Osteoporosis Risk Assessment Research Articles

Screening Tools for Osteoporosis in India: Where Do We Place Them in Current Clinical Care?

The prevalence of osteoporosis is about 40%–50% in postmenopausal women and 20% in older men. The limited availability of dual-energy X-ray absorptiometry (DXA) scanners across the country calls for the presence of alternate risk assessment tools to identify those at high risk for osteoporosis. Some of the screening tools available for osteoporosis include Simple Calculated Osteoporosis Risk Estimation and Osteoporosis Risk Assessment Tool for Asians (OSTA), and Fracture Risk Assessment Tool to assess fracture risk. Clinical parameters that may serve as surrogates include dentition and anthropometric indices. Although screening tools do not supplant the assessment of bone mineral density by DXA, they help identify individuals at high risk for osteoporosis who may be selectively referred for confirming the same.

The treatment gap: The missed opportunities for osteoporosis therapy.

Despite substantial advances in delineation of the epidemiology, pathophysiology, risk assessment and treatment of osteoporosis over the last three decades, a substantial proportion of men and women at high risk of fracture remain untreated - the so-called "treatment gap". This review summarises the important patient-, physician- and policyrelated causes of this treatment gap, before discussing in greater detail: (a) the evidence base for the efficacy of bisphosphonates in osteoporosis; (b) recent evidence relating to the adverse effects of this widely used therapeutic class, most notably atypical femoral fracture and osteonecrosis of the jaw; (c) available strategies to improve both secondary and primary prevention pathways for the management of this disorder.

Machine Learning Can Improve Clinical Detection of Low BMD: The DXA-HIP Study

Background: Identification of those at high risk before a fracture occurs is an essential part of osteoporosis management. This topic remains a significant challenge for researchers in the field, and clinicians worldwide. Although many algorithms have been developed to either identify those with a diagnosis of osteoporosis or predict their risk of fracture, concern remains regarding their accuracy and application. Scientific advances including machine learning methods are rapidly gaining appreciation as alternative techniques to develop or enhance risk assessment and current practice. Recent evidence suggests that these methods could play an important role in the assessment of osteoporosis and fracture risk. Methods: Data used for this study included Dual-energy X-ray Absorptiometry (DXA) bone mineral density and T-scores, and multiple clinical variables drawn from a convenience cohort of adult patients scanned on one of 4 DXA machines across three hospitals in the West of Ireland between January 2000 and November 2018 (the DXA-Heath Informatics Prediction Cohort). The dataset was cleaned, validated and anonymized, and then split into an exploratory group (80%) and a development group (20%) using the stratified sampling method. We first established the validity of a simple tool, the Osteoporosis Self-assessment Tool Index (OSTi) to identify those classified as osteoporotic by the modified International Society for Clinical Densitometry DXA criteria. We then compared these results to seven machine learning techniques (MLTs): CatBoost, eXtreme Gradient Boosting, Neural network, Bagged flexible discriminant analysis, Random forest, Logistic regression and Support vector machine to enhance the discrimination of those classified as osteoporotic or not. The performance of each prediction model was measured by calculating the area under the curve (AUC) with 95% confidence interval (CI), and was compared against the OSTi. Results: A cohort of 13,577 adults aged ≥40 yr at the age of their first scan was identified including 11,594 women and 1983 men. 2102 (18.13%) females and 356 (17.95%) males were identified with osteoporosis based on their lowest T-score. The OSTi performed well in our cohort in both men (AUC 0.723, 95% CI 0.659–0.788) and women (AUC 0.810, 95% CI 0.787-0.833). Four MLTs improved discrimination in both men and women, though the incremental benefit was small. eXtreme Gradient Boosting showed the most promising results: +4.5% (AUC 0.768, 95% CI 0.706–0.829) for men and +2.3% (AUC 0.833, 95% CI 0.812–0.853) for women. Similarly MLTs outperformed OSTi in sensitivity analyses—which excluded those subjects taking osteoporosis medications—though the absolute improvements differed. Conclusion: The OSTi retains an important role in identifying older men and women most likely to have osteoporosis by bone mineral density classification. MLTs could improve DXA detection of osteoporosis classification in older men and women. Further exploration of MLTs is warranted in other populations, and with additional data.

