Evaluation of bone alterations in the jaws of HIV-infected menopausal women

Caputo, Bruno Vieira; Traversa-Caputo, Gabriela Cineze; Costa, Claudio; Giovani, Elcio Magdalena; Caputo, Bruno Vieira; Traversa-Caputo, Gabriela Cineze; Costa, Claudio; Giovani, Elcio Magdalena

doi:10.1590/S1806-83242013005000014

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Brazilian Oral Research

Print version ISSN 1806-8324

Braz. oral res. vol.27 no.3 São Paulo May/June 2013 Epub Apr 19, 2013

http://dx.doi.org/10.1590/S1806-83242013005000014

Oral Diagnosis

Evaluation of bone alterations in the jaws of HIV-infected menopausal women

Bruno Vieira Caputo I, Gabriela Cineze Traversa-Caputo II, Claudio Costa III, Elcio Magdalena Giovani I

^I Center for Study and Care of Special Patients - CEAPE, Dental School, Univ Paulista - Unip, São Paulo, SP, Brazil

^II Private practice, São Paulo, SP, Brazil

^III Stomatology Department, Dental School, Univ de São Paulo, São Paulo, SP, Brazil

ABSTRACT

The advent of highly active antiretroviral therapy (HAART) has caused a reduction in mortality, thus contributing to an increase in the number of women with HIVࢧAIDS who reach the climacteric period, experience decline in ovarian function, and develop complications of viral infection and HAART, which can accelerate bone loss. The aim of this study was to detect possible alterations in the jaws of HIV-infected women by panoramic radiography. The study comprised a total of 120 women above 40 years of age who were divided into the following two groups: women who are HIV positive (Group I) and women with no known HIV infection (Group II). Measurement of the following three radiomorphometric indexes was performed by panoramic radiography: Mental Index (MI), Panoramic Mandibular Index (PMI) and Antegonial Depth (AD). A total of 70% of women in the control group and 50% of women in the HIV group were in the postmenopausal period, and the average values of both MI (p = 0.0054) and AD (p < 0.0001) for this period were lower in the HIV group than in the control group. For patients who were in the premenopausal period, the average AD was lower in the HIV group than in the control group (p = 0.0003). Despite the difference in the average age between groups, greater bone resorption in the mandible was found in the group of HIV-positive women.

Keywords: HIV; Menopause; Radiography, Panoramic; Bone Resorption

Introduction

The incidence of human immunodeficiency virus (HIV) infection is increasing among women. Over the years, the gender ratio for HIV infection has decreased gradually, and in recent years, there has also been an increase in the percentage of cases in the population over 40 years. A trend toward increased numbers of women with HIV has been observed in Brazil, and there has been an increased incidence of HIV infection among socioeconomically vulnerable populations.^¹

The advent of highly active antiretroviral therapy (HAART) has contributed to a significant increase in the life expectancy of these patients, thus providing these women with an opportunity to reach the climacteric stage. At this stage, these women experience a decline in ovarian function and may develop complications related to both HIV and HAART.^²

The menopausal period is divided into the following three phases: Premenopause begins with the decline of ovarian function, and then the phase transition (i.e., perimenopause) occurs, which is followed by menopause. Postmenopause is the period after the cessation of ovarian function, which causes a reduction in estrogen and progestin levels.^²,³

Women tend to experience a loss of bone mass at an accelerated rate after menopause; however, this demineralization in HIV-infected patients can be attributed to an important group of drugs known as antiretroviral protease inhibitors, which are known osteopenic agents. These drugs may increase the risk of bone fractures in people with HIVࢧAIDS.^⁴-⁶

The factors that may contribute to the reduction in bone density in HIV-infected women include menstrual dysfunction (hormonal imbalance), weight loss (alterations in nutritional status), decreased body mass, increased bone resorption, and Caucasian ethnicity. These risk factors are associated with an increase in the incidence of osteopenia and osteoporosis.^⁷

Bone densitometry is considered the gold standard among imaging methods used for disease diagnosis.^⁸,⁹ However, the cost and lack of access to this exam both hinder its use as a method for diagnosing the pathology. Considering this difficulty, researchers have been seeking new ways to assist in the early diagnosis of osteoporosis. Studies have shown a correlation between radiomorphometric indexes in dental radiographs and the bone mineral density of the lumbar spine, femoral neck and jaw.^¹⁰-¹³

