Bone density or bone mineral density (BMD) is the amount of bone mineral in bone tissue. The concept is of mass of mineral per volume of bone (relating to density in the physics sense), although clinically it is measured by proxy according to optical density per square centimeter of bone surface upon imaging. Bone density measurement is used in clinical medicine as an indirect indicator of osteoporosis and fracture risk. It is measured by a procedure called densitometry, often performed in the radiology or nuclear medicine departments of hospitals or clinics. The measurement is painless and non-invasive and involves low radiation exposure. Measurements are most commonly made over the lumbar spine and over the upper part of the hip. The forearm may be scanned if the hip and lumbar spine are not accessible.
There is a statistical association between poor bone density and higher probability of fracture. Fractures of the legs and pelvis due to falls are a significant public health problem, especially in elderly women, leading to much medical cost, inability to live independently, and even risk of death. Bone density measurements are used to screen people for osteoporosis risk and to identify those who might benefit from measures to improve bone strength.
Bone density tests are not necessary for people without risk factors for weak bones. Unnecessary testing is more likely to result in superfluous treatment rather than discovery of a true problem.
Indications for testing
The following are risk factors for low bone density and primary considerations for the need for a bone density test.
- females age 65 or older
- males age 70 or older
- people over age 50 with any of the following:
- Individuals with vertebral abnormalities.
- Individuals receiving, or planning to receive, long-term glucocorticoid (steroid) therapy.
- Individuals with primary hyperparathyroidism.
- Individuals being monitored to assess the response or efficacy of an approved osteoporosis drug therapy.
- Individuals with a history of eating disorders
Other considerations which related to risk of low bone density and the need for a test include smoking habits, drinking habits, the long-term use of corticosteroid drugs, and a vitamin D deficiency.
Overtesting and treatment
For those people who do have bone density tests, two conditions which may be detected are osteoporosis and osteopenia. The usual response to either of these indications is consultation with a physician.
Results are often reported in 3 terms:
- Measured areal density in g cm−2
- Z-score, the number of standard deviations above or below the mean for the patient's age, sex and ethnicity
- T-score, the number of standard deviations above or below the mean for a healthy 30-year-old adult of the same sex and ethnicity as the patient
Types of tests
While there are many different types of BMD tests, all are non-invasive. Most tests differ according to which bones are measured to determine the BMD result.
These tests include:
- Dual-energy X-ray absorptiometry (DXA or DEXA)
- Dual X-ray Absorptiometry and Laser (DXL)
- Quantitative computed tomography (QCT)
- Qualitative ultrasound (QUS)
- Single photon absorptiometry (SPA)
- Dual photon absorptiometry (DPA)
- Digital X-ray radiogrammetry (DXR)
- Single energy X-ray absorptiometry (SEXA)
DXA is currently the most widely used, but ultrasound has been described as a more cost-effective approach to measure bone density. The DXA test works by measuring a specific bone or bones, usually the spine, hip, and wrist. The density of these bones is then compared with an average index based on age, sex, and size. The resulting comparison is used to determine risk for fractures and the stage of osteoporosis (if any) in an individual.
Average bone mineral density = BMC / W [g/cm2]
- BMC = bone mineral content = g/cm
- W = width at the scanned line
Results are generally scored by two measures, the T-score and the Z-score. Scores indicate the amount one's bone mineral density varies from the mean. Negative scores indicate lower bone density, and positive scores indicate higher.
The T-score is the relevant measure when screening for osteoporosis. It is the bone mineral density (BMD) at the site when compared to the young normal reference mean. It is a comparison of a patient's BMD to that of a healthy 30-year-old. The US standard is to use data for a 30-year-old of the same sex and ethnicity, but the WHO recommends using data for a 30-year-old white female for everyone. Values for 30-year-olds are used in post-menopausal women and men over age 50 because they better predict risk of future fracture. The criteria of the World Health Organization are:
- Normal is a T-score of −1.0 or higher
- Osteopenia is defined as between −1.0 and −2.5
- Osteoporosis is defined as −2.5 or lower, meaning a bone density that is two and a half standard deviations below the mean of a 30-year-old man/woman.
|WHO category||Age 50–64||Age > 64||Overall|
The Z-score is the comparison to the age-matched normal and is usually used in cases of severe osteoporosis. This is the number of standard deviations a patient's BMD differs from the average BMD of their age, sex, and ethnicity. This value is used in premenopausal women, men under the age of 50, and in children. It is most useful when the score is less than 2 standard deviations below this normal. In this setting, it is helpful to scrutinize for coexisting illnesses or treatments that may contribute to osteoporosis such as glucocorticoid therapy, hyperparathyroidism, or alcoholism.
Use of BMD has several limitations.
- Measurement can be affected by the size of the patient, the thickness of tissue overlying the bone, and other factors extraneous to the bones.
- Bone density is a proxy measurement for bone strength, which is the resistance to fracture and the truly significant characteristic. Although the two are usually related, there are some circumstances in which bone density is a poorer indicator of bone strength.
- Reference standards for some populations (e.g., children) are unavailable for many of the methods used.
- Crushed vertebrae can result in falsely high bone density, so they must be excluded from analysis.
- Bone Density at the US National Library of Medicine Medical Subject Headings (MeSH)
- Cole RE (June 2008). "Improving clinical decisions for women at risk of osteoporosis: dual-femur bone mineral density testing". J Am Osteopath Assoc. 108 (6): 289–95. PMID 18587077.
- American Academy of Family Physicians, presented by ABIM Foundation, "Five Things Physicians and Patients Should Question" (PDF), Choosing Wisely: an initiative of the ABIM Foundation, American Academy of Family Physicians, retrieved August 14, 2012
- Consumer Reports; American Academy of Family Physicians (May 2012), "Bone-density tests: When you need them — and when you don't" (PDF), Choosing Wisely: an initiative of the ABIM Foundation, Consumer Reports, retrieved August 14, 2012
- "NOF - Bone Mass Measurement". Archived from the original on 2008-03-07. Retrieved 2008-03-20.
- "Bone densitometry". Retrieved 2008-09-02.
- Unknown, Unknown (2011-07-29). "T and Z scores.". University of Washington Bone Physics. Retrieved 2013-06-22.
- Richmond, Bradford (2007-11-13). "Osteoporosis and bone mineral density.". American College of Radiology. Retrieved 2008-05-11.
- WHO Scientific Group on the Prevention and Management of Osteoporosis (2000 : Geneva, Switzerland) (2003). "Prevention and management of osteoporosis : report of a WHO scientific group" (pdf). Retrieved 2007-05-31.
- Cranney A, Jamal SA, Tsang JF, Josse RG, Leslie WD (2007). "Low bone mineral density and fracture burden in postmenopausal women". Canadian Medical Association Journal. 177 (6): 575–80. doi:10.1503/cmaj.070234. PMC . PMID 17846439.