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Table of Contents   
ORIGINAL RESEARCH  
Year : 2019  |  Volume : 30  |  Issue : 5  |  Page : 722-730
Assessment of alveolar bone mass using radio morphometric indices in urban and rural postmenopausal women and their correlation with serum vitamin D3 level


1 Department of Oral Medicine and Radiology, Mithila Minority Dental College and Hospital, Samastipur Road, Mansukh Nagar (Ekmighat), Laheriasarai, Darbhanga, Bihar, India
2 Department of Oral Medicine and Radiology, AME's Dental College and Hospital, Bijanagera Road, Raichur, Karnataka, India
3 Department of Oral and Maxillofacial Pathology, Hi-Tech Dental College and Hospital, High Tech Hospital Road, Pandara, Rasulgarh, Bhubaneswar, Odisha, India
4 Department of Oral Medicine and Radiology, Radix Dental Care, 30/2 Fazlul Haque Sarani, Kolkata, West Bengal, India

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Date of Submission25-Apr-2018
Date of Decision01-Dec-2018
Date of Acceptance07-Jan-2019
Date of Web Publication18-Dec-2019
 

   Abstract 


Introduction: The number of women with osteoporosis i.e. with reduced bone mass and disruption of bone architecture, is increasing in India due to severe deficiency of Vitamin D. It has been reported throughout the country in urban and rural post-menopausal women. Vitamin D synthesis is affected by geographical location, atmospheric pollution, clothing, melanin pigmentation and sunlight exposure. Moreover, ageing is also associated with decreased vitamin D synthesis. Vitamin D deficiency is the most underdiagnosed medical condition in postmenopausal woman. Objective: Therefore, this study was planned to estimate and to evaluate alveolar bone mass using radio morphometric indices in postmenopausal women and its correlation with serum vitamin D3. Materials and Methods: We conducted a study comprising of a study group of 60 post-menopausal women, divided into 2 sub-groups, each group comprising of 30 individuals, depending on their occupation and domicile. Blood samples were taken to evaluate serum vitamin D3 level. Also, panoramic radiographs of all the study subjects were recorded for evaluation of 3 radio morphometric indices viz. mandibular cortical index (MCI), mental index (MI), and panoramic mandibular index (PMI). Results: Statistical analysis revealed higher significant values in rural than in urban postmenopausal woman. Conclusions: A high overall prevalence (90%) of vitamin D deficiency was also observed in the study subjects.

Keywords: Bone mineral density, osteoporosis, panoramic radiograph, ultraviolet rays, mandibular cortical index, mental index, and panoramic mandibular index

How to cite this article:
Nasreen S, Ramesh DN, Thriveni R, Bayatnal A, Chowdhury RM, Kattimani S, Saba R. Assessment of alveolar bone mass using radio morphometric indices in urban and rural postmenopausal women and their correlation with serum vitamin D3 level. Indian J Dent Res 2019;30:722-30

How to cite this URL:
Nasreen S, Ramesh DN, Thriveni R, Bayatnal A, Chowdhury RM, Kattimani S, Saba R. Assessment of alveolar bone mass using radio morphometric indices in urban and rural postmenopausal women and their correlation with serum vitamin D3 level. Indian J Dent Res [serial online] 2019 [cited 2020 Aug 5];30:722-30. Available from: http://www.ijdr.in/text.asp?2019/30/5/722/273422



   Introduction Top


Osteoporosis could be defined as a progressive systemic skeletal disorder characterized by consequent increase in bone fragility and susceptibility to fracture. Osteoporosis has a massive effect on the lives of many post-menopausal women.[1] The major risk factors for osteoporosis include smoking, alcohol consumption, physical inactivity, ageing, menopause, low calcium intake. The hormonal changes that accompany menopause are the most common cause of decrease in bone mass in woman.[2] Osteoporosis, is frequently not detected until a fracture occurs. It is considered to be a silent disease that entails significant social and economic burden. Currently, osteoporosis is considered to be a serious public health concern for elderly populations, and postmenopausal women contributes to the highest fracture risk group.[3]

