, especially old age, as postmenopausal women and remains unnoticeable until the patient presents with a fracture. Osteoporosis in human begins started with the loss of bone mass that increases with age, this is related to the decrease in bone density and an increase in porosity that will cause fractures in this osteoporotic bone. Objective was to assess the usefulness of orthopanthographic (OPG) in the early detection of osteoporosis. Methods: This is an analytic across-sectional test validation study, was done in Hawari Hospital-Benghazi, Libya which considered a referral General Hospital affiliated with University of Benghazi. This study was done during a period from March 2022 to July 2023. Sixty women were selected, divided into osteoporotic and non osteoporotic groups depending on the clinical and laboratory investigations under the supervision of an orthopedic consultant in the outpatient clinic. Panoramic radiographic X-rays were taken for evaluation and estimation of the mandibular cortex on the basis of (Mental index, Klemetti index, and Panoramic mandibular index) as a diagnostic tool to differentiate normal from osteoporotic patient, all three indices correlated significantly with bone mineral density and used as useful indicators for detected the osteopenia and osteoporosis. Results: We calculated values of the three indices (Mental index, Klemetti index, and Panoramic mandibular index) values were low especially in the osteoporotic group, as well the values of mental index and panoramic mandibular index were low compared with low bone mineral density of the patient and klemetti index with: C2, C3 categories (moderate and severe erosion) most common observed in the osteoporotic patient. Conclusions: Orthopanthographic X-rays provide a valuable tool for early detection and assessment of osteoporosis (preclinical stage) especially when characterized by a decrease in bone mineral density.

A Panoramic X-ray as a Supportive Diagnostic Tool for the Screening of Osteoporosis in Patients with Hemophilia A and B.

Hemophilia is associated with an increased risk of developing osteoporosis and osteopenia. The aim of the study was to interpret the usefulness of fractal analysis of the trabecular bone of the mandible (FD) and selected radiomorphic indices (the antegonial index (AI) and Klemetti index (KI)) to assess the risk of reduced bone mineral density (BMD) in patients with hemophilia A/B. The study group consisted of 50 patients with type A/B hemophilia. The control group consisted of 25 males without congenital bleeding disorders. The patients had a panoramic radiograph taken with the same X-ray machine (Vistapano S, Durr Dental, Bietigheim-Bissingen, Germany). The AudaXCeph software (Audax d.o.o., Ljubljana, Slovenia) was used to evaluate the AI index, and the ImageJ, software with a specially prepared script, was used to evaluate the FD. The mandibular cortex was assessed distal to the mental foramen using the Klemetti index. There were no statistically significant differences between the AI, KI and FD values between the study group and the control group. This study indicated the lack of usefulness of AI, KI and fractal analysis in identifying patients with hemophilia at risk of reduced bone mass.

Is there a Correlation between Radiographic Absorptiometry of the Phalanges of the Hand and Radiomorphometric Indices of the Mandible?

Objectives: The aim of this study was to correlate the mandibular bone quality through radiomorphometric indices in panoramic radiograph with bone quality of non-dominant hand phalanges by radiographic absorptiometry phalanx (RA). Methods: The sample consisted of 167 patients (128 women and 39 men) with a mean age of 52.09 (± 11.5) divided into four groups according to RA test: (A) 92; (B) 36; (C) 25 and (D) with 14.9. A panoramic radiograph was taken of each patient and one observer made measurements of cortical thickness at the mental foramen (mental index, MI) and gonion (goniac index, GI) regions and fractal dimension (FD) analyze in mandibular ramus. In phalangeal radiograph was made measurements of cortical thickness at the intermediate (medial phalange index, MPI) and proximal (proximal phalange index, PPI) phalangeal. Results: The results showed correlation (p < 0.00037) between Klemetti index with RA. Variance analysis MI, GI, MPI, PPI shown significant differences (p < 0.05) between the two groups (normal and low bone mineral density - BMD). Area under the ROC curve was 0.74 (sensitivity = 97.4%, specificity = 78%) for MI, 0.79 (sensitivity = 94, specificity = 54%) for GI, 0.77 (sensitivity = 94.8%, specificity = 64%) for MPI, 0.76 (sensitivity = 93.1%, specificity = 62%) for PPI, 0.71 (sensitivity = 96.5%, specificity = 86%) for FD. Conclusions: Our results suggest that the analysis of radiomorphometric indices showed moderate accuracy for detecting changes in mandibular bone quality according to AR.

