Analysis of cervical bone mineral density in children and adolescents using cone beam computed tomography combined with liquid phantoms

Analysis of cervical bone mineral density in children and adolescents using cone beam computed tomography combined with liquid phantoms | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Analysis of cervical bone mineral density in children and adolescents using cone beam computed tomography combined with liquid phantoms Linlin Wang, Song Lin, Chen Sun, Yuxin Ma, Yin Yin, Zhengyi Li, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3999548/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective To describe cervical BMD in children and adolescents using CBCT combined with K 2 HPO 4 liquid phantoms. Methods Children and adolescents aged 7–20 years who underwent CBCT for orthodontic treatment in our imaging department between January 2023 and June 2023 were selected. CT values of C2 and C3 were measured using the software supplied with the CBCT. K 2 HPO 4 liquid phantoms were prepared and scanned monthly. Regression equations were established between BMD values and CT values. BMD values of C2 and C3 were calculated and analysed. Results In the end, 455 patients were included in the study. The mean BMD values of C2 and C3 were 194.09 ± 39.16 mg/mL and 184.11 ± 43.83, respectively. The mean BMD values of C2 were higher than those of C3 (P < 0.05). The mean BMD values of C2 were 179.85 ± 29.87 mg/mL in males and 203.41 ± 41.69 mg/mL in females, and those of C3 were 165.24 ± 43.92 in males and 196.46 ± 39.19 in females, respectively. There was a significant difference in mean BMD between the sexes (P < 0.05). Conclusions The results of this study provide reference values for BMD of C2 and C3 using CBCT combined with liquid phantoms. Based on the reference values in healthy individuals, BMD could be assessed during oral treatment to diagnose osteoporosis, with great economic and social benefits. liquid phantoms bone mineral density Cone-beam computed tomography Figures Figure 1 Figure 2 Figure 3 1 Introduction Osteoporosis is one of the most common disorders of bone mass, often leading to fragility fractures and causing a significant social and economic burden. Osteoporosis in children and adolescents is increasingly recognised [ 1 ]. BMD reflects the amount of bone mass and is the main measure used to understand bone strength. Assessment of BMD is necessary in oral clinical practice for optimal therapy and avoidance of poor outcomes [ 2 , 3 , 4 , 5 ]. CBCT is an advanced piece of equipment used in oral clinical practice that offers lower exposure compared to QCT [ 6 , 7 ]. Some studies have shown that the results of CBCT bone density measurements based on K 2 HPO 4 liquid phantoms are equivalent to the results of conventional CT based on solid phantoms. [ 8 , 9 , 10 , 11 , 12 ]. Meanwhile, given the low production cost, convenient and flexible configuration, this method is worthy of clinical promotion and application. Furthermore, using CBCT to assess BMD can help avoid unnecessary examinations and is more appropriate for oral clinical practice. Cervical BMD reflects whole body BMD. Monitoring cervical BMD can help detect underlying diseases that affect bone metabolism [ 13 , 14 ]. There are several clinical studies have investigated cervical BMD in adults and established reference values [ 15 , 16 ], but reference values in children and adolescents are sparse. Therefore, the aim of this study is to describe cervical BMD in children and adolescents to provide reference values for oral clinical practice using CBCT based on K 2 HPO 4 liquid phantoms. 2 Materials and Methods 2.1. Data collection Patients who underwent CBCT in our imaging department between January 2023 and June 2023 were enrolled. The CBCT images were mainly obtained for orthodontic treatment. Inclusion criteria were good image quality without artefacts, age between 7–20 years and complete clinical data. After statistical analysis, 476 orthodontic patients were included. Exclusion criteria were any major systemic disease or metabolic bone disease, recent use of drugs related to bone such as hormones, diphosphate and estrogen, cervical spondylosis. After screening, 455 people were finally enrolled. The required sample size for a cross-sectional study is at least 100 according to statistics [ 17 ]. Therefore, a total sample size of 455 gave the study sufficient power. Information on age, sex and medical history was collected. Written informed consent was obtained from a parent or guardian for participants under 18 years of age, and written informed consent was obtained from participants aged 18 years or older. The study protocol was approved by the hospital's institutional review board. 2.2. Preparation of liquid phantoms Refer to the method in some studies [ 8 , 9 , 12 ], 0 mg/ml, 50 mg/ml, 150 mg/ml, 250 mg/ml, 350 mg/ml different concentrations of 100 ml standard solution of K 2 HPO 4 were prepared each month. These were then sealed in 15 ml plastic centrifuge tubes. 2.3 CBCT scanning condition All examinations were performed on a New Tom 5G CBCT scanner (QR Verona, Verona, Italy). CBCT was calibrated daily. Patients were in the supine position. CBCT images were acquired with the following settings: voltage, 110 kV; current, 3.00 mA; slice thickness, 0.3 mm; field of view, 21 cm×19 cm; and total scan time, 5.4 s. Liquid phantoms were performed with the same scan settings. 