Open Journal of Stomatology, 2011, 1, 61-68
doi:10.4236/ojst.2011.13011 Published Online September 2011 (http://www.SciRP.org/journal/OJST/
OJST
).
Published Online September 2011 in SciRes. http://www.scirp.org/journal/OJST
Association of type 2 diabetes mellitus with the reduction of
mandibular residual ridge among edentulous patients using
panoramic radiographs
Osama Al-Jabrah
Department of Dentistry, King Hussein Medical Center, Royal Medical Services, Amman, Jordan.
Received 15 April 2011; revised 30 May 2011; accepted 9 June 2011.
ABSTRACT
Objective: To evaluate the association between type 2
diabetes mellitus and the reduction of mandibular
residual ridge in completely edentulous patients
wearing complete dentures and to investigate the ef-
fect of gender, age and years of edentulousness/ den-
ture wearing on ridge resorption on both groups.
Methods: Seventy-two (36 men and 36 women) with a
mean age 63.5 years (range of 52 to 73 years) com-
pletely edentulous denture-wearing patients were
included in this study. Of these, there were 40 pa-
tients with type 2 diabetes mellitus and 32 control
subjects participated in the study. Resorption in the
mandibular residual ridges was assessed by using the
mental foramen and the inferior border of the man-
dible, as they appear in panoramic radiographs, as
reference points using Wical and Swoope Analysis
method. Measurements were performed using “Di-
jite” Digital Caliper. The amount of mandibular
ridge resorption was calculated and correlated with
type 2 diabetes mellitus and the results were com-
pared with control group. Differences in gender, age
and years of edentulousness were investigated. Statis-
tical analysis was performed using SPSS (V11.0). A
2-sample t-test was used to evaluate the differences in
mean values of mandibular ridge resorption between
diabetics and controls. Level of significance was set at
0.05. Results: The mean mandibular residual ridge
resorption of all participants is 8.0 mm (26.9%), dia-
betic group significantly (P < 0.01) had two times
more resorption compared with control group
(35.8% versus 18.0%). Females recorded greater
amount of resorption in diabetics 49.7% versus
21.8% (P < 0.001) and in controls 22.3% versus
13.7%, (P < 0.05) compared to males, respectively.
There were no differences in both groups regarding
the age of subjects and the length of time they have
been edentulous and years of denture wearing. The
amount of mandibular residual ridge resorption was
directly related to the number of years of edentu-
lousness. Conclusion: Completely edentulous, den-
ture-wearing diabetics, women in particular, are at
more risk to have ridge resorption than “nondia-
betic” subjects. Reduced mandibular height is di-
rectly related to years of edentulousness and den-
ture wearing with greater amount of resorption
among diabetics.
Keywords: Type 2 Diabetes Mellitus; Residual Ridge
Resorption; Mandible; Mental Foramen; Edentulous;
Complete Denture; Panoramic Radiology
1. INTRODUCTION
Residual ridge resorption (RRR) is a continuous process
of alveolar bone loss, which is greater during the first
few months after the tooth extraction than later, since it
slows down with time after extraction [1-4]. The rate of
resorption is supposed to be twice more pronounced in
the mandible than in the maxilla during a period which
follows teeth extraction and the ratio of 4:1 mandibular
to maxillary resorption increases further [5]. The mandi-
ble seems to be the bone within the human skeleton that
is most exposed to severe decrease in its height and min-
eral content as it is one of the primary source of the
available calcium in the body [2].
The factors that contribute to RRR are still not com-
pletely elucidated. Some systemic factors that contribute
to the RRR are: nutritional, hormonal imbalance, meta-
bolic bone disease, some renal diseases, drug intake,
postmenopausal hormonal disturbances in women, age,
sex, etc [6,7]. Local factors that contribute to RRR are
denture retention and stability, pressure applied to re-
sidual ridge through occlusal contacts, incorrect vertical
or horizontal relation of the dentures, night-time wearing

O. Al-Jabrah / Open Journal of Stomatology 1 (2011) 61-68 62
of dentures, balanced or non-balanced occlusion, dura-
tion of denture wearing, disuse, atrophy or reduced mas-
ticatory forces in denture wearers compared with age-
matched dentate subjects etc [8].
