Disorders of parathyroid gland

University Of Sulaimani

Faculty Of Medical Sciences

School Of Dentistry

Oral Diagnosis Department

Disorders of

Parathyroid glands

By: Garmyan Yawar

2015/2016

Parathyroid Gland• Parathyroid consists of four small glands

which are paired and located behind the thyroid gland in the neck. Parathyroid glands produce and release parathyroid hormone (PTH), which is involved in regulating the metabolism of calcium and phosphorus. So, it plays an important role in tooth and bone mineralization (1)

• (1)Oral Manifestations of Parathyroid Disorders and Its Dental Management , Sanjeev Mittal, Deepak Gupta1 , Sahil Sekhri, Shivali Goyal Department of Posthodontics, MM college of Dental Sciences and Research, Mullana, Ambala, Haryana, 1 Department of Orthodontics, HS Judge Dental College, Panjab University, Chandigarh, India

Parathyroid gland

Function of parathyroid gland

• The major function of the parathyroid glands is to maintain the body's Calcium and phosphate levels within a very narrow range, so that the nervous and muscular system can function properly by parathyroid hormone (PTH).

Disorders of Parathyroid Hormone

Hyperparathyroidism

Hypoparathyroidism

• Hyperparathyroidism is a metabolic disorder with excessive secretion of Parathyroid hormone (PTH) extensively above the normal level (12-70 pg/mL)(2) , HPT can be characterized into primary, secondary, and tertiary forms.

• (2) Primary Hyperparathyroidism Presented as Central Giant Cell Granuloma of Jaw Bones. A Report of Three Cases Ibrahim Saeed Gataa1 BDS, FICMS Faraedon M. Zardawi2* BDS, MSc, PhD

• Hyperparathyroidism (HPT) is a disorder characterized by an excessive amount of parathyroid hormone secretion by the parathyroid glands. Depending on the cause of this PTH production, HPT can be characterized into primary, secondary, and tertiary forms.(3)

• (3)Mandibular Brown Tumor of Secondary Hyperparathyroidism Requiring Extensive Resection: A Forgotten Entity in the Developed World?

• Mohammed Qaisi, 1 , * Matthew Loeb, 2 Lindsay Montague, 3 and Ron Caloss 4

Signs and SymptomsSymptoms may be so mild and nonspecific that they don't seem at all

related to parathyroid function, or they may be severe. The range of signs and symptoms include:

• Fragile bones that easily fracture (osteoporosis)• Kidney stones• Excessive urination• Abdominal pain• Tiring easily or weakness• Depression or forgetfulness• Bone and joint pain• Frequent complaints of illness with no apparent cause• Nausea, vomiting or loss of appetite

Hyperparathyroidism

Hyperparathyroidism

Primary

Parathyroid hyperplasia

Parathyroid

adenoma

Parathyroid

carcinoma

Secondary

Parathyroid

hyperplasia

Tertiary

Autonomous nodule on top of

hyperplasia

Primary hyperparathyroidism• Primary hyperparathyroidism is defined by an

increased PTH production related to a parathyroid adenoma in most cases (85%), followed by parathyroid hyperplasia and parathyroid carcinoma (1%).

Biological examination often reveals hypercalcaemia and low or normal serum phosphate level. Kidney stones (4)

• (4) Hyperparathyroidism-jaw tumour syndrome detected by aggressive generalized osteitis fibrosa cystica

• Alae Guerrouani, Abdelkader Rzin, and Karim El Khatib

In primary HPT, about 50% of patients have no symptoms and the problem is picked up as an incidental finding (via raised calcium or characteristic X-ray appearances [subperiosteal resorption of the phalanges of the index and middle fingers]). (5)

(5) Previous resource

k

subperiosteal resorption of the phalanges of the index and

middle fingers

• When the parathyroid glands are stimulated to produce increased amounts of hormones to correct abnormally low serum calcium levels in different physiologic or pathologic conditions like renal failure, intestinal malabsorption syndrome, decrease of Vitamin D production, thus resulting in parathyroid hyperplasia.

Secondary Hyperparathyroidism

Tertiary hypoparathyroidism• Tertiary When long-standing secondary

hyperplasia becomes autonomous in spite of correction of the underlying stimulant (renal transplant).

Radiographic findings

• HPT is the most common cause of generalized

rarification of the jaws. The radiograph is typically

described as loss of medullary trabecular pattern,

jaw appears finely radiopaque described as clear

“ground glass” appearance

This case shows the decreased bone trabeculation giving it a ‘ground-

glass’ or granular appearance

Diagnosis• Diagnosis Serum parathyroid hormone (normal

range 15-65 pg/ml) and calcium (normal range 9-11 mg/dl)

The gold standard of diagnosis is the parathyroid immunoassay. Once an elevated PTH has been confirmed, goal of diagnosis is to determine whether the HPT is primary or secondary in origin by obtaining a serum calcium level). Very high serum calcium level due indicate primary HPT. Whereas, low or normal calcium level may indicate secondary HPT. Tertiary HPT has a high PTH and high serum calcium. It is differentiated from primary HPT by a history of chronic kidney failure and secondary HPT.

