RADIOGRAPHIC INTERPRETATION OF SYSTEMIC DISEASES MANIFESTED IN THE JAWS

DRG. SHANTY CHAIRANI

HYPERPARATHYROIDISM
Loss of bone mineralization (osteoporosis) because of increased PTH secretion (primary) or increased demand for serum calcium (secondary) , resulting in multiple systemic complications, loss of alveolar bone architecture, and occasionally giant cell tumor ("brown tumor"). The increased secretion of parathyroid hormone causes generalized bone resorption (osteopenia), bone pain, pathological fractures and raises the serum calcium levels.

 Clinical Features: Enlargement of one or more parathyroid glands Female dilection, middle aged adults Elevated serum parathyroid hormone and blood calcium levels. The serum alkaline phosphatase level may also be elevated. Symptoms and signs : renal calculi, psychiatric problesms, bone and joint paint. There may be gradual loosening, drifting and loss of teeth

 Radiographic Features: Well defined unilocular or multilocular radiolucency Loss of lamina dura around the associated teeth The trabecular pattern becomes very fine (ground glass appearance). Granular-appearing bone in skull. Reduction in cortical bone density and thinning of the cortical border of the mandible. In a late stage, localized cyst-like radiolucencies may occur (brown tumors). After treatment the appearance becomes normal again.

HYPERPITUITARISM
Results from hyperfunction of the anterior lobe of the pituitary gland, increased production of growth hormone. Excess of growth hormone causes overgrowth of all tissues in the body. Clinical features :
If the abnormality occurs in childhood, generalized overgrowth of most tissues occurs. It terms as gigantism. If it occurs in adult, it is called acromegaly. Overgrowth of the bones, including the jaw In acromegaly, there is excessive growth of the mandible

 Radiograph features :
Enlarged of jaw, especially mandible in acromegaly. Lengthening of the condylar processes and ascending ramus of the mandible. May also be an increase in the thickness and height of the alveolar processes

HYPOPHOSPHATASIA
A genetic metabolic disorder of bone mineralization caused by a deficiency in alkaline phosphatase in serum and tissues; characterized by skeletal defects resembling those of rickets. Odontohypophosphatasia - children and adults who have only dental problems (premature loss of teeth). Clinical Features:
Skeletal changes may present in infants, children, or may be delayed until adulthood Premature loss of teeth is common in children and adults and delayed eruption of the permanent dentition

 Radiographic Features:
Excessive amount of unmineralized osteoid tissue Generalized lucency of the maxilla and mandible Reduced enamel thickness and enlarged pulp chambers and pulp canals The cortical bone and lamina dura is thin and the alveolar bone may be deficient

HISTIOCYTOSIS X
Also known as Langerhans Cell Histiocytosis and Eosinophilic Granuloma A probable neoplastic proliferation of Langerhans type of histiocytic cells with a wide spectrum of biological behavior ranging from a single lesion of the mandible to diffusely distributed bone lesions in combination with organ and other soft tissue lesions. There are 3 clinical forms of histiocytosis X :
Eosinophilic granuloma of bone Hand-Schuller-Christian disease (chronic disseminated histiocytosis X) Letterer-Siwe disease (acute disseminated histiocytosis X)

Frequently the oral changes are the first clinical signs of the disease.

 Clinical Features:
Letterer-Siwe disease
Aggressive, in infants or young children Widespread disease: skin and mucosal lesions, visceral, and bone involvement

Hand-Schuller-Christian disease
Typically begins in childhood Exophthalmos, diabetes insipidus, osteolytic skull lesions (characteristic triad) Hepatosplenomegaly and skin and mucosal lesions Oral symptoms

 Eosinophilic Granuloma disease Solitary localized bone destruction Most often in older children and young adults. Swelling and pain More often in mandible, usually in posterior regions Loosening of the teeth The sockets of teeth lost to the disease generally fail to heal normally.

Radiographic Features:
Solitary or multiple punched-out radiolucent lesion Lesion margins are usually well-defined but not corticated (punched-out). Teeth may appear "floating in space No expansion of the surrounding bone.

OSTEOPOROSIS
A deficiency of bone tissue, per unit volume of bone. There are 2 types of osteoporosis : primary osteoporosis which associated with aging and secondary osteoporosis which associated with abnormal or iatrogenic circumstances such as corticosteroid therapy or conditions such as malnutrition. Clinical features :
The most common type of metabolic bone disease. Generalized, gradual decrease in bone mass. Histologically, the bone is normal. Most common in postmenopausal women. High risk for pathologic fractures.

 Radiographic features : Generalized osteopenia.

Thinning of bone cortices A reduction in the density and thickness of the inferior mandible cortex

A. Normal bone in a 12 year old boy B. Osteoporosis in a 60 year old male

OSTEOMALACIA AND RICKETS

These abnormalities are caused by a nutritional deficiency of vitamin D In these diseases, osteoid builds up in excessive amounts because of its failure to mineralize properly. Clinical features :
Rickets in children and osteomalacia in adults. Usually bone pain and muscle weakness. Children with rickets usually have short stature and deformity of the extremities. Development of the dentition is delayed and the eruption rate of the teeth is retarded.

 Radiographic features :
Generalized osteopenia. Thinning of cortical cortex. Pathological fractures.

THALASSEMIA
Inherited, chronic condition affecting the red blood cells. The red blood cells have a shortened life expectancy. The hematopoietic system responds with proliferation of bone marrow, at the expense of the cancellous bone, in order to produce more red blood cells. Clinical features :
The face develops prominent cheekbones and a protrusive premaxilla

 Radiographic changes:
Hair-on-end calvarium Widening of the diploic space Enlarged marrow spaces in all bones Generalized osteoporosis Enlargement of jaws Thinning of all cortical structures (especially the lower border of the mandible) Dense, irregular, and coarse trabeculation. Thinning of lamina dura Shortened tooth roots.

SICKLE CELL ANEMIA

Inherited condition affecting the red blood cells. Due to abnormal hemoglobin the red blood cells become sickle-shaped under conditions of hypoxia. They have decreased capacity to carry oxygen to the tissues. The hematopoietic system responds with the proliferation of bone marrow, at the expense of the cancellous bone, in order to produce more red blood cells.

 Clinical features :
It affects mainly black populations. It occurs mostly in children and adolescents.

Radiographic changes:
Hair-on-end calvarium Widening of the diploic space Enlarged marrow spaces in all bones Generalized osteoporosis Thinning of all cortical structures (such as the skull cortex).