According to medical terms, bone density (or bone mineral density), generally refers to the amount of mineral matter per square centimeter of bones. Bone mineral density (or BMD) is used as an indirect indicator of osteoporosis and fracture risk.[4]

Osteoporosis results in reduced jaw bone mass, as well as alterations of the mandibular structure, especially of the inferior border. The benchmark for assessment of bone mineral density is the dual energy X-ray absorptiometry (DXA). However, such a scan is difficult to use in all situations due to limitations of availability and economic factors.[5]

Panoramic radiographs are routinely used in dental practice for the diagnosis of dental pathologies. Qualitative and quantitative indices such as mandibular cortical index [MCI], mental index [MI], and panoramic mandibular index [PMI] have been used in panoramic radiographs to assess alveolar bone quality and to observe signs of resorption and osteoporosis. Cortical height on radiographs and mineral density seems to follow a similar pattern as seen in general mineral status of skeleton. Changes occurring at menopause affect the bone density as well as levels of serum Vitamin D3.[6]

The occurrence of osteoporosis in postmenopausal women is quite common in India, and its pathogenesis involves the interplay of many factors such as nutritional, environmental and genetic factors.[7] Vitamin D deficiency is rampant in India and has been reported from all over the nation in both urban and rural post-menopausal women.[8] Vitamin D insufficiency has been shown to have adverse effects on calcium metabolism, osteoblastic activity, matrix ossification, bone mineral density, and bone remodeling. Low serum vitamin D3 levels are associated with increased bone turnover, and increased risk of osteoporotic fractures.[9] Vitamin D plays a primary physiological role in maintaining extracellular calcium ion levels in the human body. Extracellular calcium is vital for the functioning of many metabolic processes and neuromuscular activities.[10]

Although vitamin D deficiency is pandemic, it ranks as the most under-diagnosed and under-treated nutritional deficiency throughout the world. Vitamin D is synthesized in the skin on exposure to Ultraviolet B rays. Sun exposure alone could be sufficient for eliminating the deficiency of Vitamin D. But, Vitamin D deficiency is widely prevalent, even though there is plentiful of sunshine in tropical countries like India.[11] In addition to the skeletal effects, it is now recognized that Vitamin D deficiency increases the risk of many chronic diseases, including cancer, autoimmune diseases, Type 2 diabetes, heart disease, hypertension, infectious diseases, osteoarthritis, as well as depression.[12]

Hence, the study was planned to estimate and to evaluate alveolar bone mass using various radiomorphometric indices and correlated to levels of serum vitamin D3 level in urban and rural postmenopausal women.


   Materials and Methods Top


This study was conducted in A.M.E Dental College and Hospital, Raichur Karnataka. A total of 60 female patients from the outpatient department of Oral Medicine and Radiology were selected for the study.

The selected sample was divided into 2 groups, each consisting of 30 individuals, depending on their occupation and domicile. It is a well-documented fact that synthesis of vitamin D3 takes place in the skin from the cholesterol metabolite 7-dehydrocholesterol under the influence of ultraviolet radiation (sun rays).

Subjects

Group I Urban post-menopausal woman

Group II –Rural postmenopausal woman

Criteria for selection of subjects are as follows:

Inclusion criteria

  • Patient willing for the study
  • Selection of urban and rural depends on occupation and domicile
  • Women in good general health, not suffering from any systemic disorder or condition were selected for the study
  • Postmenopausal women within 10 years of menopause were chosen for study
  • Dentulous patient.


Exclusion criteria

  • Patients who were unwilling
  • Subjects taking estrogen, corticosteroids, or any other therapy or suffering from parathyroid dysfunction
  • Paget's disease or any other disorder likely to affect calcium metabolism
  • Subjects on drugs that can cause increased measurements in calcium levels including calcium salts (e.g. nutritional supplements or antacids), vitamin D, lithium, thiazide diuretics, and thyroxine
  • Completely edentulous and partially edentulous patient.


Screening Examination

A detailed history was obtained for bone pain and weakness, and thorough screening examination was performed for proximal muscle weakness (difficulty in climbing stairs, inability to rise from squatting position). History of bone tenderness for each subject included menstrual history (also including years since menopause).