Osteoporosis is one of the most important clinical
conditions facing the aging population due to the associ-
ated high incidence of RRR [9]. It has been found that
severity of bone loss, in both osteoporosis and residual
ridges, increases with the advance of age and favors the
female sex for predisposition. Post menopausal women
comprise most of the female edentulous population with
severe RRR. The effect of menopause on the mandible
was thought to be similar to the effect on the rest of the
skeleton and therefore places the post menopausal wo-
men at a higher risk of becoming complete denture pa-
tients with severe RRR [10,11].
Diabetes mellitus (DM) is a chronic disease, which
occurs when blood glucose concentration in body is in
excess [12]. It is characterized by hyperglycemia and
glucose intolerance [13]. The disorder is used to describe
the increased concentration of glucose in the blood while
glucose intolerance is associated with insulin resistance.
There are mainly two types of DM; type 1 and type 2
diabetes. Type 1 diabetes (T1DM), previously known as
insulin-dependent is characterized by a lack of insulin
production. Type 2 diabetes (T2DM), formerly called
non-insulin-dependent is caused by the body’s ineffec-
tive use of insulin. It often results from excess body
weight and physical inactivity. As a result of DM, it af-
fects the blood circulations and is associated with many
complications such as cardiovascular diseases, particu-
larly heart attack and stroke [12,14]. Furthermore, it is
found that DM also reduces healing of wounds [15],
causes bone resorption and has been considered to con-
tribute to failure in dental treatment [16].
Complete dentures (CDs) are widely used in restora-
tion of completely edentulous dental arches [17]. The
resulting shape and size of the residual ridge influence
the degree of stability and retention of the denture and
affect the amount of applied load [1]. Before considering
prosthodontic treatment, both the quantity and quality of
the bone must be assessed radiographically [18]. There
is a gradual deterioration of body functions with age and
any general systemic disability would make denture
success uncertain. Further, people of the CDs age are
likely to have contributing health problems which cause
denture difficulties [19].
Panoramic radiographs (OPG) were utilized because
they have certain advantages over intra-oral radiography.
These include a greater area of hard and soft tissue and
also the ability to visualize adjacent areas, thus allowing
for a more accurate localization of the mental foramen
(MF) in both the horizontal and vertical dimensions
[20,21].
The aim of the present study was to assess the amount
of mandibular RRR in edentulous patients wearing CDs
and to evaluate the relationship between RRR and
T2DM, to compare the amount of resorption between
diabetics and “nondiabetic” control subjects and to
evaluate the effect of age, gender and years of edentu-
lousness and CD-wearing on the amount of resorption.
2. MATERIALS AND METHOD
This study was carried out at the Prosthodontic Clinic,
Department of Dentistry, Prince Rashid Bin Al-Hassan
Hospital in Irbid, Jordan; over one year period from
August 2010 to July 2011.
2.1. Patients
The original sample for the present study was selected
from a general population of completely edentulous
subjects who attended (or referred to) Prosthodontic
clinic.
The study sample comprises seventy-two (36 (50.0%)
males and 36 (50.0%) females) participants with a mean
age 63.5 (±11. 6) years (ranged between 52 and 73 years)
completely edentulous patients were selected and ac-
cepted to participate in this study. Of these, there were
40 patients with type T2DM and 32 control subjects. All
participants were CD wearers.
2.2. Inclusion/Exclusion Criteria
The selected subjects had not undergone prosthetic sur-
gical procedures (i.e. sulcus deepening or ridge augmen-
tation). They were completely edentulous with not less
than one year post-tooth extraction period. All partici-
pants have been diabetics for 5 years or more.