The assessment of osteoporosis and fracture risk in patients undergoing medical rehabilitation

The assessment of osteoporosis and fracture risk in patients undergoing medical rehabilitation

Circulating MicroRNAs as Novel Biomarkers for Osteoporosis and Fragility Fracture Risk: Is There a Use in Assessment Risk?

Osteoporosis is a multifactorial skeletal disease that is associated with both bone mass decline and microstructure damage. The fragility fractures—especially those affecting the femur—that embody the clinical manifestation of this pathology continue to be a great medical and socioeconomic challenge worldwide. The currently available diagnostic tools, such as dual energy X-ray absorptiometry, Fracture Risk Assessment Tool (FRAX) score, and bone turnover markers, show limited specificity and sensitivity; therefore, the identification of alternative approaches is necessary. As a result of their advantageous features, such as non-invasiveness, biofluid stability, and easy detection, circulating cell-free miRs are promising new potential biomarkers for the diagnosis of osteoporosis and low-traumatic fracture risk assessment. However, due to the absence of both standardized pre-analytical, analytical, and post-analytical protocols for their measurement and universally accepted guidelines for diagnostic use, their clinical utility is limited. The aim of this review was to record all the data currently available in the literature concerning the use of circulating microRNAs as both potential biomarkers for osteoporosis diagnosis and fragility fracture risk evaluation, and group them according to the experimental designs, in order to support a more conscious choice of miRs for future research in this field.

Age-, Site-, and Sex-Specific Normative Centile Curves for HR-pQCT-Derived Microarchitectural and Bone Strength Parameters in a Chinese Mainland Population

High-resolution peripheral quantitative computed tomography (HR-pQCT) is an advanced 3D imaging technology that has the potential to contribute to fracture risk assessment and early diagnosis of osteoporosis. However, to date no studies have sought to establish normative reference ranges for HR-pQCT measures among individuals from the Chinese mainland, significantly restricting its use. In this study, we collected HR-pQCT scans from 863 healthy Chinese men and women aged 20 to 80 years using the latest-generation scanner (Scanco XtremeCT II, Scanco Medical AG, Brüttisellen, Switzerland). Parameters including volumetric bone mineral density, bone geometry, bone microarchitecture, and bone strength were evaluated. Age-, site-, and sex-specific centile curves were established using generalized additive models for location, scale, and shape with age as the only explanatory variable. Based on established models, age-related variations for different parameters were also quantified. For clinical purposes, the expected values of HR-pQCT parameters for a defined age and a defined percentile or Z-score were provided. We found that the majority of trabecular and bone strength parameters reached their peak at 20 years of age, regardless of sex and site, then declined steadily thereafter. However, most of the cortical bone loss was observed after the age of 50 years. Among the measures, cortical porosity changed most dramatically, and overall, changes were more notable at the radius than the tibia and among women compared with men. Establishing such normative HR-pQCT reference data will provide an important basis for clinical and research applications in mainland China aimed at elucidating microstructural bone damage driven by different disease states or nutritional status. © 2020 American Society for Bone and Mineral Research.

MON-391 Implementation of an Osteoporosis Risk Assessment Instrument (ORAI) to Increase Referral Rates for DEXA Scanning in the Primary Care Setting

