Preface

Osteoporosis is a significant social health problem, not only in terms of pain and disability but also in terms of mortality rate. Osteoporosis affects approximately 200 million people worldwide, with nearly 9 million fractures occurring annually.

This disease is defined by a generalized and progressive reduction in both bone mineral and bone matrix, which results in a bone of normal composition but decreased mass. Functionally, osteoporotic bone is characterized by greater fragility and an increased propensity to fracture. Osteoporosis ranks as the most common metabolic bone disease and the most common skeletal disorder in the world. As such, it constitutes a major public health problem. Despite heightened awareness among patients and clinicians alike, and the availability of efficacious anti-osteoporosis medications, osteoporosis is still underdiagnosed and undertreated.

Metabolic syndrome, together with major obesity and diabetes mellitus, is associated with osteoporosis, and all of these conditions have become major global health problems over the last decades. The interaction between obesity and bone metabolism is complex and not fully understood. Several mechanical, biochemical, and hormonal mechanisms have been proposed to explain the association between adipose tissue and bone. Low-grade systemic inflammation is probably harmful to the bone and increased bone marrow adipogenesis may lead to decreased bone mass in obese individuals.

A better understanding of the association between adipose and bone tissue may help to identify new molecular therapeutic targets that will promote osteoblastic activity and/or inhibit adipogenesis and osteoclastic activity. An analysis of the medical literature shows clearly that male osteoporosis is underscreened, underdiagnosed, and undertreated, both in primary and secondary prevention of fragility fractures.

In the introductory chapter, Dr. Rodrigo provides an update on the state of the art of osteoporosis in clinical practice.

The next chapter describes glucocorticoid-induced osteoporosis. It examines its main characteristics, frequency, and treatment and prevention options.

The next chapter examines the relationship between osteoporosis and diet. The authors comment on the role of inflammatory factors in food and they recommend the consumption of an anti-inflammatory diet to treat and prevent osteoporosis.

In the next chapter, the authors describe the diverse factors that can contribute to osteoporosis with an emphasis on the disease's multifactorial nature and therapeutic consequences.

The routine study of the dental maxillofacial complex including the performance of panoramic radiological pictures is a good method for detection of osteoporosis in early-stage and helps to stop its progression for the rest of bone structures of the body. This is described in the last chapter.

One interesting and sometimes forgotten aspect is the effect of osteoporosis on the dento-maxillofacial complex. In this case, panoramic radiographies can be used for the evaluation of healthy dental structure and maintenance.

Osteoporosis is called the 'silent disease' because although it does not give significant symptoms when it is not complicated, it can cause fragility fractures with serious consequences and even death. Furthermore, the consequences of osteoporosis have been calculated to weigh heavily on the costs of health systems in all countries. Osteoporosis is considered a female disease. The hormonal changes that occur after menopause certainly contribute to a significant risk of osteoporosis and fractures in women. However, while there is no doubt that women are more exposed to osteoporosis and fragility fractures, the literature clearly indicates that physicians tend to underestimate osteoporosis in men.

Bisphosphonates are standard medicine for the treatment of osteoporosis and have been innovated to overcome complicated rules for their appropriate administration or poor intestinal absorption. Weekly, as well as monthly oral bisphosphonates, are available. Furthermore, we are now allowed to choose intravenous administration of bisphosphonates for osteoporosis. Good persistence and adherence are critical and essential issues to address to achieve the aim of osteoporosis treatment with bisphosphonates. Variable formulations of bisphosphonate are now able to bring patients closer to reduced rates of fragile fracture due to osteoporosis.

Detection of osteoporosis, as a multifactorial disease, and its clinical consequence of bone fracture, has been the subject of extensive research. Recent advances in machine learning have enabled the field of artificial intelligence to make impressive breakthroughs in complex data environments where the human capacity to identify high-dimensional relationships is limited. The field of osteoporosis is one such domain, notwithstanding technical and clinical concerns regarding the application of electronic methods.

> **Luis Rodrigo MD** Professor of Medicine, University of Oviedo, Oviedo, Asturias, Spain

> > **1**

**Chapter 1**

*Luis Rodrigo*

**1. Introduction**

of life.

tal factors are involved in their onset [1].

acidosis. Some epigenetic factors can be associated [2].

Introductory Chapter:

Osteoporosis Overview

Osteoporosis is a skeletal disease, characterized by a thinning of the bone (loss of bone mass), accompanied by a deterioration of its internal architecture that compromises its resistance, producing a greater fragility of the bones and an increased risk of fractures. The most affected bones are especially those of the spine and hip, although any bone in the body can be involved. As the main risk factor for suffering bone fragility fractures, which increases with age, it is an important public health problem that has undoubted social, health and economic repercussions; but above all it causes pain, functional limitation and severe alteration in people's quality

The World Health Organization (WHO) defines it mainly in women as "the presence of a bone mineral density (BMD) less than or equal to 2.5 standard deviations below the average bone mass of healthy 20-year-olds", which is carried performed using a specific radiological test, called bone mineral densitometry. Since bone loss often occurs without symptoms, osteoporosis is often considered a "silent disease" that can occur in both sexes and increases with age. As bone tissue deteriorates, together with the architecture changes, the bone becomes so weak, that a relatively minor bump or fall, causes a vertebra to fracture or break. That is, the clinical manifestations of osteoporosis appear as a consequence of its complications, which are spontaneous fractures or after minimal trauma. Many environmen-

However, there is a risk of considering that the loss of bone mass, causes only musculoskeletal pain. Women are more susceptible to suffering from bone fractures, as direct consequences of this disease, due to the fact that faced with a calcium deficiency in the diet, together with a vitamin D deficiency, during pregnancy and lactation, the body goes to diminish the reserves of calcium in the bone, which is the cause of gradual loss of bone mass. For this reason, its appearance is later and more frequently in amenorrheic or post-menopausal women, who also have a decrease in the production of estrogens by the ovaries and other hormonal deficiencies that affect metabolism in the bone. Factors that increase the risk of developing osteoporosis are calcium and vitamin D deficiencies due to malnutrition, sedentary life or lack of physical activity, and tobacco and/or alcohol consumption. Other secondary causes have been reported, such as celiac disease, monoclonal gammopathy of uncertain origin, chronic renal failure, diabetes mellitus, and renal tubular

The best strategy for treating osteoporosis, is the prevention. Bone, or bone tissue, is a very dynamic living tissue throughout life, which is constantly formed (ossification), grows and remodels (bone turnover). For these processes (formation, growth and remodeling), important for the integrity or strength of the bone, hormonal activities, certain nutrients (calcium, phosphorus, magnesium,

#### **Chapter 1**
