Systemic Diseases Manifestedin the Jaws

C H A P T E R 25 Oral Radiology

P R I N C I P L E Sa n d I N T E R P R E T A T I O N Sixth Edition

White and pharoahSeyed vahid malek hosseini

Systemic Diseases Manifestedin the Jaws

• Disorders of the endocrine system, bone metabolism, and other systemic diseases may have an effect on the form and function of bone and teeth.

• Bone functions: support, protection, reserve of calcium for the body environment for hemopoiesis

• The effects of systemic diseases of bone are brought about by changes in the number and activity of osteoclasts, osteoblasts, and osteocytes.

Radiographic Features• 1. A change in size and shape of the bone• 2. A change in the number, size, and orientation of trabeculae• 3. Altered thickness and density of cortical structures• 4. An increase or decrease in overall bone density

Endocrine Disorders• HYPERPARATHYROIDISM

• PTH increases bone remodeling in preference of osteoclastic resorption, which mobilizes calcium from the skeleton • Women are two to three times more commonly affected than men• 30 to 60 years of age.

Clinical manifestations• renal calculi, peptic ulcers, psychiatric problems, or bone and joint

pain.• All related to hypercalcemia.• Gradual loosening, drifting, and loss of teeth may occur.

Radiographic Features

• Only about one in fi ve patients with hyperparathyroidism has radiographically observable bone changes• 1. The earliest and most reliable changes of hyperparathyroidism are

subtle erosions of bone from the subperiosteal surfaces of the phalanges of the hands.• 2. Demineralization of the skeleton results in an unusual radiolucent

appearance.• 3. Osteitis fibrosa cystica are localized regions of bone loss produced by

osteoclastic activity resulting in a loss of all apparent bone structure.

• 4. Brown tumors occur late in the disease and in about 10% of cases. These peripheral or central tumors of bone are radiolucent. The gross specimen has a brown or reddish-brown color.• 5. Pathologic calcifications in soft tissues have a punctate or

nodular appearance and occur in the kidneys and joints• 6. In prominent hyperparathyroidism, the entire calvarium

has a granular appearance caused by the loss of central (diploic) trabeculae and thinning of the cortical tables

Radiographic Features of the Jaws.• Demineralization and thinning of cortical boundaries :jaws cortical

inferior border, mandibular canal, and the maxillary sinuses• radiolucent appearance that contrasts with the density of the teeth• change in the normal trabecular pattern = ground-glass• Brown tumors in facial bones and jaws

Brown tumors• May be Multiple within a single bone• defined margins• May produce cortical expansion• If solitary, the tumor may resemble a central giant cell granuloma or

an aneurysmal bone cyst

Radiographic Features of the Teeth and AssociatedStructures

• loss of the lamina dura that may give the root a tapered appearance because of loss of image contrast.

loss of bone and lamina dura andthe granular texture of the bone

subperiosteal erosion in hyperparathyroidism

Hyperparathyroidism

HYPOPARATHYROIDISM ANDPSEUDOHYPOPARATHYROIDISM• Produce hypocalcemia• Radiographic examination of the jaws may reveal dental enamel

hypoplasia, external root resorption, delayed eruption, or root dilacerations• • On skull radiographs this calcification appears flocculent and paired

within the cerebral hemispheres on the posteroanterior view

• Radiographic examination of the jaws may reveal dental enamel hypoplasia, external root resorption, delayed eruption, or root dilacerations

dental anomalies

HYPERPITUITARISMAcromegaly and giantism• increases the production of growth hormone• causes overgrowth of all tissues in the body

• excessive growth of the mandible• enlargement of the sella turcica• enlargement of the paranasal sinuses (especially the frontal sinus)• diffuse thickening of the outer table of the skull

Radiographic Features of the Jaws• enlargement of the jaws, most notably the mandible• The increase in the length of the dental arches results in spacing of

the teeth• angle between the ramus and body of the mandible may increase• combination with enlargement of the tongue (macroglossia), may

result in anterior flaring of the teeth and the development of an anterior open bite• the most profound growth occurs in the condyle and ramus, often

resulting in a class III skeletal• The thickness and height of the alveolar processes may also increase

Radiographic Changes Associated with the Teeth• The tooth crowns are usually normal in size, although the roots of

posterior teeth often enlarge as a result of hypercementosis.• Supereruption of the posterior teeth may occur in an attempt to

compensate for the growth of the mandible.

