Systemic Diseases Manifested in the Jaws PDF

DSX 312 Systemic diseases manifested in the jaws DR. MD. MAHMUD UZ ZAMAN BDS, PhD Asst. Prof. Oral and Maxillofacial Surgery and diagnostic sciences department Ch 25 Diseases Affecting the Structure of Bone (pp.519) Oral Radiology, Principles and Interpretatio...

DSX 312 Systemic diseases manifested in the jaws DR. MD. MAHMUD UZ ZAMAN BDS, PhD Asst. Prof. Oral and Maxillofacial Surgery and diagnostic sciences department Ch 25 Diseases Affecting the Structure of Bone (pp.519) Oral Radiology, Principles and Interpretation By Mallya & Lam. (8th Ed.)  Systemic Diseases Manifested in the Jaws Endocranial Metabolic Others Hyperparathyroidism Osteopenia Progressive systemic Hypoparathyroidism Rickets and osteomalacia Sclerosis Hyperpituitrism Hypophosphatic Rickets Hypopituitrism Hypophosphatasia Sickel cell anemia Hyperthyroidism Osteopetrosis Hypothyroidism Thalassemia Hypercortisolism  Systemic Diseases Manifested in the Jaws Endocranial Metabolic Others Hyperparathyroidism Osteopenia Progressive systemic Hypoparathyroidism Rickets and osteomalacia Sclerosis Hyperpituitrism Hypophosphatic Rickets Hypopituitrism Hypophosphatasia Sickel cell anemia Hyperthyroidism Osteopetrosis Hypothyroidism Thalassemia Hypercortisolism General Radiographic Findings: Systemic diseases affect the entire body ,the radiographic changes manifested in the jaw are generalized. Change in the size and shape of the bone. Change in the number size and orientation of the trabeculae. Altered thickness and density of the cortical structures. General Radiographic Findings: An increase and decrease in overall density. Systemic conditions that result in the decrease in bone density do not effect the mature teeth.  Image of the tooth may stand out with normal density against the radiolucent jaw. Changes to Teeth and Associated Structures  Accelerated or delayed eruption. Hypoplasia. Hypocalcification. Loss of lamina dura.  Endocrinal Disorders Hyperparathyroidism :  An endocrine abnormality in which there is an excess of PTH  As a result, it mobilizes Ca from skeleton and increases renal tubular reabsorption of Ca, the net result is increase in the serum Ca levels.  Two types : Primary and secondary.  Hyperparathyroidism Primary: Benign tumor, increased PTH with the resultant hypercalcemia. Secondary: Occurs in certain kidney diseases. compensatory increase in the output of PTH in response to hypocalcemia (Vit D def). Diagnosis:  Increased level of PTH (Normal values are 10 to 55 pg/mL.)  Hypercalcemia (Normal values are 8.5-10.2 mg/dL)  Serum alkaline phosphatase may rise.  Hyperparathyroidism Clinical Features Age : 30 - 60 years Sex: More in females  Hypercalcemia results in:  Renal calculi  Peptic ulcers  Cognitive impairment  Bone and joint pain  Drifting and loss of teeth.  Serum alkaline phosphatase levels may also increase.  Hyperparathyroidism Radiographic Features: Teeth and Associated structures  Loss of the lamina dura  Tapered appearance of teeth.  Hyperparathyroidism Radiographic Features: Jaws:  Demineralization and thinning of cortical boundaries often occur in the jaws. - Inferior border of mandible - Mandibular canal - Maxillary sinuses.  Hyperparathyroidism Radiographic Features: Jaws:  The density of the jaws is decreased.  A change in the normal trabecular pattern may occur, resulting in a ground-glass appearance of numerous, small, randomly oriented trabeculae.  Hyperparathyroidism Radiographic Features: Jaws:  Brown tumors with variably defined margins and may cause cortical expansion. Multiple or solitary (DD. central giant cell granuloma).  Hyperparathyroidism Radiographic Features: The major manifestations of HPTH include: 1. Erosions in the phalanges of the hands. 2. Demineralization of the skeleton: radiolucent skeleton image. 3.Osteitis fibrosa cystica : Single or multifocal ill defined radiolucencies  Hyperparathyroidism Radiographic Features: 4. Brown tumors :Occurs later in many bones including the mandible. 5. Pathologic calcifications in soft tissues: kidneys, joints.  Hyperparathyroidism Radiographic Features: 6. Granular appearance and loss of structure of the calvaria as well as the jaw bones known as “salt and pepper skull”  Hypoparathyroidism Causes of Hypoparathyroidism: True Hypoparathyroidism: Pseudo Hypoparathyroidism - Damage of the gland. - Defect in response of the target tissue cells to PTH. - Surgery of thyroid gland.  Hypoparathyroidism Clinical features  Tetany with carpopedal spasm (sharp flexion of the wrists & ankles) and muscle spasm.  Paresthesia of hands, feet and around the mouth.  Neurologic changes, anxiety and depression, epilepsy, parkinsonism and chorea.  Hypoparathyroidism Radiographic Features: Skull  Calcification of basal ganglia Teeth  Enamel hypoplasia  External root resorption  Delayed eruption  Root dilaceration.  Hyperthyroidism o Increased Thyroxin level. o More in female. o Occurs with diffuse toxic goiter (Grave's disease), toxic nodular goiter or an adenoma of the gland. o High BMR results in tachycardia, high B.P., irritability, inability to tolerate hot weather.  Hyperthyroidism Children: Early eruption & Premature loss of primary teeth. Excessive bone resorption Adults: Generalized decrease in bone density.  Hyporthyroidism At birth: Cretinism In children: Juvenile Myxedema Clinical features  Retarded mental and physical development. Skull  Delayed closure of fontanelles and epiphysis.  Delay ossification of the base of the skull. Jaws and teeth  Relatively small mandible and maxilla.  Short roots.  Thin lamina dura.  Delayed eruption and exfoliation of teeth.  Hyporthyroidism In adults : Myxedema Clinical features  Dull expressionless face.  Periorbital edema.  Sparse hairs.  