Alkaline phosphatase (normal range 500-750

IU/L)• Alkaline phosphatase levels are usually

elevated in HPT. In primary hyperthyroidism, levels may remain within the normal range, however, this is “inappropriately normal” given the increased levels of plasma calcium.

Oral ManifestationsDental abnormalities• Obliteration of pulp chamber by pulp stone• Alterations in dental eruption• Loosening and drifting of teeth• Malocclusions• Spacing of teeth• Partial loss of lamina dura• Pariodontal ligament widening• Teeth become sensitive to percussionand mastication• Floating teeth

Oral manifestaion• Brown tumor• Generalized bone rarification of jaw• Soft tissue calcifications• Hypercalcemia may result in sialolithiasis• Mandibular tori• Complaint of vague jaw bone pain

Dental management of the patient with hyperparathyroidism• The clinical management of these patients does not

require any special consideration. We should know that there is a higher risk of bone fracture, so we must take precaution in surgical treatments.

• Jaw enlargement is treated by recontouring of the maxilla and mandible. A three-dimensional reconstruction of the computed tomography (CT) scan was helpful in evaluating the facial deformities and in treatment planning.

• A thorough clinical and radiographic examination is essential before providing endodontic treatment.

• The sequence of diagnostic procedures must begin with a well-organized review of the medical history. There are a number of systemic diseases that can cause bone lesions throughout the body. In some instances, these lesions appear in the periapical region of teeth and can lead to a misdiagnosis of a lesion of endodontic origin.[1,2,12] The finding of periapical radiolucency on a radiograph should not automatically lead to access opening and root canal therapy by the dentist.

Hypoparathyroidism• Hypoparathyroidism is a metabolic disorder

characterized by low serum calcium and high serum phosphorus concentrations due to a deficiency or absence of PTH secretion.

EtiologyIt may also develop as an isolated entity of unknown

etiology (idiopathic), or in combination with other disorders such as autoimmune diseases or developmental defects.

In primary hypoparathyroidism, parathyroid gland is either not present or atrophied or do not function normally or damage to parathyroid gland after surgical excision (acquired hypoparathyroidism). As a consequence, the concentration of PTH in the serum is often low. In pseudohypoparathyroidism (PHP), parathyroid gland function is normal, but kidneys fail to respond to PTH due to deficient receptor. As a result, the parathyroid glands secrete the hormone in excess, and serum-PTH is increased.

• Signs and symptoms of hypoparathyroidism can include:

• Tingling or burning (paresthesias) in your fingertips, toes and lips

• Muscle aches or cramps affecting your legs, feet, abdomen or face

• Twitching or spasms of your muscles, particularly around your mouth, but also in your hands, arms and throat

• Fatigue or weakness• Painful menstruation

• Patchy hair loss, such as thinning of your eyebrows• Dry, coarse skin• Brittle nails• Headaches• Depression, mood swings• Memory problems

Diagnosis• Diagnosis In primary

hypoparathyroidism, serum calcium and PTH are low, serum phosphate level is high and alkaline phosphatase is normal. In PHP serum calcium is low, PTH is high or normal

Oral and Dental manifestations of hypoparathyroidism• Dental abnormalities• Enamel hypoplasia• Delayed eruption• Hypodontia and microdontia• Poorly calcified dentin• Widened pulp chamber• Dental pulp calcification• Shortened roots with blunt apex• Malformed roots

• Delay or cessation of dental development• Dental malocclusion• Caries • Chronic candidiasis• Paresthesia of the tongue or lips• Alteration in facial muscles

Dental Management • Dental management of the patient with

hypoparathyroidism These patients have more susceptibility to caries because of dental anomalies. Dental management will be the prevention of caries with periodic check-up, advice regarding diet and oral hygiene instructions.

• Before performing the dental treatment, serum calcium levels should be determined. They must be above 8 mg/100 ml to prevent cardiac arrhythmias, seizures, laryngospasms or bronchospasms.

• As pulp chamber are large caries, easily involve the pulp causing pulpitis, requiring endodontic treatment.

• Pulp calcification and malformed root cause difficulty in endodontic treatment.

• Ankylosis causes difficulty in extraction.

• Delayed eruption and hypodontia cause malposition and has to be treated by orthodontics.

References• 1)Oral Manifestations of Parathyroid Disorders and Its Dental

Management , Sanjeev Mittal, Deepak Gupta1 , Sahil Sekhri, Shivali Goyal Department of Posthodontics, MM college of Dental Sciences and Research, Mullana, Ambala, Haryana, 1 Department of Orthodontics, HS Judge Dental College, Panjab University, Chandigarh, India

• (2) Primary Hyperparathyroidism Presented as Central Giant Cell Granuloma of Jaw Bones. A Report of Three Cases Ibrahim Saeed Gataa1 BDS, FICMS Faraedon M. Zardawi2* BDS, MSc, PhD

• (3) Hyperparathyroidism-jaw tumour syndrome detected by aggressive generalized osteitis fibrosa cystica

• Alae Guerrouani, Abdelkader Rzin, and Karim El Khatib

• (4)Mandibular Brown Tumor of Secondary Hyperparathyroidism Requiring Extensive Resection: A Forgotten Entity in the Developed World?

• Mohammed Qaisi, 1 , * Matthew Loeb, 2 Lindsay Montague, 3 and Ron Caloss 4