**4.1 Materials and methods**

Orthopantomographs (OPG X-rays) of a total of 64 patients who visited the Department of Periodontology in the month of February–March, 2020 were recruited from the records, in order to evaluate the interproximal alveolar bone loss and potential explanatory variables including age, gender and number of sites. Panoramic views were obtained using Planmeca 2002 CC Proline with Dimax 3, Panoramic digital X-ray unit (60 KV and 20 mA), 1.2 magnification ratios. The scanned version of OPG X-ray films were analyzed with the help of a publicly available free online image assessment tool viz. Image J. It is a Java-based image processing program developed at the National Institutes of Health and the Laboratory for Optical and Computational Instrumentation (LOCI, University of Wisconsin) [163, 164].

A digital method of estimating alveolar bone height on panoramic radiographs using 3X magnification was employed using constant anatomic landmarks as reference points - CEJ and alveolar crest as shown in **Figures 6** and **7**.

**Figure 6.** *Digital OPG X-ray image.*

**Figure 7.** *Method of estimating alveolar bone height on panoramic radiographs using image analysis software.*

*Gender-Associated Oral and Periodontal Health Based on Retrospective Panoramic… DOI: http://dx.doi.org/10.5772/intechopen.93695*

Bone loss was considered when the distance from the CEJ to the alveolar crest exceeded 2 mm. Radiographic images was interpreted by a single calibrated examiner in order to reduce variability in image assessment and recording of data. Distorted, overlapped, unclear images particularly at the maxillary and mandibular anterior region or patients with orthodontic appliances were excluded for evaluation. Bone loss was estimated digitally by measuring the distance between CEJ and alveolar crest at the interproximal areas minus 2 mm (physiologic high of interseptal alveolar crest) at sites with reduced normal level of interseptal bone. The data so collected was put to appropriate descriptive and inferential statistics. Student, s T test and Mann Whitney test was used to intercept the differences in the mean of normal and skewed data parameters for different categories resp. Further, odds ratio was calculated to predict the future bone loss trends for patients with existing periodontal bone loss based on the no. of sites involved in bone loss.

#### **4.2 Results**

The collected OPG X-rays were categorized according to age and gender based on the accompanying clinical history recording and it was observed that there were OPGs from 30 females and 34 males and 11 subjects were below 30 years of age and 53 were above 30 years of age (**Table 1**).

**Table 2** demonstrates the mean age and the distribution of bone loss patterns in total study population based on different defined categories of the bone loss providing mean no. of bone loss sites, along with the observed range in each category. As the study population was chronic periodontitis patients, all radiographic images showed evidence of bone loss at one or more than one site. Overall, 17 sites of bone loss were observed as an average no. of bone loss sites in the total population. Similarly, a mean value of 9.69 and 7.50 was observed for horizontal and vertical kind of bone loss sites in all population. The no. of bone loss sites extended to coronal, middle third and apical third of the root surface revealed a mean score of 3.11, 11.45, and 2.52 per individual, respectively (**Table 1**).

**Tables 3** and **4** reveals comparative analysis of gender and age based distribution of total no. of bone loss sites in the total study population in current study. According to the gender, there was not observed any statistically significant difference in the total no. of bone loss sites, whereas there existed significant difference in the total no. of bone loss sites as per age.

**Tables 5** and **6** reveals genderwise distribution of no. of bone loss site based on categories and its comparatives analysis, respectively. None of the categories revealed statistically significant difference in the no. of bone loss sites between males and females. Similarly, **Tables 7** and **8** reveals agewise distribution of no. of bone loss site based on categories and its comparatives analysis, respectively. Statistically significant difference in the no. of bone loss sites between males and


#### **Table 1.**

*Distribution of study participants based on categories.*

#### *Clinical Concepts and Practical Management Techniques in Dentistry*


**Table 2.**

*Distribution of study parameters in total study population based on different categories.*


#### **Table 3.**

*Comparative analysis of gender based distribution of total No. of bone loss sites in study population.*


#### **Table 4.**

*Comparative analysis of age-based distribution of total No. of bone loss sites in study population.*

females in the category of subjects with bone loss extending to middle third of the root, whereas none of the categories revealed statistically significant difference in the no. of bone loss sites between subjects above and below 30 years of age.

Further, a risk estimate analysis based on both age and gender as risk factors was carried out for prediction of future susceptibility of bone loss by calculating Odds ratio s, which revealed age of the individual as a significant risk determinant for the same (**Tables 9** and **10**).

#### **4.3 Discussion**

Gender has been implicated as a risk factor for many human diseases particularly rooted in chronic diseases, where disease pathogenesis is impacted significantly by immune mechanisms of the body including periodontal disease [165, 166]. The findings from the present case study revealed the presence of bone loss in all study participants which is indicative of the fact that periodontal bone loss is the hallmark of chronic periodontal disease. On average, 17 sites with bone loss were found to be


*Gender-Associated Oral and Periodontal Health Based on Retrospective Panoramic… DOI: http://dx.doi.org/10.5772/intechopen.93695*

#### **Table 5.**

*Genderwise distribution of No. of bone loss site based on categories.*


#### **Table 6.**

*Comparative analysis of genderwise distribution of No. of bone loss site based on categories.*

present across the study population. Horizontal bone loss was more prevalent than the vertical bone loss, which is again in sync with the existing knowledge regarding the periodontal bone loss patterns. Most patients suffered from moderate periodontitis in terms of the severity of bone loss as maximum sites in population revealed bone loss extending up to the middle third of the root surface. With the new 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Condition as a reference, the majority study population falls under the Stage III periodontitis category based on the residual bone level criteria for categorization [167]. Further, there was observed no statistically significant difference in the total number of bone loss sites based on gender, but there existed a significant difference in the total number of bone loss sites as per age in the study population. A statistically significant difference in the number of bone loss sites between males and females in the category of subjects with bone loss extending to the middle third of the root are also revealed, but neither of the other two categories based on age nor all categories based on gender witnessed any statistically significant differences in terms of the number of bone loss sites varied according to the severity of the bone loss.