Background/Purpose: Osteoporosis (OP)was first identified and named by healthcare professionals in the 18th century. Today, OP is still the source of fractures which impair mobility, leading to sub-acute stays at rehabilitation centers. A major obstacle is that primary care providers (PCPs) fail to identify warning signs of OP, and inform patients that Dual Energy X-Ray Absorptiometry (DEXA) scans that are one of the best procedures to assess bone health. This project addressed the issue of low rate of referrals for DEXA scans. Theoretical Framework: The Knowledge-to-Action (KTA) model was used to guide this study. Intervention: Implementation of osteoporosis risk assessment instrument. Methods (Design, Sample, Setting, Measures, Analysis): This includes pre-implementation phase, patients’ charts were reviewed; post-implementation phase, the number of people referred to have DEXA scans were analyzed; the evaluation phase, results compared to the previous data. The project focus exclusively on women and men ages 50 to 89 years in two primary care offices in New Jersey. Descriptive analyses concentrated on whether or not ORAI was the tool to increase DEXA scans. Results: The data analysis reflected that the baseline referral rates increased from 1.3 % to 42 % and patients who scored high on the risk assessment instrument have been referred more often than not. Moreover, patients who are at risk and younger than 65 years of age, risk assessment tools led to a positive referral for a DEXA scan. Those who are older than 65 years, risk assessment tools like ORAI should be given with fracture risk assessment tools. This is especially the case when dealing with men, a demographic group often overlooked in the fight against OP. Conclusions Implications: If this project is to be applied at other clinics, more and more patients would be referred, raising awareness of the medical benefits of early detection. Reasonably, covering a broader section of patients, earlier in their lives, will increase clinical income, bringing more patients to primary care offices.

Utility of an index metacarpal cortical thickness application as an osteoporosis screen in distal radius fracture patients aged over 50.

Following wrist fracture, it is desirable to identify patients with osteoporosis. A smartphone-based application (BoneGauge) that uses second metacarpal cortical thickness ratio (2MCP) measured on X-ray has been proposed. This study aims to validate this application using dual-energy X-ray absorptiometry scan in a cohort of patients with distal radius fractures. Thirty subjects aged 50 and over who sustained low-energy fractures of the radius were recruited and measurements were completed by two independent observers using the application. The interrater reliability as a screening tool was insufficient (κ = 0.61). Using the 2MCP threshold of 60% for detection of osteopaenia or osteoporosis, we found insufficient correlation between the dual-energy X-ray absorptiometry scan and the two sets of readings using the application (κ = 0.28 and 0.35, respectively). On the basis of these results, 2MCP of 60% is not sensitive enough to be used as a screening tool via a smartphone application for assessment of osteoporosis risk.

Osteoporosis risk assessment in primary dental care—The attitudes of Swedish dentists, patients and medical specialists

To explore and identify the attitudes of dentists, patients and medical specialists regarding implementation of osteoporosis risk assessment into Swedish primary dental care. Osteoporosis is a major health problem leading to fragility fractures. As shown in academic-based research, dental radiological examination can be used for osteoporosis risk assessment. A substantial number of patients undergo radiographic examinations in primary dental care each year, but little is known about implementation of osteoporosis risk assessment in this setting. A qualitative research approach using focus group discussions and manifest content analysis was applied. Five focus groups with dentists and representatives from patient support groups and a single individual interview with one medical specialist were included in the sample. From the manifest content analysis, three categories emerged: (a) barriers to change in practice, (b) benefits to change in practice, and (c) needs and requirements prior to change in practice. Most participants felt that there was insufficient knowledge of osteoporosis as well as a heavy existing workload. A concern was expressed about medical practitioners' willingness to take on responsibility for patients referred by dentists. Representatives from patient support groups highlighted a lack of knowledge about osteoporosis among both the general public and the medical professionals. Clear guidelines and improved communication channels between stakeholders would have to be established to ensure a smooth treatment path for patients. Despite interest in osteoporosis risk assessment in primary dental care, there are political, workflow and educational barriers that must be overcome for successful implementation.

