Fractal dimension (FD) calculated on oral radiographs has been proposed as a useful tool to screen for osteoporosis. This systematic review and meta-analysis firstly aimed at assessing the reliability of FD measures in distinguishing osteoporotic patients (OP) from healthy controls (HC), and secondly, to identify a standardized procedure of FD calculation in dental radiographs for the possible use as a surrogate measure of osteoporosis. A comprehensive search was conducted up to September 2020 using PubMed, Web of Science, and SCOPUS databases. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement was followed. Meta-analysis was performed on FD values calculated for HC and OP. Overall, 293 articles were identified. After a three steps screening, 19 studies were included in the qualitative appraisal and 12 were considered for meta-analysis. The methodological quality of the retrieved studies was generally low. Most of the studies included used White and Rudolph and box counting to process the images and to calculate FD, respectively. Overall, 51% of the studies found a meaningful difference between HC and OP groups. Meta-analyses showed that to date, FD measures on dental radiographs are not able to distinguish the OP from HC group significantly. From the current evidence, the use of FD for the identification of OP is not reliable, and no clear conclusion can be drawn due to the heterogeneity of studies. The present review revealed the need for further studies and provided the fundamentals to design them in order to find a standardized procedure for FD calculation (regions for FD assessment; images processing technique; methods for FD measurement). More effort should be made to identify osteoporosis using dental images which are cheap and routinely taken during periodic dental examinations.
Keywords: Bone mineral density; Cone-beam computed tomography; Dental; Fractals; Osteoporosis; Panoramic; Radiography.