2.3. Measurements
For each participant an OPG was taken using Orthoralix
9200® (Gendex, SN: 5-1822514DP; IL, USA). Man-
dibular RRR was assessed by using the MF and the infe-
rior border of the mandible, as they appear in OPGs, as
reference points using Wical and Swoope Analysis
method; in which the original height of the mandible is
assumed to be 3 times the distance between the inferior
border of the mandible to the lower border of the MF
[22]. The amount of resorption (R) from the original
mandibular alveolar level to the measured level of the
residual ridge (L) was expressed as a percentage of the
original height of the mandible (Figure 1).
The amount of resorption was calculated according to
the formula: R = 3x – L, (where R: amount of mandibu-
lar RRR; x: distance from inferior border of mandible to
the lower border of MF; L: height of mandibular residual
alveolar ridge).
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O. Al-Jabrah / Open Journal of Stomatology 1 (2011) 61-68 63
Figure 2. Dijiti carbon fiber composite digital caliper.
3. RESULTS
Variability and bias in measurements between right and
left sides were assessed by re-measuring the height of
mandible across the MF on 11 (15.3%) randomly se-
lected OPGs on the left side.
Paired Student’s t-test was performed to unveil statis-
tically significant deviation of measurements between
right and left sides, (mean difference 0.065 ± 0.13 mm; P
value = 0.92). As there were strong Cronbach’s coeffi-
cient and small mean difference between the two-side
measurements, it was assumed that the right side meas-
urements would be reliable.
Figure 1. Wical and Swoope analysis method (R = 3x – L).
Measurements were performed using Dijite carbon
fiber composite digital caliper (Guilin Digital Electronic
Co., Ltd. Guangxi, China) to the nearest tenth of a mil-
limetre for specific measured dimensions on each OPG.
The caliper has two edges; external and internal (Figure
2); the external edges were used in the measurements.
The mean age of T2DM subjects was 63.8 ± 6.7 years,
ranged between 55 and 73 years; and of control subjects
was 61.6 ± 7.4 years, ranged between 52 and 69 years.
The age and sex distribution of diabetic and control
groups are shown in Table 1.
The amount of mandibular RRR was calculated and
correlated with T2DM, and with wearing CDs. The re-
sults were compared with those of non-diabetic (control)
group. Gender and age differences were also investi-
gated and correlated to DM and CD.
Tab le 2 shows that the amount of mandibular RRR in
DM subjects is approximately twice as that in control
group. The difference between groups was statistically
significant (p < 0.01; two-sample t-test).
Measurements were performed on the right side, and
they were repeated 3 times and the mean value and
standard deviation were calculated for further analysis.
Measuring gauge had a resolution of 0.1 mm and meas-
ured dimensions were recorded to this degree of accu-
racy.
Gender differences between the two groups are shown
in Table 3. Generally, results showed that females sig-
nificantly have two times as resorption as males (P <
0.001). Statistically significant gender differences in
mandibular RRR have been recorded in DM (P < 0.001)
and control (P < 0.05) group.
2.4. Statistical Analysis Tabl e 4 shows comparison of age, mandibular RRR,
and years since edentulousness and/or wearing CDs be-
tween DM patients and controls. Statistically significant
differences in mandibular RRR were recorded between
the two groups. The DM group had approximately as
twice as compared with the controls (P < 0.01). However,
there were no differences between the two groups in the
mean age of subjects as well as in years of edentulous-
ness/CD wearing.
Statistical analysis was performed using Statistical Pack-
age for Social Sciences; Version 11 (SPSS-V11.0 Inc.,
Chicago, Ill., USA). A 2-sample t-test was used to ev-
aluate the differences in mean values of mandibular
RRR between DM and control groups of patients. Stu-
dent’s t-test was used to determine whether there were
gender differences in the amount of RRR and DM. The
Mann-Whitney U test was used to examine the differ-
ences in the duration of edentulousness between men
and women. Table 5 shows correlation of CD wearing duration
with the amount of mandibular RRR between DM and
control groups. It has been shown that RRR is directly
proportional to period of edentulousness and CD wearing.
The differences between the two groups were statistically
significant among subjects who have been wearing CDs
for 15 years or less (P < 0.001) and also in those who
have been edentulous for more than 15 years (P < 0.05).
Chi square analysis was used to study the association
between CD wearing period and amount of RRR.
