The development of bone mineral densitimometry methodologies, especially central dual energy X-ray absorptiometry (DXA) methods have allowed this quantitative tool to be used to diagnose osteoporosis before the first fragility fracture has occurred. The World Health Organization osteoporosis working group set the stage for the BMD cut-off criteria development. The wide application of DXA has brought the treatment of osteoporosis to the primary care level, a very necessary step if this increasingly prevalent disease is to have a decline in its incidence. The most difficult osteoporosis cases, for which there are many and their associated difficult DXA results and interpretation will always require specialists' involvement. In particular, the embracement of the WHO absolute fracture risk validated project will take DXA to a much greater level of value in making management decisions. In particular, the WHO absolute risk data will allow physicians, health-economic policy makers, and payors of medical services to come closer together to decide which patients are at a level of unacceptable fracture risk that justifies treatment intervention. The implementation of this validated project will also remove the unacceptable subjective computer printouts on DXA reports that often lead to the over-treatment of low risk patients and at times the under-treatment of high risk patients. The evolution of the clinical interpretation of bone densitometry has been a work in progress. Challenges in the clinical measurement of bone strength remain and will also evolve. The field of osteoporosis has grown with the use of DXA and will continue to embrace this technology as other technologies to measure fracture risk become applied in clinical practice.