2.4 Measurement methods Sagittal sections were selected according to the midline of the spine and axial images were selected at the central level of C2 and C3 using the MPR software included with the CBCT. The CT value was then measured on axial images at the central level of C2 and C3 (Fig. 1 ). The CBCT images of the liquid phantoms were reconstructed by MPR so that the sagittal plane of the images was parallel to the long axis of the tubes and the horizontal plane of the image was parallel to the circular cross-section of the tubes. A total of 10 cross-sectional images were selected for CT measurements. Subsequently, the CT values of the fluid phantoms were measured (Fig. 2 ). The region of interest is defined as a square area of about 50 mm 2 at the center of each tube. Then the linear regression equation BMD = 0.557×CT value + 6.286 was then obtained (Fig. 3 ). The cervical BMD values of 455 participants were calculated using this formula. An experienced radiologist, blinded to clinical and CBCT information, measured CT values and calculated cervical BMD values in random order to avoid selection bias. 2.5 Statistical analysis All analyses were performed using the SPSS 26 software package. The Shapiro-Wilk test was used to test the distribution of data. Normally distributed data for continuous variables are presented as mean ± SD. Data were compared using the independent samples t-test for normally distributed data. P values < 0.05 were considered significant. 3 Results 3.1 Characteristics of participants Between January 2023 and June 2023, 455 individuals were enrolled (180 males and 275 females). The patients ranged in age from 7 to 20 years, with a mean age of 13.39±3.06 years for males and 13.39±3.06 years for females. 3.2 The measured results The mean BMD values of C2 and C3 were 194.09 ± 39.16 mg/mL and 184.11 ± 43.83 mg/mL, respectively. The results of the comparisons of BMD values between C2 and C3 showed that all values had statistically significant differences (P < 0 .05). The mean BMD values were statistically significantly higher in females than in males (P < 0 .05), as shown in Table 1 . Table 1 Comparison of the mean CT values and BMD values in C2 and C3 年龄 CT values (hu) BMD values (mg/ml) t p male female male female C2 311.61 ± 53.62 353.91 ± 74.84 179.85 ± 29.87 203.41 ± 41.69 6.559 p<0.0001 C3 285.37 ± 78.84 341.43 ± 70.35 165.24 ± 43.92 196.46 ± 39.19 7.920 p<0.0001 4 Discussion Osteoporosis is a common systemic skeletal disease characterised by low bone mass, reduced bone strength and increased susceptibility to fragility fractures [ 18 ]. In oral clinical practice, osteoporosis is closely associated with oral diseases. Nara Y [ 2 ] et.al suggested that changes in bone metabolism in patients with osteoporosis may increase tooth movement during orthodontic treatment, but exacerbate root resorption. Similarly, Sirisoontorn I [ 3 ] et.al found that the experimental osteoporosis group had faster tooth movement and greater severity of root resorption than the control group. On the other hand, tooth extraction in osteoporosis increases bone fragility and the risk of fracture [ 4 ]. Fractures after tooth extraction not only increase patient pain but also waste medical resources. In addition, bone quality and quantity are considered important criteria for successful implant therapy. Chambrone L [ 5 ] et.al concluded: "osteoporotic patients may undergo dental implant therapy, but the long-term cumulative survival rates may be inferior to those of systemically healthy patients. BMD is an established measure used to diagnose patients with osteoporosis. BMD assessment in oral clinics can be used to adjust the rate of orthodontic treatment, prevent implant failure and reduce the risk of fracture. QCT has been considered an important approach to the assessment of BMD [ 19 ], but it is not widely available in oral clinics. Typical implementations of QCT involve scanning the patient with a hydroxyapatite calibration phantom or dipotassium hydrogen phosphate liquid phantom placed in the field of view [ 20 ]. The phantom is used to convert the reconstructed CT values into BMD. CBCT holds promise in oral clinics because it is inexpensive, widely available and has a lower radiation exposure compared to QCT [ 6 , 7 ]. A number of studies have shown that CBCT combined with liquid phantoms is a reliable method for assessing BMD [ 7 , 8 , 9 , 10 , 11 ]. Given the lack of reliable reference values of cervical BMD in children and adolescents, this study established it using CBCT based on K 2 HPO 4 liquid phantoms. Mandibular vBMD measurements have limited value for the evaluation of systemic bone loss and should not replace spine vBMD in clinical practice for the assessment of osteoporotic fracture risk [ 21 ]. The cervical BMD reflects whole-body BMD [ 12 , 13 ], therefore changes of the cervical BMD herald disease. In CBCT examinations for oral clinical settings, the first 3 cervical vertebrae are often included. Accordingly, we chose to analyse C2 and C3 for these images. Our present study showed that the mean BMD values of C2 and C3 were 194.09 ± 39.16mg/mL and 184.11 ± 43.83mg/mL, respectively. Yoganandan N [ 14 ] et al. suggested that the mean BMD of healthy adult females (18–40 years) was 275.3 mg/mL for C2 and 264.7 mg/mL for C3. The differences are somewhat unexpected and could be explained by the different age groups. The reference values for cervical BMD complement the previously published. The results support previous studies showing that the mean BMD values of C2 are significantly higher than those of C3 [ 22 , 23 ]. Studies have reported that mean BMD values were statistically significantly higher in females than in males [ 15 , 16 , 23 , 24 ]. This finding is consistent with our study. Weishaupt D [ 25 ] et al. reported that the mean BMD of C2 in healthy individuals (20–40 years) was 297 ± 53.2 mg/m 3 in women and 269.6 ± 45.9mg/m 3 in men. Simion G [ 26 ] et al. suggested that the mean BMD in the transitional area of C2 was 168.72 (158.08 in