Ninety-five percent confidence intervals about the mean
were constructed for differences between DM and con-
trol group and male and female participants. Level of
significance was set at 0.05.
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O. Al-Jabrah / Open Journal of Stomatology 1 (2011) 61-68 64
Table 1. Distribution of study groups (diabetic and control) according to age and gender.
Diabetic group (n = 40) Control group (n = 32) Total (n = 72)
Age range Male Female Male Female Male Female Total
50 - 54 3 4 2 4 5 8 13
55 - 59 4 4 3 4 7 8 15
60 - 64 6 6 6 4 12 10 22
65 - 69 5 4 3 3 8 7 15
70 - 74 2 2 2 1 4 3 7
Total 20 20 16 16 36 36 72
Table 2. Differences in the amount of mandibular ridge resorption between diabetic and control groups.
Group IBM-MFx 3x H L = 3x – R ROPG% = (R/3x) × 100%2-sample t-test P Value
Diabetic 10.0 29.9 19.9 19.4 10.5 35.8
Control 10.5 31.5 21.0 26.6 5.5 18.0 1.99 0.0028
P < 0.01
Mean 10.3 30.7 20.5 23.0 8.0 26.9
IBM: inferior border of the mandible; x: distance from IBM to lower border of MF; H: height of residual alveolar bone; R: amount of re-
sorption; OPG: panoramic radiograph.
Table 3. Gender differences in the amount of mandibular ridge resorption between study groups groups.
Group IBM-MFx 3x Height
above MFL = 3x – RROPG% = (R/3x) × 100% Student’s t-test p Value
M n = 20 11.5 34.5 23.0 26.2 8.3 21.8
Diabetic F n = 20 8.4 25.2 16.8 12.5 12.7 49.7 2.28 0.00016
p < 0.001
M n = 16 11.9 35.7 23.8 30.8 4.9 13.7
Control F n = 16 9.1 27.3 18.2 22.3 6.1 22.3 1.63 0.022
p < 0.05
M n = 36 11.7 35.0 32.3 28.8 6.8 18.2
Total F n = 36 8.7 26.1 17.6 16.8 9.8 37.5 2.06 0.00056
p < 0.001
Mean 10.2 30.6 25.0 22.8 8.4 27.9
M: male; F: female; IBM: inferior border of the mandible; x: distance from IBM to lower border of MF; H: height of residual alveolar bone;
R: amount of resorption; OPG: panoramic radiograph.
Table 4. Comparison of age, mandibular residual ridge resorption, and years since edentulousness and/or wearing
dentures between diabetic patients and controls.
n Age (Year)
Mandibular residual ridge
resorption (mm)
Edentulousness/Denture-wearing
(Years)
Diabetic 40 66.4 ± 8.7 10.5 ± 2.1 8.5 ± 4.1
Control 32 64.3 ± 6.9 5.5 ± 2.6 9.6 ± 5.7
Mann-Whitney U test 0.26 0.0073 0.084
P value NS <0.01 NS
NS: Not significant.
Table 5. Correlation of duration of denture wearing with the amount of mandibular ridge resorption between study
groups.
Mandibular residual ridge resorption (in %)
Diabetic Control
Denture age
Years
n % n %
Chi square testP valueLevel of significance
<3 5 19.5 4 9.4 59.6 0.024 <0.001
3 - 5 10 27.2 9 12.1 45.4 0.031 <0.001
5 - 9 12 38.3 10 18.8 33.7 0.046 <0.001
10 - 14 7 46.4 5 20.0 29.4 0.048 <0.001
15 - 19 4 55.6 3 33.7 16.5 0.084 <0.05
>20 2 68.7 1 41.5 12.2 0.093 <0.05
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4. DISCUSSION
The study population consisted of all persons who at-
tended or (referred to) the Prosthodontic Clinic, Division
of Dentistry, Prince Rashid Hospital, Irbid, Jordan; for
the provision of CD construction, or replacement or
maintenance and correction of their existing old ones
with new sets of dentures. The patients were interviewed
in the clinic, and their OPGs were evaluated to deter-
mine the amount of RRR by using the MF as a reference
point in the measurements so that the amount of man-
dibular RRR can be estimated and compared between
DM subjects and controls.