HYPOPITUITARISM• Result in dwarfism• failure of development of the maxilla and the mandible• Eruption of the primary dentition occurs at the normal time, but

exfoliation is delayed by several years• The crowns of the permanent teeth form normally, but their eruption

is delayed several years• The third molar buds may be completely absent• The jaws, especially the mandible, are small, which results in

crowding and malocclusion

HYPERTHYROIDISMThyrotoxicosis and Graves ’ disease• advanced rate of dental developmentand early eruption, with

premature loss of the primary teeth• Adults may show a generalized decrease in bone density or loss of

some areas of edentulous alveolar bone.

HYPOTHYROIDISMMyxedema and cretinism• The base of the skull shows delayed ossifi cation, andthe paranasal

sinuses only partially pneumatize. Dental development is delayed, and the primary teeth are slow to exfoliate.• in children include delayed closing of the epiphyses and skull sutures ,

production of numerous wormian bones (accessory bones in the sutures).• Effects on the teeth include delayed eruption, short roots, and thinning of

the lamina dura. The maxilla and mandible are relatively small. Patients with adult hypothyroidism may show periodontal disease, loss of teeth, separation of teeth as a result of enlargement of the tongue, and external root resorption.

DIABETES MELLITUS• no characteristic radiographic features

• Periodontal disease associated with diabetes is radiographically indistinguishable

CUSHING ’ S SYNDROME• excess of secretion of glucocorticoids

•Radiographic Features• generalized osteoporosis can result in pathologic fractures• granular bone pattern• skull can show thinning and mottled appearance• Teeth erupt prematurely• partial loss of the lamina dura

Cushing ’ s syndrome manifested in the jaws as thinningof the lamina dura

Metabolic Bone Diseases 461

OSTEOPOROSIS• generalized decrease in bone mass• changes in trabecular architecture, the volume of trabecular bone,

and the size and thickness of individual trabeculae.• occurs with the aging• The most important clinical manifestation of osteoporosis is fracture• distal radius, proximal femur, ribs, vertebrae

Radiographic Features• overall reduction in the density of bone• Reduced density and thinning of inferior mandibular cortex• Reduction in the number of trabeculae• lamina dura appear thinner

Osteoporosis evident as a loss of the normal thickness anddensity of the inferior cortex of the mandible.

RICKETS AND OSTEOMALACIA• inadequate serum and extracellular levels of calcium and phosphate• rickets is usually applied when the disease affects the growing• term osteomalacia is used when this disease affects the mature

skeleton in adults

Radiographic Features• widening and fraying of the epiphyses of the long bones• The soft weight-bearing bones such as the femur and tibia undergo a

characteristic bowing.• Greenstick fractures

Radiographic Features of the Jaws• jaw cortical structures such as the inferior mandibular border or the

walls of the mandibular canal may thin.• the trabeculae become reduced in density, number, and thickness• In severe cases, the jaws appear so radiolucent that the teeth appear

to be bereft of bony support.• an overall radiolucent appearance and sparse trabeculae.

Radiographic Changes Associated with the Teeth• Rickets• In infants and childhood may result in hypoplasia of developing dental

enamel• retarded tooth eruption• The lamina dura and the cortical boundary of tooth follicles may be

thin or missing.• Osteomalacia• does not alter the teeth• The lamina dura may be especially thin

Rickets may cause thinning (hypoplasia) or decreased mineralization(hypocalcification) of the enamel as seen in this bitewing view

HYPOPHOSPHATASIA• low level of serum alkaline phosphatase• Radiographic Features• generalized radiolucency of the mandible and maxilla• The cortical bone and lamina dura are thin alveolar bone is poorly

calcified• primary and permanent teeth have a thin enamel• Teeth• a thin enamel layer and large pulp chambers and root canals• may be hypoplastic and may be lost prematurely

large pulp chambers in the deciduous dentitionand the premature loss of the mandibular incisors

RENAL OSTEODYSTROPHYrenal rikets• bone changes result from chronic renal failure• Hypocalcemia as a result of impaired calcium absorption• Hyperphosphatemia resulting from reduction in renal phosphorus

excretion.