females, 171.85 in males). In the current study, we showed that the mean BMD values of C2 were 179.85 ± 29.87 mg/mL in males and 203.41 ± 41.69 mg/mL in females, and those of C3 were 165.24 ± 43.92 in males and 196.46 ± 39.19 in females, respectively. Differences may be explained by age, sex and population ancestry. Kindler. JM [ 27 ] et al. pointed out that measures of BMD are dependent on age, sex, and population ancestry and become increasingly variable and nonlinear with age. This study had several limitations. First, due to the retrospective single-centre design, a multicentre approach is needed to evaluate the results of our study. Second, the inclusion of healthy individuals over 20 years of age could have further complemented the analysis. In conclusion, the present study comparatively determined the BMD values of C2 and C3 in 455 subjects. Reference values for BMD at C2 and C3 have been established in children and adolescents using CBCT combined with liquid phantoms. The use of these reference values may assist in the assessment of BMD in oral clinical settings. Abbreviations CBCT Cone-beam Computed Tomography QCT quantitative computed tomography C2 the second cervical vertebra C3 the third cervical vertebra BMD bone mineral density Declarations Acknowledgements The authors would like to thank Central Laboratory, Jinan Key Laboratory of Oral Tissue Regeneration, Jinan Stomatological Hospital, Jinan, China. Ethics approval and consent to participate This study was approved by the Ethics Committee of Jinan Stomatological Hospital, Shandong, China. All procedures were explained to patients, the written informed consent was signed by the patients or their parents. And in this study all methods were carried out in accordance with relevant guidelines and regulations. Consent for publication Not applicable. Data Availability The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare no competing interests. Funding This study was supported by a grant from Central Laboratory, Jinan Key Laboratory of Oral Tissue Regeneration, Jinan Stomatological Hospital, Jinan, China. Author Contribution H.T and L.W. wrote the main manuscript text and S.L. prepared figures 1-3. All authors reviewed the manuscript. References Ciancia S, Högler W, Sakkers RJB, et al. Osteoporosis in children and adolescents: how to treat and monitor? Eur J Pediatr. 2023;182(2):501–11. Nara Y, Kitaura H, Marahleh A, et al. Enhancement of orthodontic tooth movement and root resorption in ovariectomized mice. J Dent Sci. 2022;17(2):984–90. Sirisoontorn I, Hotokezaka H, Hashimoto M, et al. Tooth movement and root resorption; the effect of ovariectomy on orthodontic force application in rats. Angle Orthod. 2011;81(4):570–7. [4] Taguchi A, Ikegami S, Tokida R, Kamimura M, Sakai N, Horiuchi H, Takahashi J, Kato H. Fragility fractures and delayed wound healing after tooth extraction in Japanese older adults. J Bone Min Metab. 2020;38(3):357–62. Chambrone L. Current status of the influence of osteoporosis on periodontology and implant dentistry. Curr Opin Endocrinol Diabetes Obes. 2016;23(6):435–9. Drage N. Cone Beam Computed Tomography (CBCT) in General Dental Practice. Prim Dent J. 2018;7(1):26–30. Kruse C, Spin-Neto R, Wenzel A, et al. Cone beam computed tomography and periapical lesions: a systematic review analysing studies on diagnostic efficacy by a hierarchical model. Int Endod J. 2015;48(9):815–28. Huang Y, Zhang H, Cai Y. Bone mineral density of cancellous bone in edentulous areas: quantitative CT measurement.Tissue engineering research in China. Chin J Tissue Eng Res. 2017;21(36):5775–80. Chen XC, Fu QH, Sun ZY, et al. QCT Method Based on Liquid Phantoms for Jaw Bone Density Measurement Using Oral CT. J Northeastern Univ (Natural Sci Edition). 2015;36(05):636–40. Cao Q, Sisniega A, Stayman JW, Yorkston J, Siewerdsen JH, Zbijewski W. Quantitative Cone-Beam CT of Bone Mineral Density Using Model-Based Reconstruction. Proc SPIE Int Soc Opt Eng. 2019;10948:109480Y. Haristoy RA, Valiyaparambil JV, Mallya SM. Correlation of CBCT gray scale values with bone densities. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;107(4):e28. Jia XY. An in vitro study to evaluate the measurement of bone mineral density and implant primary stability by cone-beam CT. Zhejiang: Zhejiang University; 2013. Yoganandan N, Pintar FA, Stemper BD, Baisden JL, Aktay R, Shender BS, Paskoff G, Laud P. Trabecular bone density of male human cervical and lumbar vertebrae. Bone. 2006;39(2):336–44. Yoganandan N, Pintar FA, Stemper BD, Baisden JL, Aktay R, Shender BS, Paskoff G. Bone mineral density of human female cervical and lumbar spines from quantitative computed tomography. Spine (Phila Pa 1976). 2006;31(1):73–6. Zhang Y, Zhou Z, Wu C, Zhao D, Wang C, Cheng X, Cai W, Wang L, Duanmu Y, Zhang C, Tian W. Population-Stratified Analysis of Bone Mineral Density Distribution in Cervical and Lumbar Vertebrae of Chinese from Quantitative Computed Tomography. Korean J Radiol. 2016;17(5):581–9. Anderst WJ, West T, Donaldson WF 3rd, Lee JY. Cervical spine bone density in young healthy adults as a function of sex, vertebral level and anatomic location. Eur Spine J. 2017;26(9):2281–9. Shi ZH, Zhang XF. statistics for traditional chinese medicine,science press. China: Bei Jing; 2009. p. 37. Atik OS, Gunal I, Korkusuz F. Burden of osteoporosis. Clin Orthop Relat Res. 2006;443:19–24. Adams JE. Quantitative computed tomography. Eur J Radiol. 2009;71(3):415–24. Mueller DK, Kutscherenko A, Bartel H, et al. Phantom-less QCT BMD system as screening tool for osteoporosis without additional radiation. Eur J Ratiol. 2011;79(3):375–81. Guo Z, Du X, Wang L, Li K, Jiao J, Guglielmi G, Zhurakivska K, Lo Muzio L, Blake GM, Cheng X. Measurements of volumetric bone mineral density in the mandible do not predict spinal osteoporosis. Dentomaxillofac Radiol. 