Frailty and prediction of recurrent falls over 10\xa0years in a community cohort of 75-year-old women

BackgroundFrailty captures the age-related declines in health leading to increased vulnerability, including falls which are commonplace in older women. The relationship between frailty and falls is complex, with one leading to the other in a vicious cycle.AimsThis study addresses the gap in understanding how patterns of frailty and falls propensity interact, particularly in those who have not yet entered the falls-frailty cycle.MethodsThe Osteoporosis Risk Assessment cohort consists of 1044 community-dwelling women aged 75, with 10 years of follow-up. Investigations were performed and a frailty index constructed at baseline, 5 and 10 years. Falls were self-reported for each previous 12 months. Analysis was two-directional, firstly based on frailty status and second, based on falls status. Recurrent falls was the primary outcome.ResultsBaseline frailty was a significant predictor of recurrent falls after 5 and 10 years [(OR 2.55 (1.62–3.99); 3.04 (1.63–5.67)]. Among women who had no history of falls at age 75, frailty was a stronger predictor of falls at 5 years [OR 3.06 (1.59–5.89)] than among women who had previously fallen.DiscussionFrailty is significantly associated with recurrent falls and most pronounced in those who are frail but have not yet fallen.ConclusionsThis suggests that frailty should be an integral part of falls-risk assessment to improve identification of those at risk of becoming fallers.

Evaluation of Lifestyle and Some Biochemical Parameters Involved in Bone Health in Pre and Postmenopausal Cameroonian Women

Aims: A healthy skeletal system with strong bones is essential to overall health. This study aimed to assess lifestyle and bone’s biomarkers of women.
 Study Design: This was a cross-sectional study.
 Place and Duration of Study: The enrollment took place at the Yaounde Military Hospital from November 2016 to July 2017.
 Methodology: A set of 105 postmenopausal and 127 premenopausal participants were enrolled from November 2016 to July 2017 in Yaounde. Their physical activities level was evaluated using a questionnaire. Sunlight exposure between 10:00AM and 4:00PM was assessed. Colorimetric methods were used to evaluate calcium, albumin, and alkaline phosphatase activity in plasma. These parameters were then compared within year since menopause (YSM) and osteoporosis risk assessment instrument (ORAI) sub-groups.
 Results: 13.4% participants were moderately active. Only 22.8% participants had at least 30 minutes sun exposure daily. A multivariable analysis of demographic, lifestyle, biochemical characteristic revealed age, BMI, albumin and calcium were the main factors that influenced bone health among our participants. A significant difference of calcium concentration was found between the two groups whereas albumin was significantly higher in premenopausal than postmenopausal. Albumin was the only variable with a significant difference in the YSM sub-groups while only calcium was non-significantly higher among the ORAI sub-groups.
 Conclusion: Elevated plasma level of calcium, albumin and alkaline phosphatase could be indicators of high bone turnover.

X-ray-based quantitative osteoporosis imaging at the spine.

Osteoporosis is a metabolic bone disease with a high prevalence that affects the population worldwide, particularly the elderly. It is often due to fractures associated with bone fragility that the diagnosis of osteoporosis becomes clinically evident. However, early diagnosis would be necessary to initiate therapy and to prevent occurrence of further fractures, thus reducing morbidity and mortality. X-ray-based imaging plays a key role for fracture risk assessment and monitoring of osteoporosis. Whereas over decades dual-energy X-ray absorptiometry (DXA) has been the main method used and still reflects the reference standard, another modality reemerges with quantitative computed tomography (QCT) because of its three-dimensional advantages and the opportunistic exploitation of routine CT scans. Against this background, this article intends to review and evaluate recent advances in the field of X-ray-based quantitative imaging of osteoporosis at the spine. First, standard DXA with the recent addition of trabecular bone score (TBS) is presented. Secondly, standard QCT, dual-energy BMD quantification, and opportunistic BMD screening in non-dedicated CT exams are discussed. Lastly, finite element analysis and microstructural parameter analysis are reviewed.