Assessment of radio morphometric indices

Digital panoramic radiographs were taken for all the study subjects using (PLANMECA 2006 75 KV and 10 Ma) and standard specifications for patient positioning which involves positioning the mid-sagittal plane laser beam for a central alignment, the Frankfort plane positioning laser beam for a Frankfort plane alignment, the canine plane positioning laser for a canine alignment.

Equipment used for panoramic radiography

  • Digital panoramic images were obtained using PLANMECA 2006
  • Lead apron.


The exposure parameters were as follows:

  • Total exposure time: 13.89 sec
  • Magnification factor: 1.27 (±10%)
  • Default KvP factor: 75 mv
  • Current: 10 mA.


The films were digitally processed after the completion of exposure cycle using DRY STAR DIGITAL PRINTER.

Measurement of radio morphometric indices

  • Equipment used for assessment of radio morphometric indices
  • Millimeter metallic scale
  • 0.7 mm diameter lead pencil
  • X-Ray viewer
  • 36- Matte acetate tracing paper
  • Divider.


All the digital panoramic radiographs were viewed on a flat viewing box under dim lighting. The landmarks were traced on a 36-Matte acetate tracing sheet. Measurement of each index was made bilaterally on both sides. Linear measurements were performed using a scale and divider.

The following indices were analyzed:

Qualitative index

Mandibular cortical index

MCI refers to the inferior mandibular cortical thickness and is categorized into three groups according to the criteria described by Klemetti et al.[13]

The index was used to assess the appearance of inferior cortex of mandible.

The inferior cortex of mandible is classified as:

C1: The endosteal margin of the cortex is even and sharp [Figure 1]

C2: The endosteal margin presents semilunar defects (lacunar resorption) or appears to form endosteal cortical residues; [Figure 2] or

C3: The cortical layer forms heavy cortical residues and is clearly porous [Figure 3].
Figure 1: C1 Category

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Figure 2: C2 Category

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Figure 3: C3 Category

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Quantitative indices

Mental index

This index was used to measure cortical width at the mental foramen region. MI is the measurement of the cortical width at the mental foramen region and is assessed according to the technique described by Ledgerton et al.[14] Accordingly, the mental foramen was identified and a line was traced that passed perpendicular to the tangent of the lower border of the mandible and through the center of the mental foramen bilaterally and an average was taken as a final measurement. The cortical width was measured at this point. [Figure 4]
Figure 4: Calculation of MI

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Panoramic mandibular index

The inferior PMI as described by Benson et al.[15] is the ratio of the thickness of mandibular cortex to the distance between the mental foramen and the inferior mandibular cortex.

Two measurements were made: one from the superior border of mental foramen to the inferior border of mandible, and the other from the inferior border of the mental foramen to the inferior border of mandible and an average was taken as the final measurement (h) [Figure 5].
Figure 5: Calculation of PMI

Click here to view


The ratio was measured using this final bilateral value.

Measurement of serum vitamin D3 level

Collection of blood sample

5 ml of blood was collected from each subject by using standard venipuncture technique in aseptic conditions. Blood was collected in a test tube, and after clotting it was centrifuged and sent to the laboratory for further measurement of Vitamin D3 levels, which was estimated by Chemiluminiscence method.


   Results and Observation Top


This study was conducted to assess alveolar bone mass using radiomorphometric indices in postmenopausal women and correlation with vitamin D3.

A total of 60 postmenopausal women who met the inclusion criteria were selected from the outpatient department over a period of two years. An information sheet was provided and an informed consent (Annexure I) was obtained from both study subjects.

Group I – Urban post-menopausal woman

Group II –Rural postmenopausal woman

After recording the detailed medical history, the duration since the onset of menopause was noted; it ranged between 5–10 years. For all the subjects, panoramic radiographs were taken, after tracing of major landmarks, three radio morphometric measurements were calculated. One qualitative index namely mandibular cortical index [MCI] and two quantitative indices viz. mental index [MI] and panoramic mandibular index [PMI] were measured.