2020;49(3):20190280. Slaidina A, Nikitina E, Abeltins A, Soboleva U, Lejnieks A. Gray values of the cervical vertebrae detected by cone beam computed tomography for the identification of osteoporosis and osteopenia in postmenopausal women. Oral Surg Oral Med Oral Pathol Oral Radiol. 2022;133(1):100–9. Jarvinen TL, Kannus P, Sievanen H. Estrogen and bone-a reproductive and locomotive perspective. J Bone Min Res. 2003;18(11):1921–31. Havill LM, Mahaney MC, Binkley T, Specker BL. Effects of genes, sex, age, and activity on BMC, bone size, and areal and volumetric BMD. J Bone Min Res. 2007;22(5):737–46. Weishaupt D, Schweitzer ME, DiCuccio MN, Whitley PE. Relationships of cervical, thoracic, and lumbar bone mineral density by quantitative CT. J Comput Assist Tomogr 2001 Jan-Feb; 25(1): 146–50. Simion G, Eckardt N, Senft C, Schwarz F. Bone density of the axis (C2) measured using Hounsfield units of computed tomography. J Orthop Surg Res. 2023;18(1):93. Kindler JM, Lappe JM, Gilsanz V, Oberfield S, Shepherd JA, Kelly A, Winer KK, Kalkwarf HJ, Zemel BS. Lumbar Spine Bone Mineral Apparent Density in Children: Results From the Bone Mineral Density in Childhood Study. J Clin Endocrinol Metab. 2019;104(4):1283–92. Additional Declarations No competing interests reported. Supplementary Files data.xls Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3999548","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":276176068,"identity":"8c2f92f0-5aa0-4f22-abf1-67d2d9a7d4ab","order_by":0,"name":"Linlin Wang","email":"","orcid":"","institution":"Jinan Stomatological Hospital","correspondingAuthor":false,"prefix":"","firstName":"Linlin","middleName":"","lastName":"Wang","suffix":""},{"id":276176069,"identity":"3a64dba7-3b6a-4da0-b7d2-833c831c4a41","order_by":1,"name":"Song Lin","email":"","orcid":"","institution":"Jinan Stomatological 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2","display":"","copyAsset":false,"role":"figure","size":34422,"visible":true,"origin":"","legend":"\u003cp\u003eThe CT values of the fluid phantoms\u003c/p\u003e","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-3999548/v1/fb41083736dda30761a163a7.png"},{"id":52104251,"identity":"7f4f4607-d6b0-45ea-a9e8-d08788ad3654","added_by":"auto","created_at":"2024-03-06 19:23:38","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":26992,"visible":true,"origin":"","legend":"\u003cp\u003eThe linear regression equation between BMD values and CT values\u003c/p\u003e","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-3999548/v1/1da70dcb7028b1fdec86ea96.png"},{"id":63657199,"identity":"71a65c5a-3840-40d7-a3fc-2a92ee3eac37","added_by":"auto","created_at":"2024-08-30 16:33:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":513323,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3999548/v1/3010afd3-108b-4ce0-931f-e5708017e3c5.pdf"},{"id":52104248,"identity":"39efc297-c0aa-4674-a8a0-d543f81835d5","added_by":"auto","created_at":"2024-03-06 19:23:38","extension":"xls","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":44544,"visible":true,"origin":"","legend":"","description":"","filename":"data.xls","url":"https://assets-eu.researchsquare.com/files/rs-3999548/v1/dcd35642ec66f38cd90fc541.xls"}],"financialInterests":"No competing interests reported.","formattedTitle":"Analysis of cervical bone mineral density in children and adolescents using cone beam computed tomography combined with liquid phantoms","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eOsteoporosis is one of the most common disorders of bone mass, often leading to fragility fractures and causing a significant social and economic burden. Osteoporosis in children and adolescents is increasingly recognised [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. BMD reflects the amount of bone mass and is the main measure used to understand bone strength. Assessment of BMD is necessary in oral clinical practice for optimal therapy and avoidance of poor outcomes [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCBCT is an advanced piece of equipment used in oral clinical practice that offers lower exposure compared to QCT [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Some studies have shown that the results of CBCT bone density measurements based on K\u003csub\u003e2\u003c/sub\u003eHPO\u003csub\u003e4\u003c/sub\u003e liquid phantoms are equivalent to the results of conventional CT based on solid phantoms. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Meanwhile, given the low production cost, convenient and flexible configuration, this method is worthy of clinical promotion and application. Furthermore, using CBCT to assess BMD can help avoid unnecessary examinations and is more appropriate for oral clinical practice. Cervical BMD reflects whole body BMD. Monitoring cervical BMD can help detect underlying diseases that affect bone metabolism [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. There are several clinical studies have investigated cervical BMD in adults and established reference values [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], but reference values in children and adolescents are sparse. Therefore, the aim of this study is to describe cervical BMD in children and adolescents to provide reference values for oral clinical practice using CBCT based on K\u003csub\u003e2\u003c/sub\u003eHPO\u003csub\u003e4\u003c/sub\u003e liquid phantoms.