Objective: The objective of this study was to investigate the diagnostic accuracy of visual assessment of the trabecular pattern in intraoral periapical radiographs to identify female subjects at risk of having osteoporosis. Study design: Six hundred female subjects underwent intraoral periapical radiography of the maxillary and mandibular premolar region. Five observers assessed the trabecular pattern as dense, heterogeneous, or sparse, with the aid of reference images. All patients received a central dual energy x-ray absorptiometry (DXA) examination of the hip and lumbar spine. Results: With sparse trabecular pattern as indicative of osteoporosis, mean specificity was high (91.6 for the upper jaw and 90.8 for the lower jaw) while the sensitivity was low (28.2 for the upper and lower jaw). The mean intraobserver agreement was comparable for radiographs of the upper and lower jaw (median κw 0.53 and 0.57, respectively). Conclusion: Visual assessment of the trabecular pattern in intraoral periapical radiographs of premolar regions is a potential method to identify women at risk of having osteoporosis. © 2008 Mosby, Inc. All rights reserved.