Radiologic Interpretation of Systemic Diseases 牙科放射線學(2) Radiologic Interpretation of Systemic Diseases Manifested in Jaws 全身性疾病於顎骨之放射線影像判讀 陳玉昆副教授: 高雄醫學大學 口腔病理科 07-3121101~2755 yukkwa@kmu.edu.tw

學 習 目 標 Know how to interpret radiographic findings of systemic diseases manifested in jaws References 1. Stuart C. White, and Michael J. Pharoah : Oral Radiology - Principles and Interpretation, 6th edition, 2009, Chapter 25 2. http://uwmsk.org/residentprojects/hpth.html 3. path.upmc.edu 4. Kunihiko Miyashta. Contemporary Cephalometric Radiography, 1st edition, 1996, frontpage

General radiographic findings of systemic diseases manifested in jaws 1. A change in bone size & shape 2. A change in trabeculae no., size, & orientation 3. Cortical structures: altered thickness & density Changes in 1, 2, 3: or in bone density Ref. 4

General radiographic findings of changes to teeth & associated structures of systemic diseases manifested in jaws 1. Accelerated/delayed tooth eruption 2. Enamel hypoplasia 3. Enamel hypocalcification 4. Loss of lamina dura Ref. 4

HYPERPARATHYROIDISM ( circulating PTH- serum calcium level) Endocrine Disorders HYPERPARATHYROIDISM ( circulating PTH- serum calcium level) Radiographic Features ~1/5 patients: radiographically observable bone changes General Radiographic Features 1. The earliest & most reliable changes: bone erosions from subperiosteal surfaces of phalanges of hands Ref. 2

HYPERPARATHYROIDISM ( circulating PTH- serum calcium level) Endocrine Disorders HYPERPARATHYROIDISM ( circulating PTH- serum calcium level) General Radiographic Features (continue) 2. Demineralization of the skeleton radiolucence 3. Osteitis fibrosa cystica: localized regions of bone loss produced by osteoclastic activity loss of all apparent bone structure 4. Brown tumors: occur late in the disease (~10% of cases) These peripheral/central bone tumors: radiolucent Gross specimen: brown or reddish-brown color 5. Pathologic calcifications in soft tissues: a punctate/ nodular appearance & occur in kidneys & joints

HYPERPARATHYROIDISM ( circulating PTH- serum calcium level) Endocrine Disorders HYPERPARATHYROIDISM ( circulating PTH- serum calcium level) General Radiographic Features (continue) 6. Prominent hyperparathyroidism: entire calvarium has a granular appearance caused by the loss of central (diploic) trabeculae & thinning of cortical tables A, Axial, B, sagittal CT images of a case of secondary hyperparathyroidism Ref. 1

HYPERPARATHYROIDISM ( circulating PTH- serum calcium level) Endocrine Disorders HYPERPARATHYROIDISM ( circulating PTH- serum calcium level) Radiographic Features of the Jaws A, Bone loss results radiopaque teeth standing out in contrast to the radiolucent jaws B, loss of lamina dura & granular texture of bone Ref. 1

HYPERPARATHYROIDISM ( circulating PTH- serum calcium level) Endocrine Disorders HYPERPARATHYROIDISM ( circulating PTH- serum calcium level) Radiographic Features of the Jaws A, Axial, B, coronal CT of a case of secondary hyperparathyroidism with a brown tumor involving maxilla. This tumor has features of a central giant cell granuloma with a granular expanded cortex of maxilla & very subtle & ill-defined internal septa. Refs. 1, 3

HYPERPARATHYROIDISM ( circulating PTH- serum calcium level) Endocrine Disorders HYPERPARATHYROIDISM ( circulating PTH- serum calcium level) Radiographic Changes of the Teeth & Associated Structures A & B, Characteristic granular bone pattern Loss of lamina dura & floor of maxillary antrum C, The same case reveals a brown tumor in the apical region of the second & third molars. Ref. 1

Endocrine Disorders HYPOPARATHYROIDISM ( secretion of PTH) Radiographic Features Dental anomalies: enamel hypoplasia, external root resorption, delayed eruption, or root dilaceration Ref. 1

Endocrine Disorders HYPERPITUITARISM (acromegaly-adult & giantism-child) ( anterior lobe of the pituitary gland, growth hormone) Radiographic Features of the Jaws A case of acromegaly manifesting as excessive growth of mandible class III skeletal relationship of jaw The same patient: enlargement of sella turcica Ref. 1

Endocrine Disorders HYPERPITUITARISM (acromegaly-adult & giantism-child) ( anterior lobe of the pituitary gland, growth hormone) Radiographic Changes of the Teeth A, Tooth crown: normal in size B, Roots of posterior teeth: hypercementosis, the result of functional & structural demands on teeth instead of a secondary hormonal effect C, Supereruption of posterior teeth: attempt to compensate for the growth of mandible