25 The Post Fall Review- An Opportunity to Intervene for Bone Health

Abstract Background Falls are a common occurrence in Irish hospitals and can result in much morbidity and mortality for our patients. According to NICE guidelines, a multi-factorial falls risk assessment should be carried out for those patients at risk of falling, including assessment of osteoporosis risk and medication review. In practice, the post falls assessment is a golden opportunity to assess Osteoporosis risk and adequate bone protection. Methods We compiled a list of patient falls registered on the Datix incident reporting system for our five wards over a three-month period from 13/10/18-15/1/19. We looked at the note post fall from the reviewing doctor and documented whether bone protection was addressed and also whether a known history of osteoporosis was documented. This was done on our electronic patient record system. Results A total of 106 falls were recorded during this time period. 87% of falls had a documented review post fall. 83 reviews were by the intern on call and team reviewed in 54 cases, often after the intern. 2 of the notes documented whether or not the patient had a known history of Osteoporosis. There was no mention about the presence or absence of bone protection in any of the notes. 14%(15) patients were on bone protection. 37%(40) were on vitamin D or calcium. 2 patients sustained a fracture in their fall. Conclusion This audit highlights that bone protection and osteoporosis risk are rarely being addressed post fall. To improve this we are going to give education on post falls assessment (including evaluating osteoporosis risk and assessing current bone protection or need for bone protection) to incoming intern groups and doctors on teams assessing falls. We will reaudit 3 months after this education to evaluate whether there has been an improvement.

A comparison of 6 osteoporosis risk assessment tools among postmenopausal women in Kuala Lumpur, Malaysia

ObjectivesTo compare and assess the performance of 6 osteoporosis risk assessment tools for screening osteoporosis in Malaysian postmenopausal women. MethodsSix osteoporosis risk assessments tools (the Simple Calculated Osteoporosis Risk Estimation [SCORE], the Osteoporosis Risk Assessment Instrument, the Age Bulk One or Never Estrogen, the body weight, the Malaysian Osteoporosis Screening Tool, and the Osteoporosis Self-Assessment Tool for Asians) were used to screen postmenopausal women who had not been previously diagnosed with osteoporosis/osteopenia. These women also underwent a dual-energy X-ray absorptiometry (DXA) scan to confirm the absence or presence of osteoporosis. ResultsA total of 164/224 participants were recruited (response rate, 73.2%), of which only 150/164 (91.5%) completed their DXA scan. Sixteen participants (10.7%) were found to have osteoporosis, whilst 65/150 (43.3%) were found to have osteopenia. Using precision-recall curves, the recall of the tools ranged from 0.50 to 1.00, whilst precision ranged from 0.04 to 0.14. The area under the curve (AUC) ranged from 0.027 to 0.161. The SCORE had the best balance between recall (1.00), precision (0.04–0.12), and AUC (0.072–0.161). ConclusionsWe found that the SCORE had the best balance between recall, precision, and AUC among the 6 screening tools that were compared among Malaysian postmenopausal women.