\u003c/p\u003e"},{"header":"2 Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Data collection\u003c/h2\u003e \u003cp\u003ePatients who underwent CBCT in our imaging department between January 2023 and June 2023 were enrolled. The CBCT images were mainly obtained for orthodontic treatment. Inclusion criteria were good image quality without artefacts, age between 7\u0026ndash;20 years and complete clinical data. After statistical analysis, 476 orthodontic patients were included. Exclusion criteria were any major systemic disease or metabolic bone disease, recent use of drugs related to bone such as hormones, diphosphate and estrogen, cervical spondylosis. After screening, 455 people were finally enrolled. The required sample size for a cross-sectional study is at least 100 according to statistics [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Therefore, a total sample size of 455 gave the study sufficient power. Information on age, sex and medical history was collected. Written informed consent was obtained from a parent or guardian for participants under 18 years of age, and written informed consent was obtained from participants aged 18 years or older. The study protocol was approved by the hospital's institutional review board.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Preparation of liquid phantoms\u003c/h2\u003e \u003cp\u003eRefer to the method in some studies [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], 0 mg/ml, 50 mg/ml, 150 mg/ml, 250 mg/ml, 350 mg/ml different concentrations of 100 ml standard solution of K\u003csub\u003e2\u003c/sub\u003eHPO\u003csub\u003e4\u003c/sub\u003e were prepared each month. These were then sealed in 15 ml plastic centrifuge tubes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 CBCT scanning condition\u003c/h2\u003e \u003cp\u003eAll examinations were performed on a New Tom 5G CBCT scanner (QR Verona, Verona, Italy). CBCT was calibrated daily. Patients were in the supine position. CBCT images were acquired with the following settings: voltage, 110 kV; current, 3.00 mA; slice thickness, 0.3 mm; field of view, 21 cm\u0026times;19 cm; and total scan time, 5.4 s. Liquid phantoms were performed with the same scan settings.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Measurement methods\u003c/h2\u003e \u003cp\u003eSagittal sections were selected according to the midline of the spine and axial images were selected at the central level of C2 and C3 using the MPR software included with the CBCT. The CT value was then measured on axial images at the central level of C2 and C3 (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The CBCT images of the liquid phantoms were reconstructed by MPR so that the sagittal plane of the images was parallel to the long axis of the tubes and the horizontal plane of the image was parallel to the circular cross-section of the tubes. A total of 10 cross-sectional images were selected for CT measurements. Subsequently, the CT values of the fluid phantoms were measured (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The region of interest is defined as a square area of about 50 mm\u003csup\u003e2\u003c/sup\u003e at the center of each tube. Then the linear regression equation BMD\u0026thinsp;=\u0026thinsp;0.557\u0026times;CT value\u0026thinsp;+\u0026thinsp;6.286 was then obtained (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The cervical BMD values of 455 participants were calculated using this formula. An experienced radiologist, blinded to clinical and CBCT information, measured CT values and calculated cervical BMD values in random order to avoid selection bias.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Statistical analysis\u003c/h2\u003e \u003cp\u003eAll analyses were performed using the SPSS 26 software package. The Shapiro-Wilk test was used to test the distribution of data. Normally distributed data for continuous variables are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD. Data were compared using the independent samples t-test for normally distributed data. P values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"3 Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Characteristics of participants\u003c/h2\u003e \u003cp\u003eBetween January 2023 and June 2023, 455 individuals were enrolled (180 males and 275 females). The patients ranged in age from 7 to 20 years, with a mean age of 13.39\u0026plusmn;3.06 years for males and 13.39\u0026plusmn;3.06 years for females.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.2 The measured results\u003c/h2\u003e \u003cp\u003eThe mean BMD values of C2 and C3 were 194.09\u0026thinsp;\u0026plusmn;\u0026thinsp;39.16 mg/mL and 184.11\u0026thinsp;\u0026plusmn;\u0026thinsp;43.83 mg/mL, respectively. The results of the comparisons of BMD values between C2 and C3 showed that all values had statistically significant differences\u003cem\u003e(P\u0026thinsp;\u0026lt;\u0026thinsp;0\u003c/em\u003e.05). The mean BMD values were statistically significantly higher in females than in males\u003cem\u003e(P\u0026thinsp;\u0026lt;\u0026thinsp;0\u003c/em\u003e.05), as shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of the mean CT values and BMD values in C2 and C3\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e年龄\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eCT values (hu)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eBMD values (mg/ml)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003emale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003efemale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003emale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003efemale\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e311.61\u0026thinsp;\u0026plusmn;\u0026thinsp;53.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e353.91\u0026thinsp;\u0026plusmn;\u0026thinsp;74.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e179.85\u0026thinsp;\u0026plusmn;\u0026thinsp;29.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e203.41\u0026thinsp;\u0026plusmn;\u0026thinsp;41.