Radiographic Features• density of the mandible and maxilla may be less than normal• decrease or an increase in the number of internal trabeculae• The cortical boundaries may be thinner or less apparent. • Hypoplasia & hypocalcification of the teeth• lamina dura may be absent or less apparent in instances of bone

sclerosis

areas of radiolucencycorresponding to loss of bone mass, loss ofdistinct lamina dura, and a sclerotic bone patternaround the roots of the teeth

diffuse sclerotic (radiopaque) bonepattern throughout the jaws. Note the loss of adistinct inferior cortex of the mandible resultingfrom an increase in the radiopacity of the internalaspect of the bone.

HYPOPHOSPHATEMIAVitamin D – resistant rickets and hypophosphatemic rickets

• conditions that produce renal tubular disorders resulting in excessive loss of phosphorus.

Radiographic Features• extreme cases are remarkably radiolucent.• thin enamel caps and large pulp chambers and root canals• periapical and periodontal abscesses occur• Periapical rarefying osteitis• defects in the formation of dentin• patient has premature loss of the teeth.• lamina dura may become sparse• cortical boundaries around• tooth crypts may be thin

radiolucent appearance of thejaws and hence the lack of bone density and the large pulp chambers

bone loss around the teeth, a granularbone pattern, large pulp chambers, and external root resorption.

OSTEOPETROSISAlbers-Schönberg and marble bone disease• defect in the differentiation and function of osteoclasts• Radiographic Features• increased radiopacity• any internal structure and even the roots of the teeth may not be

apparent• delayed eruption, early tooth loss, missing teeth,• malformed roots and crowns, and teeth that are poorly calcified and

dense calcification of all the bones.

increased density of the jaws, lack of eruption of the mandibular second bicuspids, narrow inferior alveolar nerve canal, and development of osteomyelitis in the body of the left mandible with periostitis

Other Systemic Diseases• PROGRESSIVE SYSTEMIC SCLEROSIS• a generalized connective tissue disease that cause collagen deposition• erosions at regions of muscle attachment• resorption is typically bilateral and fairly symmetric. Most of these

erosive borders are smooth and sharply defined. This resorption may be progressive with the disease.

an unusual pattern of mandibular erosions atregions of muscle attachment such as the angles, coronoid process, digastric region, or condyles

Radiographic Changes Associated with the Teeth• increase in the width of the periodontal ligament (PDL) spaces around

the teeth at least twice as thick as normal. • The lamina dura remains normal.

widening of the periodontalmembrane space around some of the teeth.

SICKLE CELL ANEMIA• The thinning of individual cancellous trabeculae and cortices is most

common in the vertebral bodies, long bones, skull, and jaws.• The skull may have widening of the diploic space and thinning of the

inner and outer tables• the outer table of the skull will not be apparent and a hair-on-end

appearance may occur• Osteomyelitis infections due to hypovascularity.

Radiographic Features of the Jaws• general osteoporosis• bone marrow hyperplasia may cause enlargement and protrusion of

the maxillary alveolar ridge

thickened diploic space and thinning of the skull cortex right=normal

hair-on-end bone pattern

THALASSEMIA• General Radiographic Features• Similar to sickle cell anemia, the radiographic features of thalassemia

generally result from hyperplasia of the ineffective bone marrow

• Theskull shows a generalized granular appearance

Radiographic Appearance of the Jaws.• Severe bone marrow hyperplasia prevents pneumatization of the

paranasal sinuses, especially the maxillary sinus, and causes an expansion of the maxilla that results in malocclusion.

granular appearance ofthe skull and thickening of the diploic space

thickened diploic space and that there is hint linear orientation of the trabeculae,especially in the frontal bone

thickened body of the mandibleand the sparse trabeculae and lack of maxillary antra

thick trabeculae and large bone marrow spaces