Blood samples of 5 ml were taken through standard venipuncture technique to evaluate serum vitamin D3 level and comparison made between both urban and rural patients [Table 1].
Table 1: Comparison of [Mean (SD)] of Vitamin D3 levels among both the groups using unpaired t-test

Click here to view


Quantitative indices

Panoramic mandibular index

Mean value of panoramic mandibular index (PMI) in group I was 0.24 and mean value of panoramic mandibular index (PMI) in group II was 0.32.

Comparison was done by using unpaired t test. It was found to be highly significant and t value was found to be 6.00 and P value <0.001 [Table 2].
Table 2: Comparison of [Mean (SD)] of panoramic mandibular index (PMI) among both the groups using unpaired t-test

Click here to view


Mental index

Mean value of mental index (MI) in group I was 2.88 and mean value of mental index (MI) in group II was 3.82.

Comparison was done by using unpaired t test. It was found to be highly significant and t value was found to be 6.417 and P value < 0.001 [Table 3].
Table 3: Comparison of [Mean (SD)] of mental index (MI) among both the groups using unpaired t-test

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Mean value of vitamin D3 levels in urban, population group was estimated to be 11.93 and that of rural population was 28.59.

Comparison was done by using unpaired t test. It was found to be highly significant, t value is 9.690 and P value is < 0.001 [Table 4].
Table 4: Cross tabulation of both the groups with lower border cortex of the mandible as viewed on panoramicradiographs

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Qualitative index

Mandibular cortical index

When the mandibular cortical indices were assessed, it was found that among the study subjects with urban group I, out of 30 subjects none (0.0%) subjects in the C1 category, 12 (40.0%) subjects were in C2 category and 18 (60.0%) subjects in the C3 category. Amongst the rural group II out of 30 subjects 14 (46.7%) subjects in the C1 category, 13 (43.3%) subjects in the C2 category, and 3 (10%) subjects to the C3 category.

The comparison was done by chi square test and high significant difference was found between their indices P < 0.001. χ2, Chi square test: 24.754 [Table 5]
Table 5: Area Under the Curve

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Sensitivity and Specificity analysis [Table 5] and [Table 6] with Charts 1 and 2 respectively]

Based on the above statistical results, the sensitivity and specificity of the significant indices was determined and receiver operator curve (ROC) was plotted to determine the cutoff value for each of these indices {Co-ordinates of ROC-PMI and MI-Annexure 3}. The sensitivity and specificity of panoramic mandibular index was 90% and 100% respectively at PMI value of 0.176 and the P value was 0.000. For the Mental index, the sensitivity and specificity values are 90% and 100% respectively at a MI value of 2.025 and P value was 0.00. These were highly significant.
Table 6: Area Under the Curve

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Correlation between alveolar bone mass [PMI, MI] and serum vitamin D3

Correlations in group I [Table 7] and [Table 8]
Table 7: Correlations in group I

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Table 8: Correlation in group I, Mental Index (Urban)

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Pearson's correlation coefficient revealed there was a positive correlation between PMI and Vitamin D3, MI and vitamin D3, but there were not statistically significant.

Correlations in group II [Table 9] and [Table 10]
Table 9: Correlations in group II

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Table 10: Correlation in group II, Mental Index (Rural)

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Pearson's correlation coefficient revealed there were a negative correlation between MI and vitamin D3, PMI and vitamin D3 was not statistically significant.

According to the definition of the World Health Organization (WHO) formulated in 1994, osteoporosis is a systemic disease characterized by low bone mineral density (BMD), deterioration of bone structure and increased bone fragility.[16]


   Discussion Top


In India one out of eight males, and one out of three females suffer from osteoporosis, making India one of the largest affected countries in the world.[17]

Osteoporosis is a global health issue that is common in both developed and developing countries. It is characterized by loss of bone density causing skeletal weakness, which is associated with high mortality in older adults. Since the older adult population is predicted to increase by more than two-fold over the next 25 years, consideration of osteoporotic fractures is important for future healthcare planning.[18]

Various methods have been used to assess bone density. These include Single Photon Absorptiometry, Dual Photon Absorptiometry, Dual Energy X-Ray Absorptiometry and Quantitative Computed Tomography. All these techniques use ionizing radiations to measure bone mineral density (BMD). Quantitative Ultrasound uses sound waves rather than ionizing radiation to assess properties of bone that are related to density and bone strength and it is noninvasive. The gold standard for the assessment of bone mineral density is Dual Energy X-Ray Absorptiometry.[19]

The aim of the present study was to assess alveolar bone mass using radiomorphometric indices in both urban and rural postmenopausal women and their correlation with Vitamin D3 level.