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6.559\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep\u0026lt;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e285.37\u0026thinsp;\u0026plusmn;\u0026thinsp;78.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e341.43\u0026thinsp;\u0026plusmn;\u0026thinsp;70.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e165.24\u0026thinsp;\u0026plusmn;\u0026thinsp;43.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e196.46\u0026thinsp;\u0026plusmn;\u0026thinsp;39.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e7.920\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep\u0026lt;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eOsteoporosis is a common systemic skeletal disease characterised by low bone mass, reduced bone strength and increased susceptibility to fragility fractures [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In oral clinical practice, osteoporosis is closely associated with oral diseases. Nara Y [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] et.al suggested that changes in bone metabolism in patients with osteoporosis may increase tooth movement during orthodontic treatment, but exacerbate root resorption. Similarly, Sirisoontorn I [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] et.al found that the experimental osteoporosis group had faster tooth movement and greater severity of root resorption than the control group. On the other hand, tooth extraction in osteoporosis increases bone fragility and the risk of fracture [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Fractures after tooth extraction not only increase patient pain but also waste medical resources. In addition, bone quality and quantity are considered important criteria for successful implant therapy. Chambrone L [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] et.al concluded: \"osteoporotic patients may undergo dental implant therapy, but the long-term cumulative survival rates may be inferior to those of systemically healthy patients. BMD is an established measure used to diagnose patients with osteoporosis. BMD assessment in oral clinics can be used to adjust the rate of orthodontic treatment, prevent implant failure and reduce the risk of fracture.\u003c/p\u003e \u003cp\u003eQCT has been considered an important approach to the assessment of BMD [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], but it is not widely available in oral clinics. Typical implementations of QCT involve scanning the patient with a hydroxyapatite calibration phantom or dipotassium hydrogen phosphate liquid phantom placed in the field of view [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The phantom is used to convert the reconstructed CT values into BMD. CBCT holds promise in oral clinics because it is inexpensive, widely available and has a lower radiation exposure compared to QCT [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. A number of studies have shown that CBCT combined with liquid phantoms is a reliable method for assessing BMD [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Given the lack of reliable reference values of cervical BMD in children and adolescents, this study established it using CBCT based on K\u003csub\u003e2\u003c/sub\u003eHPO\u003csub\u003e4\u003c/sub\u003e liquid phantoms.\u003c/p\u003e \u003cp\u003eMandibular vBMD measurements have limited value for the evaluation of systemic bone loss and should not replace spine vBMD in clinical practice for the assessment of osteoporotic fracture risk [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The cervical BMD reflects whole-body BMD [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], therefore changes of the cervical BMD herald disease. In CBCT examinations for oral clinical settings, the first 3 cervical vertebrae are often included. Accordingly, we chose to analyse C2 and C3 for these images.\u003c/p\u003e \u003cp\u003eOur present study showed that the mean BMD values of C2 and C3 were 194.09\u0026thinsp;\u0026plusmn;\u0026thinsp;39.16mg/mL and 184.11\u0026thinsp;\u0026plusmn;\u0026thinsp;43.83mg/mL, respectively. Yoganandan N [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] et al. suggested that the mean BMD of healthy adult females (18\u0026ndash;40 years) was 275.3 mg/mL for C2 and 264.7 mg/mL for C3. The differences are somewhat unexpected and could be explained by the different age groups. The reference values for cervical BMD complement the previously published. The results support previous studies showing that the mean BMD values of C2 are significantly higher than those of C3 [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Studies have reported that mean BMD values were statistically significantly higher in females than in males [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. This finding is consistent with our study. Weishaupt D [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] et al. reported that the mean BMD of C2 in healthy individuals (20\u0026ndash;40 years) was 297\u0026thinsp;\u0026plusmn;\u0026thinsp;53.2 mg/m\u003csup\u003e3\u003c/sup\u003e in women and 269.6\u0026thinsp;\u0026plusmn;\u0026thinsp;45.9mg/m\u003csup\u003e3\u003c/sup\u003e in men. Simion G [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] et al. suggested that the mean BMD in the transitional area of C2 was 168.72 (158.08 in females, 171.85 in males). In the current study, we showed that the mean BMD values of C2 were 179.85\u0026thinsp;\u0026plusmn;\u0026thinsp;29.87 mg/mL in males and 203.41\u0026thinsp;\u0026plusmn;\u0026thinsp;41.69 mg/mL in females, and those of C3 were 165.24\u0026thinsp;\u0026plusmn;\u0026thinsp;43.92 in males and 196.46\u0026thinsp;\u0026plusmn;\u0026thinsp;39.19 in females, respectively. Differences may be explained by age, sex and population ancestry. Kindler. JM [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] et al. pointed out that measures of BMD are dependent on age, sex, and population ancestry and become increasingly variable and nonlinear with age.