Sperm Count and Hypogonadism as Markers of General Male Health

BackgroundSome evidence suggests that infertile men, who are at increased risk for hypogonadism, metabolic derangements, and osteoporosis, have higher long-term morbidity and mortality than controls, but data are scarce and not conclusive. ObjectiveWe tested whether semen quality and reproductive function could represent a marker of general male health. Design, setting, and participantsA retrospective study of 5177 individuals from a prospectively collected database of 11516 males of infertile couples who had semen analysis in a tertiary university center. Outcome measurements and statistical analysisOf them, 5177 had all data for reproductive hormones, testis ultrasound, and biochemical determinations for glucose and lipid metabolism. Hypogonadism was defined as testosterone <10.5nmol/l and/or luteinizing hormone >9.4 IU/l. Individuals with a total sperm count of <10 million had genetic testing (karyotype, Y chromosome microdeletions, and CFTR gene mutations) and those with hypogonadism underwent dual-energy x-ray absorptiometry for bone mineral density. Descriptive statistics and odds ratio (OR) calculation were used. Results and limitationsMen with a low sperm count (<39 million/ejaculate) are at a high risk of hypogonadism (OR 12.2, 95% confidence interval [CI] 10.2–14.6) and have higher body mass index, waist circumference, systolic pressure, low-density lipoprotein cholesterol, triglycerides, and homeostatic model assessment (HOMA) index; lower high-density lipoprotein cholesterol; and a higher prevalence of metabolic syndrome (OR 1.246, 95 CI 1.005–1.545). All data are worse in men with hypogonadism, but a low sperm count per se is associated with a poor metabolic parameter. Men with hypogonadism have lower bone mineral density and 51% prevalence of osteoporosis/osteopenia. Longitudinal studies are necessary to support these data. ConclusionsThis is the largest study with comprehensive evaluation of semen quality and reproductive function, etiology and risk factor determination, and metabolic, cardiovascular, and osteoporosis risk assessment, performed in men referred for fertility evaluation. A low sperm count is associated with poorer metabolic, cardiovascular, and bone health. Hypogonadism is mainly involved in this association, but a low sperm count in itself is a marker of general health. Patient summaryThis large study evaluated semen quality, reproductive function, and metabolic risk in men referred for fertility evaluation, and showed that a man’s semen count is a marker of his general health. Men with low sperm counts are more likely than those with normal sperm counts to have greater body fat, higher blood pressure, higher “bad” (low-density lipoprotein) cholesterol and triglycerides, and lower “good” (high-density lipoprotein) cholesterol. They also have a higher frequency of metabolic syndrome and insulin resistance, a condition that can lead to diabetes. Men with low sperm counts had a 12-fold increased risk of hypogonadism or low testosterone levels, and half of them had osteoporosis or low bone mass. Fertility evaluation gives men the unique opportunity for health assessment and disease prevention.

Evaluation of osteoporosis using DEXA scan among low income group women in South India

Introduction and Objectives: Osteoporosis is one of the most common consequences of menopause and is characterized by low bone mass with micro architectural deterioration of bone tissue leading to bone fragility. Hip fracture is the worst complication of osteoporosis, with substantial morbidity and high one-year mortality. Hence it is essential to identify post-menopausal women at risk of developing osteoporosis. Dual energy x-ray absorptiometry (DEXA) is a valuable tool for screening women prone to osteoporosis. The objective of the present work was to estimate the prevalence of low bone mass in low income Indian women above 40 years for the assessment of osteoporosis and fracture risk using DEXA scan. Materials and Methods: This study was conducted in Coimbatore from 2012-2017 with a sample size of 500 patients for the diagnosis of osteoporosis in low income group women from 40 to 70 years. Bone mineral density was done using DEXA Scan (Hologic) at lumbar spine and hip zones. Results: The prevalence of osteoporosis in our study by hip BMD score was 38% and osteopenia was 24% and by spine BMD score osteoporosis was 36% and osteopenia was 38%. Overall, in the age group of between 41 and 65 years, the prevalence of osteopenia (36%) and osteoporosis (30%) together was 66%, which is higher than other developed countries. Conclusion: Risk of osteoporosis among women from the age of 40 years can be identified by DEXA scan method so that effective therapeutic measures can be initiated at the earliest. Keywords: DEXA, Osteoporosis, South India.

Evaluation of relationship between bone mineral density and fragility fracture in perimenopausal women between 40-58 years of age: a hospital based prospective observational study

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; At present the risk assessment for osteoporosis using low bone mineral density (BMD) is based on data obtained from elderly females, largely ≥ 65 years of age. The risk factors for low peak bone mass or accelerated bone loss that occurs during perimenopausal phase is ignored in this risk assessment. Osteoporosis is found to occur at a relatively younger age in the Indian population. Although lower BMD values have an established identity as a major risk factor for fractures in postmenopausal women, we endeavour to evaluate relationship between bone mineral density and fragility fracture in perimenopausal women.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; 65 Patients were recruited for the study. After X-ray of involved part, patients were divided into cases (with fracture, n=33) and control (no bony injury, n=32). All patients underwent dual energy X-ray absorptiometry (DEXA) scan. Results of DEXA scans were evaluated in both the groups. BMD was expressed in g/cm&lt;sup&gt;2&lt;/sup&gt;.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; 33 patients (50.77%) were diagnosed as fracture, 32(49.23%) had no bony injury. Threshold bone mineral density (BMD) for fragility fracture found out asfor L1, cut off ≤0.767. For L2, cut off ≤0.829. For L3, cut off ≤0.811. L4, cut off ≤0.798. For L1-L4, cut off ≤0.845. For left femur total hip, cut off ≤0.918. For left forearm-total, cut off ≤0.411. For right femur total hip-cut off ≤0.795. For right forearm-total, cut-off≤0.382.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Perimenopausal women having BMD below threshold for involved site are at risk of fragility fracture and should be given prophylactic treatment to improve bone mineral density.&lt;/p&gt;