Evaluation of the effect of antiepileptic drugs on mandibular bone quality by fractal analysis.

Antiepileptic drugs (AEDs) are used to control seizures in epilepsy and their long-term use is common. AED use has been associated with decreased bone mineral density. The aim of this study is to determine the effect of AEDs on mandibular bone quality using fractal analysis and panoramic morphometric indices. In this study, dental and medical records of 132 patients (66 AED users and 66 control group) were used. Fractal analysis (FA), the panoramic mandibular index (PMI), mandibular cortical width (MCW), and Klemetti index (KI) measurements were performed on panoramic radiographs. In all metrics, the mean values of the study group were significantly lower than the control group (p < 0.000). There is a statistically significant difference between the study and control groups in terms of KI distribution (p < 0.000). The mean fractal dimension (FD) values in each measured region of the female patients in the study group were found to be significantly lower than the female patients in the control group (p < 0.05). The mean FD values measured in ROI-2 and ROI-3 of male patients in the study group were found to be significantly lower than male patients in the control group (p < 0.05). The side effects of AEDs on bone metabolism were shown in this study. Dentists examining patients with epilepsy should be careful about osteoporotic changes in the jaws.

Value of MDCT data of mandibular condyle cancellous bone to osteoporosis screening

The purpose of this study was application of age- and gender-related differences in mandibular condyle CT values on multidetector-row computed tomography imaging to osteoporosis screening. The mandibular CT images of 327 patients were analyzed retrospectively. The ovoid-shaped region of interest contouring was manually performed on both sides of the mandibular condyle on axial images to determine the mean CT value. The Klemetti index (KI) for each patient was categorized into C1, C2 and C3 based on coronal CT images. The mean CT values of the mandibular condyle were decreased with age in both males and females. The mean CT values of the mandibular condyle also decreased as the KI progressed. Our result suggested that the mean CT values of the mandibular condyle may be a new predictor for screening osteoporosis on multidetector-row computed tomography images.

Does childhood chemotherapy affect mandibular bone structures in a lifetime?

Chemotherapy, one of the most important treatment modalities for treating childhood cancers, is a major cause of bone loss in patients and survivors. This study aimed to evaluate mandibular bone structures in childhood cancer survivors (CCSs) by means of fractal dimension (FD) analysis and the Klemetti index (KI), and to compare them with regard to the control group. In this retrospective study, the panoramic radiographs of 49 CCSs were included as the study group and the panoramic radiographs of 49 cancer-free volunteers were included as the control group. Based on the panoramic radiographs, FD and KI were determined. No significant differences were observed between the study and control groups in terms of mean FD values for regions of interest (ROIs) ROI_1, ROI_2 and ROI_3 (p = 0.750, p = 0.490 and p = 0.910, respectively). The mean FD values for ROI_1 for the study and control groups were 1.08 ±0.18 and 1.07 ±0.14, respectively. The mean FD values for ROI_2 for the study and control groups were 1.11 ±0.13 and 1.09 ±0.13, respectively. The mean FD values for ROI_3 for the study and control groups were 1.15 ±0.14 and 1.15 ±0.15, respectively. Statistically significant differences between the study and control groups were noted only in the distribution of the KI categories (p = 0.015). Childhood chemotherapy may affect mandibular bone structures during a lifetime. The Klemetti index should be considered a useful clinical diagnostic tool for the examination of mandibular bone structures.

