Patients’ thoughts about assessment of fracture risk in a dental setting using FRAX—a qualitative interview study

Fragility fractures, i.e. fractures of the hip, wrist, upper arm, and pelvis, are associated with frailty in older persons and can result in the need for extensive care, a place in a nursing home and even death. Sweden has among the highest incidences of fragility fractures in the world, but many of them could be prevented with medication and fall-preventive measures if the persons with high risk are identified [1]. The most common method of identifying persons with a high risk of sustaining fragility fractures is the FRAX tool [2]. It is a validated instrument based on large cohorts from different countries used to assess the risk of fragility fracture within 10 years [3]. It uses an algorithm including risk factors such as age, sex, BMI, previous fractures, heredity, and smoking. The FRAX risk score can be used to guide health care if further handling of the patient is needed. For example, the Swedish National Board of Health and Welfare recommends antiresorptive medication if the FRAX risk score of a major osteoporotic fracture exceeds 30% [4].

FRAX has been used in a dental setting in previous studies but only to find associations with dental diagnoses. The association between osteoporosis and dental health has been studied from different angles, with or without using FRAX. Several studies have focused on the association between chronic periodontitis and osteoporosis, and systematic reviews indicate that postmenopausal women with osteopenia or osteoporosis have more severe periodontitis [5, 6]. Higher FRAX scores have been associated with impaired periodontal status in postmenopausal women [7], and Penoni et al. also found in a later study that periodontal disease was not a predictor for osteoporosis, although FRAX was “a useful tool to suggest periodontal evaluation” [8]. In another study, Priebe et al. found an association between the number of missing teeth, hip fractures, and a FRAX assessment of fracture risk [9].

In the Nordic countries, most of the adult population has regular contact with their dentist, which could be used to try to prevent fragility fractures in connection with a scheduled check-up. Features on dental radiographs, such as the trabecular pattern and width of the mandibular cortex, are associated with low bone mass density (BMD), and these have been suggested as useful for finding patients at risk of fragility fractures. Intraoral radiographs have been used for both visual and semi-automated assessments of the trabecular pattern of the mandibular bone [10‐12]. The visual method is operator dependent and requires careful calibration, and there is no semi- or automated method that uses intraoral radiographs with sufficient scientific evidence to justify individual risk assessment [13]. Studies using panoramic radiographs have included different aspects of the morphology of the mandible, such as the cortical width and porosity, and trabecular structure, often using different indexes, to identify patients with a higher risk of osteoporosis or fragility fracture [14‐17]. However, panoramic radiographs are not available in all dental clinics; they are also more expensive and imply higher doses of radiation than intraoral radiographs. In contrast, the FRAX tool offers a validated, inexpensive, and frequently used method to find patients with a high risk of fragility fractures. Before suggesting the use of the FRAX tool in a dental setting, there are important aspects to be investigated such as what patients, and dental and medical staff, think about this. Qualitative studies of methods for medical risk assessment in a dental setting have been made, but none using FRAX. Gullberg et al. used focus groups to study the implementation of a method of risk assessment for osteoporosis by evaluating the trabecular pattern on intraoral radiographs [18]. The focus groups included both dental and medical staff as well as persons from patient support groups. The latter expressed a lack of knowledge of osteoporosis, both among the public and medical professionals. They saw screening for osteoporosis at a regular dental visit as positive for both the patient and society and expressed a need for referral to medical care if the risk was high. The willingness to pay for an osteoporosis risk assessment was also studied [19], where a majority were willing to pay, with a mean of about 45 €. Most participants found it valuable if dental clinics would offer osteoporosis risk assessment. Friman et al. studied screening for cardiovascular disease and diabetes in a dental setting, including a qualitative study with patient interviews [20, 21]. Their participants appreciated medical screening and thought it important that the dental staff possesses sufficient medical knowledge. They also emphasised the need for good cooperation between dental and medical care, with referrals if necessary. In a British study using questionnaires, most of the patients had a very positive attitude towards chair-side medical screening in the dental setting [22].

General health screening is not done on a general basis in Swedish dentistry, and there is no register for this. There are several research projects going on in Sweden using the dental appointment to identify patients with high blood pressure, high blood glucose, or risk for pre-diabetes. In Sweden, private practitioners treat about 2/3 of the adult population. Some of these offer assessments of blood pressure and blood sugar as a service to their patients. Except for the previously mentioned studies by Friman et al. [20, 21], there are so far no published studies or evaluations of these services. Some Swedish private dentists have previously offered an assessment of the risk of osteoporosis by uploading intraoral radiographs on a website together with some information about gender, age, etc. The trabecular pattern of the bone on the radiograph was assessed over several years by a private company, and this resulted in a high, medium, or low risk of osteoporosis, although the scientific evidence supporting this method of assessing fracture risk on an individual level was poor [12, 13]. Some pharmacies in Sweden offer a measurement of blood pressure or blood sugar, often in collaboration with a private primary health care provider. However, these data are not easily shared between the different medical professions, e.g. doctors, dentists, and pharmacies, unless referrals are made. Primary care physicians never have access to dental records, for instance, even though many patients think that they do. This leaves the patient responsible for any action due to the screening result, which may inhibit the good intentions associated with the screening. This qualitative study aimed to explore the thoughts of dental patients about assessing the risk of fragility fractures using the FRAX tool in a dental setting, for example, in conjunction with a regular check-up.