Skin feels doughy to touch. Jaws and teeth  Periodontal disease and loss of teeth.  Enlarged tongue may be with spacing of teeth.  External root resorption.  Metabolic Bone Disease Osteopenia  Imbalance of bone deposition and resorption that results in a net decrease in bone formation.  Histopathologic appearance of the bone may seem normal.  Changes in the trabecular architecture and the size and thickness of individual trabeculae.  Osteopenia Clinical Features  Asymptomatic at most of early stages.  Fracture of bones (radius, femur, ribs and vertebrae).  Bone pain.  Most population at risk are postmenopausal females.  Osteopenia Radiographic Features  Overall reduction of bone density.  Thinning and reduced density of the cortical boundaries.  Occasionally the lamina dura may appear thinner than normal.  In mandible, a reduction in the number of trabeculae may be evident.  Osteopenia Management  Administration of estrogens and calcium and vitamin D supplements after menopause.  Weight-bearing exercise.  Oral antiresorptive medications.  Rickets and Osteomalacia Nutritional deficiency of vitamin D Clinical Features of Rickets Early  In the first 6 months of life, tetany or convulsions. Later  Craniotabes , softening of the parietal bones.  The child is of short stature.  Deformity of extremities (bowing of legs ).  Swelling of wrists and ankles.  Delayed development of dentition.  Delayed eruption of teeth.  Enamel and dentin may be hypocalcified.  Osteomalacia Clinical Features of Osteomalacia  Bone pain.  Muscle weakness.  “Penguin” gait.  Tetany.  Green stick fracture.  Rickets Radiographic Features of Rickets Jaws and Teeth  Before 3 years, enamel hypoplasia & delayed tooth eruption.  Thinning or missing of cortical structures, inferior border, mandibular canal, lamina dura & follicular wall of developing teeth.  Finer trabeculation of bone and in severe cases there is an overall radiolucency.  Rickets Radiographic Features of Rickets General Features  Widening of epiphysis of long bones  Bowing of weight bearing bones.  Green stick fractures.  Osteomalacia Radiographic Features General Features  Cortex of bone may be thin.  Pseudofractures occur most commonly in the ribs, pelvis, and weight-bearing bones and rarely in the mandible. Jaws and Teeth  An overall radiolucent appearance and sparse trabeculae.  The lamina dura may be especially thin in individuals with long- standing or severe osteomalacia.  Osteopetrosis Clinical Features Infants and Young Children  The more severe recessive form is fatal in early in life.  Progressive loss of the bone marrow and its cellular products  Severe increase in bone density.  The narrowing of bony canals results in hydrocephalus, blindness, deafness, vestibular nerve dysfunction, and facial nerve paralysis. Clinical Features Osteopetrosis Adult  The more benign, dominant form.  Milder and may be entirely asymptomatic.  Incidental finding or appear as a pathologic fracture of a bone.  In some of the more chronic cases, bone pain and cranial nerve palsies caused by neural compression. Osteomyelitis may complicate this disease because of the relative lack of vascularity of the dense bone (more common in mandible).  Osteopetrosis Radiographic features General Features.  Increased density, which is bilaterally symmetric.  Homogeneous and diffused density.  Trabecular patterns of the medullary cavity may not be visible.  Reduces the contrast between the outer cortical border and the cancellous portion of the bone.  The entire bone may be mildly enlarged. Osteopetrosis Osteopetrosis  Osteopetrosis Radiographic Features Jaws.  Early tooth loss, missing teeth, malformed roots and crowns, and teeth that are poorly calcified and prone to caries.  The normal eruption pattern may be delayed.  The lamina dura and cortical borders may appear thicker than normal.  Fail to reveal any internal structure, and even the roots of the teeth may not be apparent.  The normal interface between cortical and cancellous bone may be lost.  The inferior alveolar canal may appear very prominent.  The bone may appear underexposed due to failure of the incident x-ray beam to penetrate the bone.  Sickle Cell Anemia A hereditary hemolytic blood disorder characterized by abnormal hemoglobin which results in sickle shaped red blood cells. Clinical Features Mild attacks : Fatigability, weakness, shortness of breath, muscle and joint pain. Severe exacerbations: Called sickle cell crises, severe abdominal, muscle and joint pain, high temperature and may be circulatory collapse (elicited by exercise).  Sickle Cell Anemia Radiographic Features Jaw features  General osteopenia.  Thinning of cortical plates.  In the alveolar bone, coarser trabeculation.  Sickle Cell Anemia Radiographic Features  Thinning of cancellous trabeculae due to bone marrow hyperplasia , vertebral bodies, long bones, skull and jaws.  Skull: widening of the diploic space and thinning of outer and inner tables and may be “ hair on end appearance “.  Sclerotic areas.  Osteomyelitis if infection occurs.  Thalassemia Cooly’s anemia , Mediterranean anemia (Mediteranian, Africa, India, South Asia) Clinical Features In infants : A severe form of the disease occurs with short survival time. In adults : A milder form of the disease occurs. Prominent cheek bones and protruded premaxilla. “rodent-like” face. Radiographic Thalassemia Features  Skull: Widening of the diploic space and thinning of outer and inner tables and may be “ hair on end appearance “.  Generalized lucency of long bones with occasional pathological fracture. Radiographic Thalassemia Features  Jaw : large marrow spaces , coarse trabeculae , thin lamina dura & short roots.  Prominent premaxilla resulting in malocclusion.  The trabeculae are large and coarse. Thank you