Evaluation of temporomandibular joint components and mandibular bone structure in ankylosing spondylitis patients

The study aimed to investigate the mandible and temporomandibular joint (TMJ) in patients with ankylosing spondylitis (AS) who had no signs or symptoms of TMJ-related disease and compare them with a control group. In total, 128 panoramic radiographs (63 patients with AS, 65 controls) were evaluated. Fractal analysis was conducted on the mandibular condyle (ROI1), angle of the mandible (ROI2), and the area adjacent to the mental foramen (ROI3). Articular eminence inclination (AEI) values were measured. Klemetti index (KI) evaluation of the mandibular cortex was also performed. Fractal dimension (FD) values were significantly lower in the patients with AS than the controls in ROI1 and ROI2 (P=.001), but there were no significant differences between groups for FD in ROI3, AEI, or KI (P ≥ .09). No significant differences were found in any parameters between patients with AS with different disease durations (P ≥ .06). Patients with AS displayed significantly lower FD values in condyles and the angle of the mandible and slightly lower AEI values; therefore, they should be examined routinely for TMJ disorders. Clinicians should be aware of the possibility of secondary osteoporosis in patients with AS and consider its probable effects on the mandible.

Proton pump inhibitors and mandibular bone quality: A preliminary study.

Proton pump inhibitors (PPI) provide a long-lasting anti-acidic effect by inhibiting the proton pump, and they are one of the most commonly prescribed drugs worldwide. PPIs adversely affect the bone structure via deficiency of vitamins and minerals. The aim of this study was to investigate the possible PPI-induced bone changes in the mandible on panoramic radiographs with the methods of fractal analysis and panoramic morphometric indices. Panoramic radiographs of 402 patients were used (201 PPI users, 201 control group). Fractal analysis was performed on 4 regions of interests (ROI): 1- upper part of the ramus, 2- angulus, 3- anterior of the mental foramen, 4- distal of the middle ramus. Also, the panoramic mandibular index (PMI), mandibular cortical width (MCW), and Klemetti index (KI) were performed on radiographs. There were significant differences in terms of ROI3, MCW, and KI between the control and study groups (p < 0.05) while there was no significant difference for ROI1, ROI2, ROI4, and PMI (p > 0.05). Males were severely affected than females. Osteoporotic changes were detected in the trabecular and cortical bone in the mental foramen region in PPI users with fractal analysis and morphometric indices, while there were no differences for mandibular ramus and angulus regions according to fractal analysis.

Medição da cortical óssea através de radiografia panorâmica para diagnóstico de osteopenia e osteoporose em mulheres

Modelo do estudo: Estudo de prevalência. Objetivo: Avaliar a prevalência de osteopenia e osteoporose diagnosticadas por radiografia panorâmica através de medidas qualitativas do córtex ósseo mandibular. Materiais e métodos: Foram utilizados o índice de Klemetti e o índice de Benson através de paquímetro digital. A análise descritiva dos dados foi realizada no Statistical Package for the Social Sciences (SPSS) V.20.0. Resultados: Das cinquenta radiografias panorâmicas avaliadas de mulheres com média de idade de 43,04 anos, 15 mulheres (30%) foram diagnosticadas com osteopenia pelo índice de Klemetti, não havendo casos de osteoporose na amostra. Em relação ao índice de Benson, os resultados mostraram média de 4,24 mm (DP: 0,54), com valor mínimo de 3,30 e máximo de 6,10 mm. Conclusão: Nossos achados evidenciam a importância da radiografia panorâmica para o diagnóstico precoce de osteopenia e osteoporose. A radiografia panorâmica apresenta baixo custo e facilidade de uso pelos cirurgiões-dentistas, sendo um exame amplamente utilizado em diversas áreas da odontologia.

The effect of selective serotonin reuptake inhibitors on the human mandible.