#### *Clinical Concepts and Practical Management Techniques in Dentistry*


#### **Table 7.**

*Agewise distribution of No. of bone loss site based on categories.*


#### **Table 8.**

*Comparative analysis of agewise distribution of No. of bone loss site based on categories.*

Previous literature has also reported that there was no significant sex difference. Gender is inherently a very complex risk factor that may play a role through diverse mechanisms as discussed in earlier sections. Premenopausal women exhibit the lower prevalence of periodontitis as compared with men and on contrary, after menopause, with a weakening estrogen signal, women may show equal or even greater periodontal destruction as compared to age matched men [168]. Wulandari et al. reported no difference in periodontal severity between perimenopausal and postmenopausal women, however, emphasized the role of the bacterial plaque regarding periodontal disease severity in perimenopausal and postmenopausal women in a cross-sectional investigation in 63 subjects, aged 45–59 years, in East Jakarta [169]. Paramashivaiah et al. examined 104 postmenopausal women, agegroup ranging from 35 to 60 years, and reported radiographic alveolar bone loss correlated with clinical indicators including attachment loss. Most females had periodontitis and low serum 17-β estradiol and calcium levels [170]. Lee et al. indicated an association between hormone replacement therapy (HRT) and periodontal disease, after adjusting for various potential confounders for periodontal diseases. The authors showed that the HRT+ group was less likely to develop periodontal diseases

*Gender-Associated Oral and Periodontal Health Based on Retrospective Panoramic… DOI: http://dx.doi.org/10.5772/intechopen.93695*


### **Table 9.**

*Risk estimate of bone loss based on gender as a risk determinant.*


#### **Table 10.**

*Risk estimate of bone loss based on age as a risk determinant.*

than the HRT- group upon analysis of 45 and 74years old menopausal women [171]. Another study by Pizzo et al. in 91 Italian menopausal women (50 ~ 62years) reported similar periodontal pocket depths between the group who underwent HRT and who did not, but the group without HRT had a higher level of dental plaque [172]. López-Marcos et al. [173] studied in 210 Spanish menopausal women aged 40–58years that the estrogen patch group showed a reduction in periodontal pocket depth. People with a longer menopausal period and lower bone mass more evidently witnessed the effects of esterogen deficiency [174, 175]. The authors recommend that the studies aimed at a clear delineation of the role of gender as a risk factor should rather be more meticulously designed in terms of studying the role of gender in differential age-groups, larger study samples, and well-designed investigations as females undergo specific periods of hormonal fluctuations according to the stage of their reproductive life cycle.

A study was conducted by Wouters et al. in 1989 in 733 randomly selected dentate individuals aged 20 years and above using periapical radiographs with interproximal intrabony periodontal defect depth and width of at least 5 and 10 mm, respectively, to determine the relationship between the prevalence of interproximal periodontal intrabony defect and age. It was reported that the prevalence increased with age and was higher in men than in women [168]. However, the significantly lower prevalence of interproximal periodontal intrabony defect in women than in men does not support the studies of Nielsen et al. [176], in which no significant sex differences were reported [177]. The present study findings still need to compare with caution as it differed in the X-ray images taken as reference was OPGs of the study subjects. So the differences in study settings, design and tools may also be responsible for the observed heterogeneity in study results.

A higher incidence of bone loss in adult patients (24–30 years old) is a fact, that periodontitis is an age dependent disease the incidence and severity of bone loss and attachment loss increase with age (16) as a result of longer exposure to local factors as age grows older. The present study revealed a nonsignificantly higher prevalence of bone loss among females than males, and the authors attributed these findings to a higher prevalence of aggressive periodontitis among females rather than males [178].

Khateeb et al. carried out an investigation in a total of 190 female patients (mean age, 22.4 ± 2.46 years) and Patients' age was found to be a good predictor for alveolar bone loss and number of periapical lesions (P ≤ 0.05) [179]. Another study from China revealed that 40–59-year-old patients with chronic periodontitis had severe bone loss. And a lesser degree of alveolar bone loss was seen in males than females [179]. Menopause in females and smoking in both genders may have affected the level of bone loss. Male smokers experienced a greater degree of bone loss (41.67 ± 5.76%) than male non-smokers (32.95 ± 4.31%). A 42.23 ± 6.34% bone loss was found in menopausal females versus 31.35 ± 3.62% in non-menopausal females [180].

Bansal M et al. (2015) [181], in a cross-sectional prevalence study among hospital-based Indian population, assessed the prevalence of the periodontal disease. They stated that healthy periodontium was found in 19 (3.9%) subjects with the highest percentage in the 15–19 years age-groups and after 44 years no person had healthy teeth. Also, advanced stages were more prevalent in older age-groups, deep pockets occurring in 87 (17.90%) subjects that increased as the age advanced up to 45–54. According to them, males were more affected with moderate and severe periodontitis as compared to females. Bokhari et al. (2015) [28], reported that subjects aged 40 years and above were four times more likely to have periodontitis using Community Periodontal Index (CPI) methods. Marya, CM, et al. (2020) [182], in a cross sectional study assessed if there are any gender differences in oral health-related quality of life (OHRQoL) among the elderly population of Haryana. Genderwise, no significant association was found with different parameters of periodontitis. They found a significant association of OHRQoL with the main factor causing periodontal problems, that is, mobile teeth and no comparable difference

was observed in the OHRQoL among males and females. They suggested one needs to target the geriatric population as a whole for planning and implementing public oral health strategies.