Panoramic radiography is a low-cost exam that is routinely performed in dental clinics, and a large number of tests are performed annually to aid in the diagnosis of oral pathologies, such as dental caries. Hence, it would be beneficial if radiographs could be used to identify menopausal women with undetected osteoporosis. Dentists could evaluate the mandibular alveolar ridge and make necessary referrals for patients who require a more specific diagnosis and treatment.^¹⁴,¹⁵

The erosion in the lower jaw cortex, which is detected on panoramic radiographs, may be an important indicator for identifying older individuals or postmenopausal women with low bone mineral density.^¹⁵-¹⁷ Because of the possible alterations in bone structure of the jaws in general and especially in HIV patients who are being treated with HAART, our aim was to identify these bone alterations in women with HIV who are 40 years of age or older and are experiencing pre-, peri- or postmenopause.

Methodology

A randomized cross-sectional study of HIV-positive menopausal women who were undergoing dental care was conducted by surveying data on the signs, symptoms, and characteristics of menopause and performing an analysis of panoramic radiography. The study was approved by the Ethics Committee of Paulista University (220ࢧ10).

A total of 120 women were included in the study; they were divided into the following two groups:

Group I: Sixty women were selected from among those referred to the Center for Study and Care of Special Patients (CEAPE) at Paulista University in Brazil from June 2010 to February 2011. The inclusion criteria for this group were as follows:
- 40 years of age or older,
- experiencing at least three symptoms of menopause,
- HIV-positive status (ELISAࢧWestern blot), and
- using HAART.
Group II (control group): This group included 60 women who attended the Integrated Clinic at Paulista University in Brazil from June 2010 to February 2011 and were not HIV-positive. Inclusion criteria, which were similar to those in the other group, were as follows:
- 40 years of age or older and
- experiencing at least three symptoms of menopause.

The patients were classified based on the period of menopause according to the presence or absence of bleeding, as in the study by Ferreira et al. ^²

Panoramic radiography was performed using a Rotograph Plus^® X-ray machine (Villa Medical System, Buccinasco, Italy) with an exposure time of 16 seconds and an average increase of 25% under a working milliamperage of 10 mA and a kilovoltage of 70 kVp.

Subsequently, the subjects were scanned using a Scanner HP Scanjet G4050^® (Hewlett-Packard Development Company, L.P., Palo Alto, USA) in positive mode using the transparent materials adapter (TMA) at a resolution of 300 dpi and 100% gray-scale. The scanned image was downloaded and opened in ImageJ^® software, version 1.44 for Mac OS X operating system (Public domain image processing program, National Institutes of Health, Bethesda, USA), in which readings of the entire bone structure were taken, particularly of the trabecular bone, to observe bone integrity (or the loss thereof) and possible resorption at the points of interest. The following linear measurements were also performed:

The Mental Index (MI) ^¹⁷ is the marking of the route that parallels the lower border of the mandible and is perpendicular from the center of the mental foramen (MF) to the cortical lower jaw. This index measures the height of the mandibular inferior cortex (the normal value is greater than or equal to 3.1 mm) (Figure 1).
Antegonial Depth (AD) ^¹⁸ measures the distance along the perpendicular line from the deepest point of the concave antegonial notch depth to the lower cortical line that is parallel to the edge of the mandible (Figure 1).
The Panoramic Mandibular Index (PMI) ^¹⁹ is the ratio of the mandibular cortical thickness as measured on a line that is perpendicular to the base of the mandible, the height of the center of the mental foramen, the distance between the bottom of the mental foramen and the base of the mandible (the normal value is greater than or equal to 0.3 mm) (Figure 2).

Figure 1 A cropped panoramic radiograph showing the MI and AD measurements.

Figure 2 A cropped panoramic radiograph showing the PMI measurements (cࢧb). Lines a (parallel to the lower border of the mandible), b (distance between the bottom of the mental foramen and the base of the mandible, and c (cortical thickness).

Measurements were obtained in millimeters bilaterally. Panoramic radiographs were randomly selected from a sample to collect measurements, and a blind observer made these measurements for each group. The data were statistically analyzed such that the quantitative variables were compared between groups using Student's t-test. For the qualitative variables, we used the chi-square test of traditional homogeneity. In addition, group comparisons were performed in terms of the radiomorphometric degree indexes using the Mann-Whitney test to confirm the results. For variables with only two levels, we used Fisher's exact test, and for the other variables, we used the chi-square test. For all of the tests, the significance level was 5%.