Selective serotonin reuptake inhibitors (SSRI) are a group of drugs that selectively and strongly block the serotonin transporter. Aim of this study was to evaluate the mandibular bone structure of patients who are using SSRIs with fractal analysis and panoramic morphometric indices [mandibular cortical width (MCW), panoramic mandibular index (PMI) and Klemetti index (KI)] and to compare with control group. Patients who declared using SSRIs for more than six months had been included in the study group. In total, 212 dental panoramic radiographs (DPR) were assessed. For fractal analysis; three regions of interest (ROIs) were determined: ROI1 and ROI2 were chosen within trabecular bone, ROI3 was selected from cortical bone. MCW, PMI, and KI were obtained from DPRs. The study group was categorized into five subgroups of various SSRIs. The fractal dimension (FD) values and panoramic morphometric indices of these subgroups were also compared. There was no significant difference between the groups for age and gender (p = 0.57, p = 0.5). There were significant differences in the mean FD values between the study and control groups both for the ROI1 and ROI2 (p < 0.01, p < 0.01). There was no significant difference between the groups for the mean FD value of ROI3, MCW, PMI and KI (p = 0.93, p = 0.98, p = 0.74, p = 0.06). There were no significant differences for all the values between the SSRI subgroups (p = 0.52, p = 0.7, p = 0.76, p = 0.24, p = 0.31, p = 0.08) CONCLUSIONS: Trabecular rich sites of the mandible were found to be affected by SSRI usage.

Evaluation of jawbonemorphology and bonedensityindices in panoramic radiographs of selectiveserotoninreuptakeinhibitorusers: a preliminary study.

To assess the influence of selective serotonin reuptake inhibitor (SSRI) use on jawbone and bone mineral density by retrospective analysis of panoramic radiographs. Radiographic and clinical records were sourced from the Division of Orthodontics and TMJD, Eastman Institute for Oral Health, University of Rochester. Randomly selected adults (20-65 years) were categorized into: "Active" (with history of SSRI use of >6 months) and a "Control" group. Panoramic indices: Klemetti index (KI), panoramic mandibular index, antegonial notching index, condylar pathology, mandibular cortical width (MCW)⁠ and mean ramus height were recorded. Frequency-weighted Χ2 tests and multinomial regression controlling for age and gender were applied to categorical indices (KI, condylar pathology, antegonial notching index). Multivariate generalized linear modeling was applied to mean ramus height, MCW and panoramic mandibular index. Multiple regression analyses determined: (a) panoramic indices that best predicted SSRI use, and (b) independent predictors of KI category. 64 SSRI users and 48 Controls were assessed. SSRI users had significantly higher odds of having worse KI status than normal [mildly to moderately eroded cortex: odds ratio (OR) = 2.926, 95% CI (1.07-8.04) and severely eroded cortex: OR = 19.86, 95% CI (3.91-100.69)], more frequent flat condylar anatomy (right side: p = 0.009, left side: p < 0.001) but greater ramus height (p = 0.001) and mandibular cortical width (p = 0.032). Age, gender, SSRI use each significantly impacted KI. Only SSRI use significantly impacted condylar pathology, ramus height and MCW. KI category (OR = 1.3) was the best panoramic predictor of SSRI use. Conversely, KI category C3 was significantly predicted by SSRI use (OR = 31.2, p = 0.002), female gender (17.5, p = 0.006), and severe antegonial notching (OR = 1289, p < 0.001). SRRI use was significantly associated with worse panoramic morphometric indices: KI, condylar pathology, ramus height, and MCW, where KI was its strongest predictor. Worse KI was independently predicted by SSRI use.

Efficacy of Panoramic Radiography in the Detection of Osteoporosis in Post-Menopausal Women When Compared to Dual Energy X-Ray Absorptiometry.

Objective:It is a well-known fact that osteoporosis affects the people with old age and remains unnoticeable until the patient presents with fracture. Various studies in the literature reveal that panoramic radiographs may prove to be beneficial in the detection of Osteoporosis in patients. Henceforth this present study was aimed to validate the use of Klemetti Index (KI) on panoramic radiographs so as to detect osteoporosis in the patients at an early stage.Methods:60 postmenopausal women were selected. A panoramic radiograph was taken to grade their mandibular cortex on the basis of Klemetti Index. All the panoramic radiographs were evaluated by 5 different Oral Medicine and Radiology specialists. Later all the patients were subjected to dual energy X-ray absorptimetry (DEXA) scan for bone mineral density evaluation. The results were evaluated statistically.Results:The average accuracy of the five observers to demonstrate normal bone, osteopenia and osteoporosis when compared to DEXA scan was 58.08%, 63.3% and 64.74% respectively. The observations of the 5 observers on the basis of KI were not statistically different from the BMD evaluation done with the help of DEXA Scan.Conclusion:Panoramic radiographs can be used as a screening tool for the evaluation as well as early detection of osteoporosis with the usage of Klemetti Index.