We recruited seven women (65–74 years old) and three men (65–75 years old), with a mean age of 70 years (Table 1). Most participants were retired, while a few were still working, although not full-time. The participants had different social backgrounds and educational levels, although this was not an expressed goal in recruitment. (One participant was a former dental nurse and supervisor who was briefly acquainted with CE and had worked with PS earlier). The 10-year risk of a major fragility fracture, according to the FRAX assessment, ranged from 6 to 34%. One participant, who was found to have a risk > 30%, was recommended to contact primary care.

The analysis resulted in three main categories with up to nine subcategories (Table 2).

An overarching theme was that patients think offering FRAX in the dental setting is a good service, but they doubt if the dentists have the interest, time, and knowledge to do it.

We found that the patients were generally positive about doing the FRAX assessment in the dental setting. They had little knowledge of osteoporosis or fragility fractures unless they had risk factors such as corticosteroid medication and had been informed by their doctors. While they thought it would be a good service to do the FRAX assessment at the dental clinic, some doubted that the dental staff had the knowledge or the interest for it. Most participants were willing to pay for the assessment, but not more than what it would cost in primary care.

Some of the participants were aware that fragility fractures could be prevented, mainly by avoiding falling. Exercising was also mentioned, both to obtain a better balance and muscular strength. However, none of the participants mentioned medication as a method to prevent fractures, although medication with both bisphosphonates and denosumab is known to have a good effect, with a decreased risk of new vertebral fractures of about 40–70% [24, 25].

Our results are in line with another qualitative study, made in preparation of implementing a method of risk assessment for osteoporosis evaluating the trabecular pattern in intraoral radiographs to predict fracture risk [18]. They interviewed focus groups including both dental and medical staff, as well as persons from patient support groups. The latter had usually joined the support group after having been diagnosed with osteoporosis, often after several fragility fractures, and they were all female. Since they suffered different levels of impairment due to these fractures, they expressed that they would have liked to have had the diagnosis before the fractures had occurred. It is possible that they were biased towards any fracture risk assessment because of their experience of osteoporosis or fragility fractures. In a quantitative study using questionnaires, Greenberg et al. found that patients had a positive attitude towards chair-side medical screening in a dental setting [26]. Their participants ranked the fact that the assessment was not done by a physician as the least important potential barrier to the implementation of medical screening. Performing the screening of the individual participants, while investigating their thoughts about it, could influence their thoughts or attitudes, but studies have been conducted both with and without screening the participants, and the results are similar. Previously mentioned studies by Creanor et al. and Greenberg et al. found the participants to be positive towards medical screening in a dental setting without having undergone the screening itself [22, 26]. In the study by Friman et al., and a Practice-Based Research Network study in the US and Sweden, the screening method was used in conjunction with the interviews/questionnaires, and they also found that patients had positive attitudes towards medical screening in a dental setting [21, 27]. The risk of causing feelings of uncertainty and worry by just informing of the risk of osteoporosis, as studied by Hvas et al., was not confirmed in this study [28]. Our participants were more pragmatic and thought they would be happy to discover whether they had an elevated risk of fragility fractures so they could prevent fractures through training.

The strengths of this study include that the participants were representatives of regular patients at the public dentistry. This increases the credibility of the study. We excluded medical doctors and dentists as patients because their role as clinicians probably overrules their role as a patient. However, we had one dental assistant/nurse and supervisor, as well as one radiology nurse, both of whom were still working part time. They had slightly more knowledge about osteoporosis and fragility fractures and had more traditional views concerning who should do what in risk identification. The researchers in this study have different professions (three medical doctors and two dentists), and all have different clinical working fields and different research experiences. This also contributes to the credibility of the study by way of researcher triangulation in the analysis process. The interviews went smoothly, perhaps because the interviewer has over 30 years of experience communicating with patients as a dentist.

A limitation of the study may be that since the FRAX instrument, which was developed about 15 years ago, uses a binary categorisation for sex as a risk factor, we also used this in our study. Another limitation with the study is that we only included participants with Swedish ethnicity. This was done because the validation of the FRAX instrument was done on a Swedish population. Moreover, the fact that the interviewer is a dentist, which was known to all participants, may have influenced their responses and therefore be a further limitation of the study. The interviewer’s background as a dentist may also have influenced her interpretation and analysis of the interviews. On the other hand, being familiar with the dental setting may facilitate the research and increase credibility. As the patients that were asked by the dentists to participate were probably partly selected for their presumed willingness to participate and their ability to communicate, this could result in a selection bias of the cohort. However, we are dependent on the ability to participate and communicate so this is most likely inevitable.

Although the participants had little knowledge of osteoporosis or fragility fractures, most of them were positive about having FRAX and other health assessments done in the dental clinic, at a cost not exceeding that charged in primary care. However, some of them doubted that the dentists would have the interest, time, and knowledge to do it. If they were found to have a high risk, they expected the dentist to collaborate with their family doctor/GP for further investigation and advice.

The ageing of the population, with added years of health but also frailty, may imply more suffering for the affected patients and increased costs for society. To meet this challenge, it may be necessary to use all possible ways of medical screening to find high-risk individuals, and the dental setting may be one of these. FRAX may be a useful tool in the right hands, but this study shows that there are thoughts among patients to bear in mind before considering introducing it there.