There was intraexaminer agreement for the measurements that were repeated 14 days after the initial measurements, and the results were compared with the first measurements.

Results

There was a significant difference in the mean age of the patients between groups; the mean age of the patients in the control group was 56.1 years, and that of the patients in the HIV group was 46.9 years. Both groups were predominantly Caucasian (66.7% of the control group and 60.0% of the HIV group). There was a predominance of postmenopausal women in both groups (Table 1). There was no significant difference in any of the signs and symptoms between groups (p > 0.16).

Table 1 Prevalence (%) of menopausal symptoms according to the characteristics of the studied population.

Characteristics	Group I		Group II (control)		p
Characteristics	n	%	n	%	p
Menopause classification
Premenopause	8	13.3	10	16.7	0.0126
Perimenopause	22	36.7	8	13.3
Postmenopause	30	50	42	70
Signs and symptoms of menopause
Psychological	58	96.7	53	88.3	0.1629
Vasomotor	48	80	48	80	1.0000
Insomnia	44	73.3	40	66.7	0.4256
Genito-urinary	43	71.7	42	70	0.8408
Palpitations	24	40	24	40	1.0000
Weight gain	21	35	20	33.3	0.8474
Hormonal therapy
Yes	2	3.3	18	30	0.0001
No	58	96.7	42	70	0.0001
Prevention of bone resorption
Vitamin D	4	6.7	6	10	0.7430
Alendronate sodium	4	6.7	12	20	0.0575
Calcium	0	0	6	10	0.0274
Proper diet	4	6.7	0	0	0.1187
None	50	83.3	40	66.7	0.0350

The proportion of patients who were taking hormone replacement therapy was higher in the control group than in the HIV group (p = 0.0001). In both groups, most of the women did not engage in any type of preventive practice for osteoporosis (66.7% of women in the control group and 83.3% of women in the HIV group). In the control group, 20.0% of women were taking alendronate sodium, 10.0% of women were taking vitamin D, and 10.0% of women were taking calcium.

Regarding the HIV patients, Table 2 shows the frequency distributions of the CD4 count, viral load, and HAART variables.

Table 2 Characteristics of women according to HIV status.

Characteristics	Prevalence
Characteristics	n	%
CD4 count (cellsࢧmm³)
0–199	12	20
200–499	22	36.7
≥ 500	26	43.3
HIV status (number of copies)
Undetectable	46	76.7
0–50000	8	13.3
> 50000	6	10
HAART
NRTI	56	93.3
PI	38	63.3
NNRTI	20	33.3
II	2	3.3
CCR5 receptor	2	3.3

Table 3 shows the average results for the radiomorphometric index measures. Comparing the groups according to the stage of menopause, the AD was lower in the HIV group than in the control group (p = 0.0003) in the premenopausal period. In postmenopausal women, the values of both MI (p = 0.0054) and AD (p < 0.0001) were lower in the HIV group (Figure 3) than in the control group (Figure 4).

Figure 3 A panoramic radiograph of a 47-year-old HIV-infected postmenopausal woman with lower values of the indexes.

Figure 4 A panoramic radiograph of a 57-year-old postmenopausal woman (control group) with higher values of the indexes.

Table 3 Mean, standard deviation and p value of indexes (in mm) in patients.

Indexes	Group	Mean	SD	p
Premenopause
MI	Control	4.01	0.56	0.4349
MI	HIV	3.86	0.12	0.4349
PMI	Control	0.36	0.06	0.8882
PMI	HIV	0.36	0.06	0.8882
AD	Control	1.24	0.29	0.0003
AD	HIV	0.68	0.20	0.0003
Perimenopause
MI	Control	4.06	0.45	0.8957
MI	HIV	4.10	0.89	0.8957
PMI	Control	0.33	0.05	0.9891
PMI	HIV	0.33	0.06	0.9891
AD	Control	1.04	0.32	0.3049
AD	HIV	1.26	0.58	0.3049
Postmenopause
MI	Control	3.84	0.73	0.0054
MI	HIV	3.36	0.63	0.0054
PMI	Control	0.33	0.07	0.1723
PMI	HIV	0.31	0.06	0.1723
AD	Control	1.34	0.37	< 0.0001
AD	HIV	0.91	0.46	< 0.0001

Discussion

The results for the mean age and ethnicity were in accordance with those of another study conducted by Ferreira et al. ^² in which the authors studied women with HIV and controls. According to Kojic et al.,^²⁰ women with HIV present with early menopause (between 47 and 48 years of age), which explains the age discrepancies between the study group and the control group.