Radiographic signs of bone mineral density in panoramic radiographs from pre and postmenopausal patients.

Objective: The aim of this study was to evaluate the potential of panoramic radiographs (PR) and their radiomorphometric indices as an auxiliary method for the diagnosis of osteoporosis. Material and Methods: Twenty five women were selected, who had been prescribed PR for different purposes. The PR were analysed according to the MCI, which evaluates the mandibular cortex below the mental foramen, and then divided into two groups: normal and bone mineral loss. Bone densitometry scans were obtained (DXA) from the lumbar spine and neck of the femur/whole femur, which were used as the gold standard for comparison against the MCI. Kappa test (p&lt;0.05) was used to determine the association between the MCI and bone densitometry readings. Results: Regarding the DXA, 7 patients were normal at the lumbar spine or femur, 24 subjects showed osteopenia at the lumbar spine or femur and 9 subjects had osteoporosis at the lumbar spine or femur. Regarding the association between DXA and MCI, 18 subjects showed some degree of bone loss at the spine detected by both DXA and the Klemetti index. Conclusions: PR may be useful to assess the risk of such diseases being present.

Osteoporosis: Current state and need for screening with the help of oral health physicians

Osteoporosis is characterized by low bone mineral density (BMD) and deterioration of bone structure resulting in an increased susceptibility to fractures of the hip, spine and wrist. Osteoporosis contributes to a great deal of morbidity and mortality and is a large burden to the health service. In the last four decades, numerous research teams have reported oral radiographic findings associated with osteoporosis. Digital orthopantomographs (OPGs), taken for routine dental evaluations, have a significant role in screening for initial osteoporotic changes. A number of mandibular cortical indices (MCIs) have, also, been developed to allow quantification of mandibular bone mass and identification of osteoporosis. Klemetti Index (KI), mental index (MI), panoramic mandibular index (PMI), antegonial index (AI) and gonial index (GI) are, all, associated with a low bone mineral density (BMD) and of help in the initial screening of osteoporosis.

Osteoporosis: Current State and need for screening- Possible role of oral physicians

Osteoporosis is characterized by low bone mineral density (BMD) and deterioration of bone structure resulting in an increased susceptibility to fractures of the hip, spine, and wrist. Osteoporosis contributes to a great deal of morbidity and mortality and is a large burden to the health service. In the past four decades, numerous research teams have reported oral radiographic findings associated with osteoporosis. Digital orthopantomographs (OPGs), taken for routine dental evaluations, have a significant role in screening for initial osteoporotic changes. A number of mandibular cortical indices have also been developed to allow quantification of mandibular bone mass and identification of osteoporosis. Klemetti index, mental index, panoramic mandibular index, antegonial index , and gonial index are all associated with a low BMD and of help in the initial screening of osteoporosis.

Digital panoramic radiography: An aid in the early detection of osteoporotic signs

Background: Osteoporosis is a worldwide problem demanding attention in the modern world. In the last four decades, numerous research teams have reported oral radiographic findings associated with osteoporosis. The preponderance of the evidence shows that the jaws of subjects with osteoporosis show reduced bone mass and altered morphology. A number of mandibular cortical indices (MCIs) have also been developed to allow quantification of mandibular bone mass and identification of osteoporosis. Aims and Objectives: The aim of the present study was to measure various radiomorphometric indices and/or, mandibular cortical indices (MCIs) on digital panoramic radiographs (Orthopantomographs [OPGs]) of postmenopausal females; to assess the bone mineral density (BMD) of postmenopausal females using dual energy X-ray absorptiometry (DEXA); and to compare the radiomorphometric indices on digital panoramic radiographs with BMD values and thereby assessing the efficacy of digital panoramic radiographs in detecting mandibular osteoporotic changes so as to screen osteoporosis. Materials and Methods: One hundred postmenopausal females were randomly selected from the outpatient department. All the patients were explained about the need for the study. Informed consent was taken, and a detailed case history was obtained. After subjecting the patients to digital panoramic radiography, the patients were taken for BMD evaluation using DEXA scans. Statistical Analysis: The data obtained were subjected to statistical analysis using SPSS version 14. P < 0.05 was considered statistically significant. ANOVA with post hoc Tukey's test, Chi-square test, Pearson correlation coefficient, and Spearman correlation coefficient were used for statistical analysis. Results: Klemetti index showed that a patient with C3 cortical appearance had a low BMD. Among the quantitative indices, mental index, panoramic mandibular index, antegonial index, and gonial index, showed significantly lower values among the osteoporotic group. Conclusion: Digital panoramic radiographs (OPGs) have a significant role in the initial screening of elderly females for early osteoporotic changes.