\u003c/p\u003e \u003cp\u003eThis study had several limitations. First, due to the retrospective single-centre design, a multicentre approach is needed to evaluate the results of our study. Second, the inclusion of healthy individuals over 20 years of age could have further complemented the analysis. In conclusion, the present study comparatively determined the BMD values of C2 and C3 in 455 subjects. Reference values for BMD at C2 and C3 have been established in children and adolescents using CBCT combined with liquid phantoms. The use of these reference values may assist in the assessment of BMD in oral clinical settings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eCBCT\u003c/strong\u003e\u0026nbsp; Cone-beam Computed Tomography\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQCT\u003c/strong\u003e\u0026nbsp; quantitative computed tomography\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eC2\u003c/strong\u003e\u0026nbsp; the second cervical vertebra\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eC3\u0026nbsp;\u003c/strong\u003e the third cervical vertebra\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBMD\u003c/strong\u003e\u0026nbsp; bone mineral density\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank Central Laboratory, Jinan Key Laboratory of Oral Tissue Regeneration, Jinan Stomatological Hospital, Jinan, China.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of Jinan Stomatological Hospital, Shandong, China. All procedures were explained to patients, the written informed consent was signed by the patients or their parents. And in this study all methods were carried out in accordance with relevant guidelines and regulations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by a grant from Central Laboratory, Jinan Key Laboratory of Oral Tissue Regeneration, Jinan Stomatological Hospital, Jinan, China.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eH.T and L.W. wrote the main manuscript text and S.L. prepared figures 1-3. All authors reviewed the manuscript.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCiancia S, H\u0026ouml;gler W, Sakkers RJB, et al. Osteoporosis in children and adolescents: how to treat and monitor? Eur J Pediatr. 2023;182(2):501\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNara Y, Kitaura H, Marahleh A, et al. Enhancement of orthodontic tooth movement and root resorption in ovariectomized mice. J Dent Sci. 2022;17(2):984\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSirisoontorn I, Hotokezaka H, Hashimoto M, et al. Tooth movement and root resorption; the effect of ovariectomy on orthodontic force application in rats. Angle Orthod. 2011;81(4):570\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e[4] Taguchi A, Ikegami S, Tokida R, Kamimura M, Sakai N, Horiuchi H, Takahashi J, Kato H. Fragility fractures and delayed wound healing after tooth extraction in Japanese older adults. J Bone Min Metab. 2020;38(3):357\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChambrone L. Current status of the influence of osteoporosis on periodontology and implant dentistry. Curr Opin Endocrinol Diabetes Obes. 2016;23(6):435\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDrage N. Cone Beam Computed Tomography (CBCT) in General Dental Practice. Prim Dent J. 2018;7(1):26\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKruse C, Spin-Neto R, Wenzel A, et al. Cone beam computed tomography and periapical lesions: a systematic review analysing studies on diagnostic efficacy by a hierarchical model. Int Endod J. 2015;48(9):815\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuang Y, Zhang H, Cai Y. Bone mineral density of cancellous bone in edentulous areas: quantitative CT measurement.Tissue engineering research in China. Chin J Tissue Eng Res. 2017;21(36):5775\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen XC, Fu QH, Sun ZY, et al. QCT Method Based on Liquid Phantoms for Jaw Bone Density Measurement Using Oral CT. J Northeastern Univ (Natural Sci Edition). 2015;36(05):636\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCao Q, Sisniega A, Stayman JW, Yorkston J, Siewerdsen JH, Zbijewski W. Quantitative Cone-Beam CT of Bone Mineral Density Using Model-Based Reconstruction. Proc SPIE Int Soc Opt Eng. 2019;10948:109480Y.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaristoy RA, Valiyaparambil JV, Mallya SM. Correlation of CBCT gray scale values with bone densities. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;107(4):e28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJia XY. An in vitro study to evaluate the measurement of bone mineral density and implant primary stability by cone-beam CT. Zhejiang: Zhejiang University; 2013.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoganandan N, Pintar FA, Stemper BD, Baisden JL, Aktay R, Shender BS, Paskoff G, Laud P. Trabecular bone density of male human cervical and lumbar vertebrae. Bone. 2006;39(2):336\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoganandan N, Pintar FA, Stemper BD, Baisden JL, Aktay R, Shender BS, Paskoff G. Bone mineral density of human female cervical and lumbar spines from quantitative computed tomography. Spine (Phila Pa 1976). 2006;31(1):73\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang Y, Zhou Z, Wu C, Zhao D, Wang C, Cheng X, Cai W, Wang L, Duanmu Y, Zhang C, Tian W. Population-Stratified Analysis of Bone Mineral Density Distribution in Cervical and Lumbar Vertebrae of Chinese from Quantitative Computed Tomography. Korean J Radiol. 