HYPOPITUITARISM ( secretion of pituitary hormones) Endocrine Disorders HYPOPITUITARISM ( secretion of pituitary hormones) Radiographic Features A, Primary dentition: erupt at normal time, but delayed exfoliation by several years B, Crowns of permanent teeth: form normally, but delayed eruption by several years C, Third molar buds: completely absent D, Jaws (esp. mandible): small crowding & malocclusion

Endocrine Disorders HYPERTHYROIDISM (thyrotoxicosis & Graves’ disease) ( production of thyroxin in thyroid gland) Radiographic Features A, Results in an advanced rate of dental development & early eruption, with premature loss of primary teeth B, Adults: bone density/loss of some areas of edentulous alveolar bone

Endocrine Disorders HYPOTHYROIDISM (myxedema & cretinism) ( secretion of thyroxine by thyroid glands despite the presence of TSH) Radiographic Features A, Children: delayed closing of epiphyses & skull sutures numerous wormian bones (suture bones) B, Effects on teeth: delayed eruption, short roots, and thinning of lamina dura C, Jaws: relatively small D, Adults: periodontal disease, tooth loss, tooth separation of as a result of tongue enlargement & external root resorption

Endocrine Disorders DIABETES MELLITUS (Type I, insulin-dependent DM, results from insulin, normally produced by  cells of islets of Langerhans in pancreas) (Type II, non-insulin-dependent DM, due to insulin resistance) Radiographic Features A, Jaws/teeth: no characteristic radiographic features B, Periodontal disease associated with DM is indistinguishable radiographically from periodontal disease without DM

CUSHING’ S SYNDROME ( secretion of glucocorticoid of adrenal gland) Endocrine Disorders CUSHING’ S SYNDROME ( secretion of glucocorticoid of adrenal gland) Radiographic Features of the Jaws A, Generalized osteoporosis, which may have a granular bone pattern This demineralization may result in pathologic fractures. B, Skull: diffuse thinning accompanied by a mottled appearance C, Teeth: premature eruption & partial loss of lamina dura Ref. 1

Metabolic Bone Disorders OSTEOPOROSIS ( bone mass but normal bone histology) Radiographic Features of the Jaws Loss of normal thickness & density of inferior cortex of mandible Ref. 1

Metabolic Bone Disorders RICKETS(infant, child) & OSTEOMALACIA(adult) ( serum & extracellular levels of calcium & phosphate, minerals required for normal calcification of bone & teeth) ( activity of metabolites of vitamin D, esp. 1,25(OH)2D, required for resorption of calcium in intestine) Radiographic Features of the Jaws A, In rickets, mandibular border/walls of IAN canal: thin B, Changes in jaws occur after changes in ribs & long bones C, Trabeculae within cancellous portion of jaws: density, no. & thickness D, Severe cases: jaws appear so radiolucent that the teeth appear to be bereft of bony support A, Osteomalacia (Most) : no radiographic manifestations in jaws B, Radiographic manifestations: an overall radiolucence & sparse trabeculae

Metabolic Bone Disorders RICKETS(infant, child) & OSTEOMALACIA(adult) ( serum & extracellular levels of calcium & phosphate, minerals required for normal calcification of bone & teeth) ( activity of metabolites of vitamin D, esp. 1,25(OH)2D, required for resorption of calcium in intestine) Radiographic Changes Associated with the Teeth A, Enamel hypoplasia & hypocalcification B, Early rickets: retarded tooth eruption C, Lamina dura & cortical boundary of tooth follicles: thin or missing Ref. 1

Metabolic Bone Disorders HYPOPHOSPHATASIA (inherited disorder- production/defective function of alkaline phosphatase) Radiographic Features of the Jaws A, Mandible & maxilla: generalized radiolucency B, Cortical bone & lamina dura: thin C, Alveolar bone: poorly calcified & may appear deficient Radiographic Changes Associated with the Teeth Large pulp chambers in the deciduous dentition & premature loss of lower incisors Ref. 1

Metabolic Bone Disorders RENAL OSTEODYSTROPHY (Renal rickets) (kidney disease interferes with hydroxylation of 25(OH)D into 1,25(OH)2D, which normally occurs in kidney) Radiographic Features of the Jaws Areas of radiolucency corresponding to loss of bone mass, loss of lamina dura & a sclerotic bone pattern around the roots of the teeth Ref. 1

Metabolic Bone Disorders RENAL OSTEODYSTROPHY (Renal rickets) (kidney disease interferes with hydroxylation of 25(OH)D into 1,25(OH)2D, which normally occurs in kidney) Radiographic Features of the Jaws A diffuse sclerotic (radiopaque) bone pattern throughout the jaws Inferior cortex of mandible: indistinct resulting from radiopacity of internal aspect of bone Ref. 1