Assessment of osteoporotic alterations in achondroplastic patients: a case series

Achondroplasia (ACH) is the most common form of human dwarfism and has been associated with biochemical alterations of the bone tissue, also observed in cases of osteoporosis. The present case series aimed at assessing low bone density, diagnosed with spinal bone mineral density (BMD) analysis and with panoramic radiograph measurements, in ACH patients. Spinal BMD was measured by means of dual-energy X-ray absorptiometry at the lumbar region (L1-L4). On dental panoramic radiographs of the patients, the mandibular cortical width was measured separately on the right and left sides. The Klemetti Index was also assigned as appropriate for evaluating the cortical area below the mandibular foramen. Additional parameters such as patient age, gender, body mass index, and number of teeth were also recorded. BMD results showed that 5/11 cases presented with skeletal osteopenia/osteoporosis diagnoses. Additionally, mandibular cortical erosion was detected in panoramic radiographs in 8/11 cases. The BMD and panoramic radiographic alterations found in this study suggest that the diagnosis of low bone density may have a special clinical relevance in cases of bone tissue disorders, such as achondroplasia.

EARLY DETECTION OF OSTEOPOROSIS IN PATIENTS OVER 55 USING ORTHOPANTOMOGRAPHY

Osteoporosis is a condition characterized by a loss on bone mineral density and there is micro- architectural deterioration in bone tissue leading to fracture. Dental radiographs are the most frequently used imaging modalities for teeth and jaw pathology. The purposes of this study were to review the role of panoramic radiograph in routine dental treatment for an initial evaluation of osteoporosis and to discuss the reliability and accuracy of reported panoramic indices. We present to the dental society the Klemetti index (Mandibular cortical index- MCI). In this technique the inferior cortex both sides of the mandible, distal to the foramen mentale, is classified into three groups, according to the mandibular bone thickness, shape and porosity. C1- normal cortex- the endosteal margin of the cortex is even and sharp on both sides. C2- mildly to moderately eroded cortex, the endosteal margin has resorptive cavities with cortical residues one to three layers thick on one or both sides. C3- Severely eroded cortex, the cortical layer forms endosteal cortical residues and is clearly porous. Patients having positive findings related to MCI should be evaluated further for potential risk of osteoporosis and could be referred to a medical specialist for densitometry. In conclusion, valuation of mandibular cortical index (thickness and shape of inferior cortex of mandible), measured from panoramic radiography was a simple technique in osteoporosis screeming of dental patients, giving the maximum benefit of being radiographed.

Dental and radiographic findings as predictors of osteoporosis in postmenopausal women

The objective of this study was to evaluate the relationship between dental findings and osteoporosis in postmenopausal women. One hundred and eight postmenopausal women were recruited for the study. All participants underwent dual X-ray absorptiometry (DXA). The number of remaining teeth, clinical attachment loss, pocket depth and mobility of each tooth were determined. Radiodensitometric analyses were performed on digital periapical radiographs utilizing an aluminum stepwedge technique. The appearance of inferior mandibular cortex posterior of the mental foramina region was scored according to the classification by Klemetti. The number of remaining teeth, attachment loss values, Klemetti Index scores and the radiodensitometric scores showed a significant relationship with skeletal bone density. Tooth loss, an increased clinical attachment level, reduced density on digital periapical radiographs and an eroded appearance of the inferior mandibular cortex in panoramic radiographs are associated with low-skeletal bone mineral density.