WTP for osteoporosis risk assessment in dental care

WTP for osteoporosis risk assessment in dental care

Willingness to pay for osteoporosis risk assessment in primary dental care

BackgroundFragility fracture related to osteoporosis among postmenopausal women is a significant cause of morbidity. The care and aftercare of these fractures are associated with substantial costs to society. A main problem is that many individuals suffer from osteoporosis without knowing it before a fracture happens. Dentists may have an important role in early identification of individuals with osteoporosis by assessment of dental radiographs already included in the dental examination. The aim of this study was therefore to investigate postmenopausal women’s preferences for an osteoporosis risk assessment in primary dental care.ResultsMost respondents (129 of 144 (90%)) were willing to pay for an osteoporosis risk assessment in primary dental care. The overall mean willingness to pay (WTP) including respondents that denoted none or zero WTP was 44.60 € (CI 95% 38.46–50.74 €) (median 34.75 €). A majority (80.6%) of the respondents that denoted WTP also gave a motivation for their answer. The two most common reasons denoted for being willing to pay for osteoporosis risk assessment were the importance of early diagnosis and preventive care to avoid fractures (41.0%) and the importance of knowledge of a risk of osteoporosis (26.4%). A majority of respondents (67.8%) considered it valuable if dental clinics would offer osteoporosis risk assessment.ConclusionsPostmenopausal women seem to find it valuable to be offered osteoporosis risk assessment in primary dental care and are willing to pay for such a risk assessment. From a societal perspective early diagnosis of osteoporosis by risk assessment in primary dental care could prevent osteoporotic related fractures and benefit women’s health and quality of life, as well as have a major impact on the health-care budget in terms of cost-savings.

Diagnostics and fracture risk prediction

Diagnostics in osteoporosis and fracture risk prediction should never rely on bone mineral density (BMD) measurements alone. Data from the National Osteoporosis Risk Assessment (NORA) in the USA revealed some 15 years ago that only 6.4% of postmenopausal women with new fragility fractures had T-scores of −2.5 or less (WHO definition of osteoporosis) in BMD tests performed one year before the event. The majority of fractures occurs in patients with osteopenia or normal BMD. Many of them are middle-aged women, 40 to 65 years old, an age group not much attended to in most studies on osteoporosis. A study on 100.000 women treated in a specialized Viennese menopause and osteoporosis clinic showed that 66.8% of patients with non-vertebral fractures were less than 65 years of age. Such results point to the urgent need of moving away from the preoccupation with BMD alone to a multi-causal risk-of-fracture approach for improving identification of women at risk. Fracture risk assessment tools as FRAX® may be of great help to ease the handling of anamnestic information, weight clinical risk factors and spot secondary causes of osteoporosis. Beside the medical history and physical examination of patients more attention should be paid to x-ray imaging of the spine for detection of vertebral fractures, which otherwise are overlooked to a great extent, to measuring muscle mass and -strength for diagnosing sarcopenia, and to laboratory tests for evaluating the impact of a wide array of diseases and functional disorders on the bone and mineral metabolism. Both, primary fracture prevention by identification of women at risk as early as age 40, and secondary prevention in patients with preexisting fractures, preferably by fracture liaison services, will be of crucial importance to avoid detrimental sequelae for the affected patients and associated costs to the health-care system.