In the present study three radiomorphometric indices were measured viz. PMI, MI and MCI.

The study revealed that the mean values of PMI decrease as the age of the subject increases and within groups the highest mean value [0.32] was observed in group II and the lowest value in Group I [0.24], also a highly statistically significant difference among both these groups were noted.

These results were similar to those carried out by C S Valerio et al. (2013) wherein the morphology of the mandibular cortex was evaluated using the mandibular cortical index (MCI) and the inferior mandibular cortex width was evaluated using the mental index (MI) in 64 female patients who had undergone dual energy X-ray absorptiometry assessment, and the authors concluded that there were significant differences between the normal and lower bone mineral density groups (osteopenia and osteoporosis) for MCI (P < 0.01).[17]

In the present study, when visual estimation of the width of the mandibular cortex was assessed, the following results were amongst the subjects with urban and rural postmenopausal woman. In urban postmenopausal women out of 30 subjects no (0.0%) subject showed a maximum thickness C1 of the mandibular cortex, 12 (40%) subjects had C2 intermediate mandibular cortical thickness and 18 (60%) subjects C3 showed thin mandibular cortical thickness and in the rural postmenopausal women out of 30 subjects, 14 (46.7%) had maximum mandibular cortical thickness C1, 13 (43.3%) subjects had intermediate mandibular cortical thickness C2 and 3 (10%) subjects had thin mandibular cortical thickness C3.

In the present study, there was a highly statistically significant correlation between visual estimation of the width of the mandibular cortex and the BMD. This result was identical to a research which documented that the bone mineral density determined at different sites was significantly lower in patients with thinning and resorption of mandibular cortex identified by the visual estimation of the width of the mandibular cortex. (P < 0.05).[20]

A study to evaluate the significance of panoramic radiomorphometric indices (mandibular cortical index [MCI], mental index [MI] and panoramic mandibular index [PMI]) as useful tools for identifying osteoporosis was done by Mansour et al. (2013) which concluded that Panoramic indices (MI, PMI, and MCI) were positively correlated with the t score and BMD of the lumbar spine and the MCI was found to be the most reproducible index.[19] Similar results are evident from the present study which emphasizes the alveolar bone mass loss identified by all the three indices (i.e) PMI, MI, MCI with a statistical significant difference.

Klemetti had first proposed the mandibular cortical index. He suggested that a thin or eroded inferior cortex of the mandible detected on dental panoramic radiographs, an indicator of alterations of the mandible, is useful for identifying postmenopausal women with undetected low skeletal BMD or osteoporosis.[11] In the present study when the MCI was evaluated, it was found that C1 category was highest in group II (postmenopausal women of rural region) followed by a highly statistically significant difference among the two groups urban and rural postmenopausal woman [P value <0.001]. These are identical to the results of a study by A Taguchi et al. (2008), in which the authors evaluated the detection of an eroded mandibular cortex on panoramic radiographs and questionnaire-based screening tools as diagnostic efficacies for identifying osteoporosis in post-menopausal women and they concluded that panoramic radiography is superior to questionnaire-based screening for identifying women who are at high risk of fracture.[21]

In the present study when the vitamin D3 level was evaluated in rural and urban postmenopausal woman it was found that vitamin D3 level was better in rural group II than urban group I, which was highly significant (P value <0.001) in rural group than urban.

