Carteles de caballete

In general, there tends to be less utilisation of health services in rural and remote areas and poorer global health outcomes.135 _{However, data specifically relating to the burden of OP in rural and remote areas} compared to urban areas was not available.

The Working Group performed an analysis of bone densitometry claims processed by Medicare Australia between 2001 and 2005 for this guideline (Table 3). Age standardised densitometry claims have increased by 29% from 2001 to 2005, suggesting there is a growing awareness and activity for OP. A similar proportional increase is seen across urban, rural and remote areas; however the densitometry utilisation rates remain significantly lower in rural and remote areas. Women had BMD measurement seven times as often as men in 2001, decreasing to four times as often in 2005. This gender difference was more pronounced in rural and remote areas.19 _{This analysis suggests there is a particular need to facilitate health service activity for} the detection and management of OP in rural and remote areas. Important factors are likely to be access to primary health care (PHC) in rural areas, where PHC workforce issues are known to be a major issue,136 _{as is} access to densitometry services.

Table 3. Analysis of bone densitometry claims processed by Medicare Australia, 2001–2005

People aged 45+ years in

2005

Capital

city metropolitan Other centre

Large rural centre

Small rural

centre Other rural Remote centre remoteOther

Men 7.6 7.0 6.9 6.1 4.6 1.8 2.3

Women 35.6 35.3 29.2 27.6 22.7 13.3 17.4

Ratio women/ men

4.5 5 4 4.5 5 7 7.5

Note: Tests per 1000 population per year. Direct age standardisation to 2001 gender specific population

Gender

The analysis of bone densitometry utilisation also suggests there is relative underutilisation in men. Two Australian studies help to define the true gender difference in the prevalence of OP and the incidence of fragility fractures.137,138 _{These studies suggest the true prevalence ratio F:M is around 2:1 compared to the} range of ratios for densitometry utilisation of 4.5:1 to 7.5:1 seen in different settings in Australia in 2005 (Table 3).

Aboriginal and Torres Strait Islander issues

Research on differences in the burden of OP in the indigenous population is very limited. A 2001 study from the Cairns Hospital in northern Queensland reported similar overall age standardised rates for fractured neck of femur in the indigenous compared to the non-indigenous population of that area, but with a pattern of older age at the time of fracture for indigenous women.139

Differing patterns of risk factors such as smoking, nutrition, exercise, underweight, and high alcohol consumption are likely to be important. The interaction of these factors, lower life expectancy, higher comorbidity rates, widely variable access to health services and socioeconomic factors, is hard to estimate. Promotion of good nutrition and reduction of risk factors is very important for a wide range of health issues, not only OP.

It is anticipated that Aboriginal and Torres Strait Islander women and men will suffer at least the same, if not a greater, limitation to densitometry access as noted for other rural and remote living people. There is no reliable data on the incidence of osteoporotic fractures in Aboriginal people and Torres Strait Islanders. It is not known whether their recognised shorter life expectancy influences absolute fracture incidence. Ethnic and minority groups

Osteoporosis is most common in caucasian people, followed by Asian and African Americans.140 _Therefore, there is an advantage in using normal ranges derived from ethnicity appropriate BMD T-scores. However, BMD data are lacking for Indigenous Australians. Some ethnic groups in Australia are at greater risk of vitamin D insufficiency (Asians, people with darker skin, and veiled women) and relatively low calcium intakes and both should be corrected before initiating anti-osteoporotic therapy.

Osteonecrosis of the jaw

Bisphosphonate associated ONJ is a relatively recently described entity. A confirmed case of bisphosphonate associated ONJ can be defined as an area of exposed bone in the maxillofacial region that did not heal within 8 weeks after identification by a health care provider and use of standard dental therapy, in a patient who was receiving or had been exposed to a bisphosphonate, and had not had radiation therapy to the craniofacial region.

The incidence of ONJ in patients receiving bisphosphonates for OP is not known, but appears to be relatively low.141 _{Both USA pharmaceutical industry estimates of the worldwide, cumulative reporting rate and a recent} German study of prevalence of ONJ are consistent at less than one in 100 000 patient treatment years. However, data from Australia and Israel suggest that the incidence could be up to 10-fold higher.85 _More information is needed on the true incidence of bisphosphonate associated ONJ as well as the major other risk factors for developing this complication, but poor dental hygiene, dental extraction and periodontal disease, as well as immunosuppressive therapy have been implicated.

Treatment is currently mainly supportive and involves local antibiotics to improve oral hygiene. Consideration should be given to avoiding invasive dental procedures such as dental extractions, and using more

conservative techniques in patients on oral bisphosphonates and treating periodontal disease to minimise the risk of ONJ. The risk of ONJ is not great enough to recommend routine dental examinations in patients before commencing treatment with oral bisphosphonates for OP. However, there should be close communication between GPs and dentists when patients are receiving oral bisphosphonates.