Osteoporosis - Part 3: Interpreting Bone Density Test Reports
by Dr. Jason Kwok
You can listen to an audible version of this article.
The results of a bone density test are usually reported in two numbers: the T-score and the Z-score.
Currently, the most commonly used bone density test is the dual energy x-ray absorptiometry (DEXA) which involves lying on a bed and receiving a small dose of X-rays. The X-ray detector scans the spine and hip bones, measures the amount of X-rays that pass through them, and calculates the bone density. The test only takes a few minutes, is painless, and does not require any injections. During the test, the legs may need to be lifted to straighten the back. The amount of X-rays received during the test is also very low and is not enough to cause any serious side effects.
The Z-score is a unit that measures the deviation of an individual's bone density from the normal values of people of the same age, gender, weight, and ethnicity. These units are called "standard deviations" (SD), which indicate how much the difference is. Positive symbols (+) are given for values above normal, and negative symbols (-) for values below normal. Comparing bone density to that of someone of the same age can be misleading for older adults because their bone density is usually lower. Therefore, the Z-score is not used to diagnose osteoporosis. However, a Z-score of -2 or lower indicates abnormal bone loss due to factors other than age, and doctors will conduct further tests to identify the underlying problem and determine the appropriate treatment to prevent or slow further bone loss.
The T-score is a unit that measures the deviation of an individual's bone density from that of a healthy young person of the same gender. Similarly, positive symbols are given for values above average, and negative symbols for values below average. The World Health Organization (WHO) classifies T-scores as follows: (1) -1 or higher: normal; (2) -1 to -2.5: osteopenia - bone density is lower than normal, and this can progress to osteoporosis; (3) -2.5 or lower: osteoporosis.
Doctors cannot assess the risk of fractures based solely on bone density test results and the WHO classification. They need to calculate the risk of fractures over ten years for the individual being tested. Currently, there are two assessment methods:
(1.) for all people over 65 years of age; and
(2) for postmenopausal women and men aged between 50 and 65 years who have the following high-risk factors for fractures:
• A fragility fracture after the age of 40;
• X-rays show spinal fractures or low bone density;
• A parent has had a hip fracture;
• Drinking a lot of alcohol (drinking three or more alcoholic drinks per day);
• Smoking;
• Low body weight (less than 132 pounds or 60 kilograms);
• A weight loss of 10% or more since the age of 25;
• Taking medications that increase the risk of osteoporosis, such as long-term use of corticosteroids, aromatase inhibitors used to treat breast cancer, or androgen deprivation therapy used to treat prostate cancer, among others.
(3.) Younger individuals (under 50 years old):
• A history of fragility fracture;
• Taking medications that increase the risk of osteoporosis, such as corticosteroids, aromatase inhibitors, and androgen deprivation therapy;
• Having diseases that cause bone loss, including rheumatoid arthritis and other chronic inflammations, Cushing's disease, etc.
For most people, the two methods of calculating the risk assessment are roughly the same, and the choice of which method to use is purely a matter of personal preference and convenience for the doctor. However, it can provide doctors with useful information to assess the patient's risk of fracture over a ten-year period and make appropriate preventive measures and treatment plans. 
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