These are similar to the results of a study by Agarwal N et al. (2013),

in which authors evaluated a significant urban and rural difference that was seen in the serum level of 25(OH) D but despite long hours of sun exposure, the rural population is also deficient.[7]

In a study conducted was by Chailurkit LO in 2011, both lifestyle and environmental factors are important determinants of serum 25(OH) D concentration because of their relationship to ultraviolet exposure. A difference in vitamin D status between populations in rural and urban areas was clearly demonstrated. Lower vitamin D levels in the urban populations were evident in almost all geographical regions of Thailand. Although, a number of studies have investigated the vitamin D status of urban or rural residents, the disparity in vitamin D status between rural and urban populations has been investigated less often; but existing studies have generally shown lower vitamin D reserves among urban populations.[20]

Renvert et al. (2011) evaluated the mandibular cortex in the panoramic radiographs of 778 individuals (53% women) in the age of 59-96 years. The researchers observed the endosteal margin of the mandibular cortical bone, if presented in full or image, showed lacunar resorption and related to BMD previously assessed by DXA. The results were significant, with relationship between low BMD and lacunar resorption in mandibular cortical bone.[22]

The present study showed significant correlation between MCI and BMD and demonstrated that none of the patients with osteoporosis was classified as C1 and there was a prevalence of C3 (60%) in group 1.

Musa Nurbazlin et al. (2013) reported a significant difference in mean 25(OH) vitamin D concentrations between urban and rural subjects and reported that rural subjects had higher 25(OH) vitamin D concentrations compared to that of urban subjects.[23] In this present study too, rural subjects had higher vitamin D3 levels than urban subjects.

In present study, among rural subjects, one subject was normal, 29 subjects had vitamin D deficiency and among urban subjects, two were deficient, and 28 subjects were insufficient similar to a study conducted by C. V Harinarayan et al. (2007) in the rural subjects, vitamin D –deficient, -insufficient, and sufficient states were observed in 44% 39.5% and 16.5% of the men and 70%, 29%, and 1% of the woman, respectively. In the urban subjects, vitamin D deficient, -insufficient, and –sufficient states were observed in 62%, 26%, and 12% of the men and 75%, 19% and 6% of the woman respectively.[24]

MI (Mental Index) is measurement of the cortical width at the mental foramen region, as described by Ledgerton et al.[12] A study done by Egle jagelavince et al. (2016), evaluating the relationship between panoramic radiomorphometric indices of the mandible and calcaneus [heel bone] bone mineral density in postmenopausal women revealed that a statistically significant correlation was found between the mental index and bone mineral density in the calcaneus (r = 0.356, P < 0.001) and between the panoramic mandibular index and bone mineral density in the calcaneus (r = 0.397, P < 0.001).[25] These findings are similar to present study in which MI and PMI measured alveolar bone loss to be highly statistically significant in both the groups and the correlation between MI and PMI with serum VitaminD3 levels was positive correlation in group I (urban).

In the present study, Pearson's coefficient found a positive correlation between alveolar bone mass and vitamin D3 in urban postmenopausal group and negative correlation between alveolar bone and vitamin D3 in rural postmenopausal woman and was not statistically significant. A similar study by Amitha Ramesh et al. (2011),

Pearson's correlation coefficient did not reveal any statistically significant relationship between alveolar bone mass and serum calcium.[5] A study conducted by M Beg et al., (2014) also showed a positive correlation between vitamin D and bone mineral density, although the relation was not statistically significant.[1]

Rachna B et al. (2015) reported similar to present study Urban subjects had significantly higher prevalence of insufficient 25(OH) D levels compared to their rural counterparts (94.12% vs 81.25% with P < 0.05). It could perhaps be attributed to a greater exposure to sunlight in the rural as compared to urban areas. Also, there is a greater tendency among urbanites to use protective sunscreens which could prevent vitamin D synthesis by UV light.[26]

The present study evaluates panoramic radiographs by morphometric indices and correlates its findings to the serum vitamin D3 level.


   Conclusion Top


This study shows that panoramic radiography could be used as a screening tool for detection of osteoporosis by using various radiomorphometric indices and could also be used to assess the sensitivity and specificity of the individual panoramic radiomorphometric indices in the screening of osteoporosis. Comparison of osteoporosis among post-menopausal women in rural and urban areas as well as estimation of levels of vitamin D3 along with direct information on the role of vitamin D3 and sun exposure could be deduced from this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Correspondence Address:
Dr. Ripon Md Chowdhury
Department of Oral and Maxillofacial Pathology, Hi-Tech Dental College and Hospital, High Tech Hospital Road, Pandara, Rasulgarh, Bhubaneswar, Odisha - 751 025
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdr.IJDR_369_18

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