Alveolar ridge resorption after teeth extraction is a
chronic, progressive and cumulative disease of bone
reconstruction. Extensive RRR is one of the many prob-
lems in prosthetic dentistry rehabilitation [23,24]. Many
local and systemic factors are related with RRR. Local
factors include conditions after teeth extraction (quality,
quantity and shape of the residual ridge, muscle attach-
ment, etc.), edentulousness, bite stress from the denture
to the edentulous ridge. Systemic factors include pa-
tient’s age, gender, Ca deficiency, Ca and P metabolism
disorders, systemic osteoporosis and hormonal distur-
bances. All these factors together cause resorptive ch-
anges in the edentulous parts of the maxilla and mandi-
ble [25].
DM is a common disorder of carbohydrate metabo-
lism through either decreased production of insulin or
tissue resistance to the effects of insulin [26]. The risk
for alveolar bone loss is greater, and bone loss progres-
sion more severe, for subjects with poorly-controlled
T2DM compared to nondiabetic individuals or with bet-
ter controlled diabetes [27]. T2DM was positively asso-
ciated with greater risk for a change in bone score
(compared to subjects without diabetes) [28]. These re-
sults suggest that poorer glycemic control leads to both
an increased risk for alveolar bone loss and more severe
progression over those without T2DM [29].
In this study it was found that the amount of man-
dibular RRR among T2DM subjects was higher than that
among nondiabetic subjects. It has been reported that
diabetic patients have a wide range of defects that delay
the healing process and that increase their susceptibility
to infection [30].
Furthermore, the prevalence of bone resorption among
patients with diabetes tends to be greater than among the
general population; this difference may be related to
hyperglycemia in the former group [31].
Accursi [32] examined the impact of DM on the suc-
cess of dental implants. He concluded that the diabetic
patients were more likely to have greater loss in crestal
bone levels around the implants than the nondiabetic
patients. In addition, he also reported interesting soft-
tissue and neurological complications in the diabetic
group. He found that soft-tissue complications were
similar in number in the diabetic and control groups; in
both groups, these complications were mainly of a minor
nature and resolved with improvement in oral hygiene.
In the present study, gender-related differences were
recorded in both groups. Female subjects were shown to
have more amount of mandibular RRR compared with
their male counterparts. In addition, diabetic females
suffered more resorption than the female controls. Most
of the females in the present study were past the usual
age for menopause, and this may explain the gen-
der-related difference observed in this study. Previous
studies have reported similar results [33,34]. Further-
more, experimental evidence has shown that estrogen
depletion leads to a significant loss of bone mass in the
edentulous mandible but not in the dentate mandible
[35].
Xie et al. [36] have found that females have more al-
veolar RRR than males, while Atwood and Coy have
presented a slightly higher rate in males [37]. The results
of the present study have suggested that alveolar RRR is
more noticeable in females. This phenomenon could be
explained with the effect of the menopausal activity in
women on the alveolar RRR.
Previous studies showed that women had reduced ma-
sticatory function compared with males, because women
had greater amount of mandibular bone reduction which
is associated with reduced cortical thickness [38], and
resulted in reduction in bone height [39]. Conversely,
some researchers have reported that it is not known, if
mandibular bone loss observed in the edentulous mandi-
ble in association with estrogen deficiency [35], results
from increased bone resorption alone or the combined
effect of increased bone resorption and reduction in bone
formation rate [40].
The amount of mandibular RRR was significantly
correlated with the number of years subjects were eden-
tulous, however, diabetic patients were shown to have
more resorption when compared with control subjects.
These findings are in agreement with previous studies
[41-43].