2016;17(5):581\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnderst WJ, West T, Donaldson WF 3rd, Lee JY. Cervical spine bone density in young healthy adults as a function of sex, vertebral level and anatomic location. Eur Spine J. 2017;26(9):2281\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShi ZH, Zhang XF. statistics for traditional chinese medicine,science press. China: Bei Jing; 2009. p. 37.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAtik OS, Gunal I, Korkusuz F. Burden of osteoporosis. Clin Orthop Relat Res. 2006;443:19\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdams JE. Quantitative computed tomography. Eur J Radiol. 2009;71(3):415\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMueller DK, Kutscherenko A, Bartel H, et al. Phantom-less QCT BMD system as screening tool for osteoporosis without additional radiation. Eur J Ratiol. 2011;79(3):375\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuo Z, Du X, Wang L, Li K, Jiao J, Guglielmi G, Zhurakivska K, Lo Muzio L, Blake GM, Cheng X. Measurements of volumetric bone mineral density in the mandible do not predict spinal osteoporosis. Dentomaxillofac Radiol. 2020;49(3):20190280.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSlaidina A, Nikitina E, Abeltins A, Soboleva U, Lejnieks A. Gray values of the cervical vertebrae detected by cone beam computed tomography for the identification of osteoporosis and osteopenia in postmenopausal women. Oral Surg Oral Med Oral Pathol Oral Radiol. 2022;133(1):100\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJarvinen TL, Kannus P, Sievanen H. Estrogen and bone-a reproductive and locomotive perspective. J Bone Min Res. 2003;18(11):1921\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHavill LM, Mahaney MC, Binkley T, Specker BL. Effects of genes, sex, age, and activity on BMC, bone size, and areal and volumetric BMD. J Bone Min Res. 2007;22(5):737\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeishaupt D, Schweitzer ME, DiCuccio MN, Whitley PE. Relationships of cervical, thoracic, and lumbar bone mineral density by quantitative CT. J Comput Assist Tomogr 2001 Jan-Feb; 25(1): 146\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSimion G, Eckardt N, Senft C, Schwarz F. Bone density of the axis (C2) measured using Hounsfield units of computed tomography. J Orthop Surg Res. 2023;18(1):93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKindler JM, Lappe JM, Gilsanz V, Oberfield S, Shepherd JA, Kelly A, Winer KK, Kalkwarf HJ, Zemel BS. Lumbar Spine Bone Mineral Apparent Density in Children: Results From the Bone Mineral Density in Childhood Study. J Clin Endocrinol Metab. 2019;104(4):1283\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"liquid phantoms, bone mineral density, Cone-beam computed tomography","lastPublishedDoi":"10.21203/rs.3.rs-3999548/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3999548/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e \u003cb\u003eObjective\u003c/b\u003e To describe cervical BMD in children and adolescents using CBCT combined with K\u003csub\u003e2\u003c/sub\u003eHPO\u003csub\u003e4\u003c/sub\u003e liquid phantoms.\u003c/p\u003e \u003cp\u003e \u003cb\u003eMethods\u003c/b\u003e Children and adolescents aged 7\u0026ndash;20 years who underwent CBCT for orthodontic treatment in our imaging department between January 2023 and June 2023 were selected. CT values of C2 and C3 were measured using the software supplied with the CBCT. K\u003csub\u003e2\u003c/sub\u003eHPO\u003csub\u003e4\u003c/sub\u003e liquid phantoms were prepared and scanned monthly. Regression equations were established between BMD values and CT values. BMD values of C2 and C3 were calculated and analysed.\u003c/p\u003e \u003cp\u003e \u003cb\u003eResults\u003c/b\u003e In the end, 455 patients were included in the study. The mean BMD values of C2 and C3 were 194.09\u0026thinsp;\u0026plusmn;\u0026thinsp;39.16 mg/mL and 184.11\u0026thinsp;\u0026plusmn;\u0026thinsp;43.83, respectively. The mean BMD values of C2 were higher than those of C3 (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The mean BMD values of C2 were 179.85\u0026thinsp;\u0026plusmn;\u0026thinsp;29.87 mg/mL in males and 203.41\u0026thinsp;\u0026plusmn;\u0026thinsp;41.69 mg/mL in females, and those of C3 were 165.24\u0026thinsp;\u0026plusmn;\u0026thinsp;43.92 in males and 196.46\u0026thinsp;\u0026plusmn;\u0026thinsp;39.19 in females, respectively. There was a significant difference in mean BMD between the sexes (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003cb\u003eConclusions\u003c/b\u003e The results of this study provide reference values for BMD of C2 and C3 using CBCT combined with liquid phantoms. Based on the reference values in healthy individuals, BMD could be assessed during oral treatment to diagnose osteoporosis, with great economic and social benefits.\u003c/p\u003e","manuscriptTitle":"Analysis of cervical bone mineral density in children and adolescents using cone beam computed tomography combined with liquid phantoms","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-06 19:23:33","doi":"10.21203/rs.3.rs-3999548/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"59ffcdbe-5d15-4ebc-951a-ee5388954eaa","owner":[],"postedDate":"March 6th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-08-30T16:25:40+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-06 19:23:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3999548","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3999548","identity":"rs-3999548","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}