The decisions regarding the sample size accounted for the difficulty in identifying HIV-positive women who are at a more advanced age, need medical care and are willing to proceed with dental treatment. The division of the periods of menopause is in agreement with that used in previous studies.^²

A considerable number of patients (43.3%) had CD4 T counts that were equal to or greater than 500 cellsࢧmm³, while a slightly lesser number of patients (36.7%) had CD4 T counts between 200 cellsࢧmm³ and 499 cellsࢧmm³. Regarding the viral load, most of the patients had undetectable loads (76.7%), while 13.3% of the patients had a load of less than 50000 copies. The lower the cell counts of CD4 T lymphocytes circulating in the blood, the more immunocompromised the patient and the more likely it is that the patient may be affected by opportunistic infections, complications, and alterations in bone structure. These complications are likely to occur if the patient has a CD4 count below 200 cellsࢧmm³, and the CD4 count is considered an important indicator for monitoring HIV patients in general.^¹

In both groups, menopausal symptoms were mostly psychological symptoms, followed by vasomotor symptoms; this finding is in agreement with the existing literature.^²,²¹ Studies have shown that menopausal symptoms are common among HIV-infected women, even when they have not yet reached menopause. Several topics, such as the use of hormone replacement therapy by HIV-positive women, have not been discussed in the literature, but these topics have been studied in menopausal HIV-negative women.^²,²² Some authors have emphasized that middle-aged women with HIV infection have reduced bone mineral density independent of the use of HAART and that the presence of osteopenia and osteoporosis cannot be attributed solely to the use of antiretroviral therapy.^²³,²⁴

Several studies have shown that HAART may be associated with an increased prevalence of osteopenia and osteoporosis, which can increase the risk of bone fractures in people with HIV. Furthermore, protease inhibitors are known osteopenic agents; however, a more consistent link between this group of drugs and bone loss remains to be proven.^{⁴-⁶,²⁵-²⁸}

Panoramic radiography can be considered an auxiliary tool for dentists in the detection of possible alterations and bone fractures in the jaw, especially in postmenopausal women.^{¹³,¹⁴,²⁹} Measurements of MI, PMI, and AD have already been used and have been validated in the scientific literature.^{¹⁰,¹⁷-¹⁹,²⁹} In the postmenopausal subjects in this study, the values of both MI (p = 0.0054) and AD (p < 0.0001) were lower in the HIV group compared with those in the control group.

The mandibular cortical thickness below the mental foramen correlates with the mineral density of the lumbar spine and the proximal femur. A mandibular cortical thickness below the mental foramen of less than or equal to 3 millimeters could be considered a parameter for the diagnosis of low bone mineral density, and patients meeting this criterion could be referred for a bone densitometry examination. The authors also found that the low value of MI in postmenopausal women can be used to identify women with osteoporosis because this index is quantitative and has a moderate correlation with the BMD of the hip and lumbar regions, with high accuracy in intra and inter-examination.^{¹⁰,¹²,¹⁷,²⁹}

Due to the lack of related studies involving HIV patients, we do not have sufficient data with which to compare our results for the radiomorphometric indexes of the HIV group, but other studies with HIV-negative patients have found a decrease in the AD.^¹⁸,³⁰ However, a recent study reported no significant differences in the mean AD or in the gonial angles compared to the bone mineral density values of the lumbar spine and hip.^²⁹

Conclusion

Panoramic radiography was demonstrated to be an efficient method for performing jaw measurements correlated to bone density. Despite the difference in the average age between groups, greater bone resorption in the mandible was found in the group of HIV-positive women. Further studies are required to identify and establish links between HIV-infected women, HAART, and menopause.

Acknowledgements

To Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Programa de Suporte à Pós-Graduação de Instituições de Ensino Particulares (CAPES-PROSUP).

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Received: September27, , 2012; Accepted: February5, , 2013; Revised: February14, , 2013

Declaration of Interests: The authors certify that they have no commercial or associative interest that represents a conflict of interest in connection with the manuscript.

Corresponding Author: Bruno Vieira Caputo E-mail: bruvc@globo.com

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.