MF landmark selected for the present study is com-
monly used for studies of mandibular bone as it is fairly
reproducible [44-46]. The location of the MF relative to
the inferior and superior borders of normal mandibles, as
expressed by the mean ratio of total bone height to
height of the foramen above the inferior border, appears
to be consisted enough to justify its use as a reference
point in clinical studies. Since the bone below MF con-
stitutes a predictable proportion of the total bone height
in the majority of normal subjects, and since this bone is
not significantly affected by resorption until extreme

O. Al-Jabrah / Open Journal of Stomatology 1 (2011) 61-68 66
atrophy occurs, its height may serve as the basis for es-
timating the original mandibular height in elderly sub-
jects [22].
In this study, Wical and Swoope method was used to
evaluate the amount of mandibular RRR [22]. Clinically,
the lower edge of the MF appears to be a more useful
reference mark in OPGs. Observing the distance from
the inferior border of the mandible to the lower edge of
MF and using the approximate ratio of 3:1 can help to
estimate conveniently the original height of the mandible
before resorption [47,48].
The main objectives of preoperative assessment are to
determine if there is sufficient bone in the alveolar ridge
and to determine the precise position of the anatomical
structures in order not to be damaged during surgery
[17,49].
OPG is a widely used technique because it has the
advantage of providing, in a single film, the image of
both jaws, with a relatively low radiation dose, in a short
period of time, and at lower cost if compared to more
sophisticated techniques [50]. This technique can offer
information about the localization of anatomic structures
and vertical bony dimensions. However, without know-
ing the magnification degree and the image distortion,
mistakes in measurements may occur, in addition, OPG
does not provide the buccolingual view of the bone [51].
As changes in the mandibular cortex can be detected
on the OPG of patients with osteoporosis, it can be con-
sidered an important diagnostic tool [52] provided that
diagnostic values are not lost due to projection errors
resulting from disposition of the head [53]. OPGs can be
used in determining the bone density, as a relationship
between mandibular bone mineral density and the skele-
tal areas in evaluating osteoporosis has been shown [54].
Several studies have reported that OPGs are repro-
ducible and accurate for the linear and angular meas-
urements on mandibles [50,55]. It has been shown that
reliability of the OPG technique for imaging of the man-
dible is highly dependent on head position [36,56].
RRR has been measured using various radiographic
techniques [22,23,37]. In the present study, OPGs were
made by an experienced radiograph technician using the
same panoramic unit. The technique for the measure-
ment of the alveolar ridge resorption used was essen-
tially the same as that described by Wical and Swoope.
[22]. In a study of Wilding et al., in which the reliability
of this technique was tested, it has been concluded that
the use of this technique is sufficient to provide informa-
tion about RRR of mandibular alveolar bone compared
to a more complicated method [50].
The results of this study highlight on the association
between DM and RRR in completely edentulous, CD
wearers. It has been shown that women in particular, are
at risk of RRR than nondiabetic subjects. For diabetics,
effort should be taken to retain natural teeth to the long-
est time possible as the amount of resorption would in-
crease with increasing CD wearing period. Basker et al.
reported that the amount of bone resorption in edentu-
lous area is eight times than that in dentate area in the
same subject [57].
Further research on a larger sample and including
other factors; such as other local and systemic factors,
denture quality measures, general health status and wider
age range may be needed before the results of this study
can be applied on the general population.
5. CONCLUSIONS
Within the limitations of this study, the following con-
clusions can be withdrawn;
1) The mean amount of mandibular RRR in the whole
sample is approximately 27%.
2) Statistically significant difference (P < 0.01) be-
tween the two study groups has been recorded, diabetic
patients has two times greater amount of RRR compared
to controls (35.8% versus 18.0%).
3) When compared with males, female subjects sig-
nificantly have greater amount of RRR in both groups (P
< 0.001). Significantly, diabetic females recorded the
highest amount of RRR compared to diabetic males
(49.7% versus 21.8%; P < 0.001). Similar figures were
recorded in control group (22.3% versus 13.7%; P <
0.05).
4) There were no differences in both groups regarding
the age of the participants and the length of time they
have been edentulous and years of CD wearing.
5) The amount of mandibular RRR was directly re-
lated to the number of years subjects were edentulous.
Diabetic patients were significantly shown to have more
resorption when compared with control subjects.
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