Metabolic Bone Disorders RENAL OSTEODYSTROPHY (Renal rickets) (kidney disease interferes with hydroxylation of 25(OH)D into 1,25(OH)2D, which normally occurs in kidney) Radiographic Changes Associated with the Teeth A, Enamel hypoplasia & hypocalcification loss of radiographic evidence of enamel B, Lamina dura: absent or less apparent in instances of bone sclerosis Ref. 1

Metabolic Bone Disorders HYPOPHOSPHATEMIA (vitamin D-resistant rickets & hypophosphatemic rickets) (distal renal tubules fail to reabsorb phosphorus serum phosphorus- hypophosphatemia) (Multiple myeloma 2nd damage to kidney hypophosphatemia) Radiographic Features of the Jaws Radiolucence of jaws & hence lack of bone density & large pulp chambers Ref. 1

Metabolic Bone Disorders HYPOPHOSPHATEMIA (vitamin D-resistant rickets & hypophosphatemic rickets) (distal renal tubules fail to reabsorb phosphorus serum phosphorus- hypophosphatemia) (Multiple myeloma 2nd damage to kidney hypophosphatemia) Radiographic Changes Associated with the Teeth Bone loss around the teeth, a granular bone pattern, large pulp chambers & external root resorption Ref. 1

Metabolic Bone Disorders OSTEOPETROSIS (Albers-Schönberg & marble bone disease) ( normal function osteoclast bone mass) (autosomal recessive type-osteopetrosis congenita; autosomal dominant type-osteopetrosis tarda) General Radiographic Features Dense calcification of skull & facial bones Dense calcification of chest, pelvis & femurs (fracture of the proximal right femur) Ref. 1

Metabolic Bone Disorders OSTEOPETROSIS (Albers-Schönberg & marble bone disease) ( normal function osteoclast bone mass) (autosomal recessive type-osteopetrosis congenita; autosomal dominant type-osteopetrosis tarda) Radiographic Features of The Jaws density of jaws, uneruption of tooth 35, narrow IAN canal & development of osteomyelitis in left mandiblular body with periostitis (arrow) Ref. 1

Metabolic Bone Disorders OSTEOPETROSIS (Albers-Schönberg & marble bone disease) ( normal function osteoclast bone mass) (autosomal recessive type-osteopetrosis congenita; autosomal dominant type-osteopetrosis tarda) Radiographic Changes Associated with the Teeth A, Delayed eruption, early tooth loss, missing teeth, malformed roots & crowns, & teeth that are poorly calcified & prone to caries B, Bone density/ankylosis: delayed eruption of the primary & secondary C, Lamina dura & cortical border: thicker than normal Ref. 1

Other Systemic Diseases PROGRESSIVE SYSTEMIC SCLEROSIS (Scleroderma) (a generalized connective tissue disease: collagen deposition hardening of skin & other tissues) Radiographic Features of the Jaws Loss of bone in mandibular angle (arrows) & the right coronoid process (arrow), which are locations of muscle attachments Ref. 1

Other Systemic Diseases PROGRESSIVE SYSTEMIC SCLEROSIS (Scleroderma) (a generalized connective tissue disease: collagen deposition hardening of skin & other tissues) Radiographic Changes Associated with the Teeth Widening of periodontal membrane space around some of the teeth Ref. 1

Other Systemic Diseases SICKLE CELL ANEMIA (autosomal recessive, chronic hemolytic blood disorder) (deoxygenated Hb: capacity to carry oxygen to tissues &, because of damage to their membrane lipids & proteins, adhere to vascular endothelium & obstruct capillaries) General Radiographic Features Thickened diploic space & thinning of skull cortex Skull showing hair-on-end bone pattern Ref. 1

Other Systemic Diseases SICKLE CELL ANEMIA (autosomal recessive, chronic hemolytic blood disorder) (deoxygenated Hb: capacity to carry oxygen to tissues &, because of damage to their membrane lipids & proteins, adhere to vascular endothelium & obstruct capillaries) Radiographic Features of the Jaws A, Osteoporosis because of volume of trabecular bone B, Thinning of cortical plates Ref. 1

Other Systemic Diseases THALASSEMIA (Cooley’s, Mediterranean, & erythroblastic anemia) (hereditary Hb synthesis defect involve α-/β-globulin genes) (resultant RBC: Hb content, thin, life span) (heterozygous form: thalassemia minor, is mild; homozygous form (thalassemia major), is severe; thalassemia intermedia) General Radiographic Features Granular appearance of skull & thickening of the diploic space Ref. 1

Other Systemic Diseases THALASSEMIA (Cooley’s, Mediterranean, & erythroblastic anemia) (hereditary Hb synthesis defect involve α-/β-globulin genes) (resultant RBC: Hb content, thin, life span) (heterozygous form: thalassemia minor, is mild; homozygous form (thalassemia major), is severe; thalassemia intermedia) Radiographic Appearance of the Jaws Thickened mandibular body & sparse trabeculae & lack of maxillary antra Ref. 1

Other Systemic Diseases THALASSEMIA (Cooley’s, Mediterranean, & erythroblastic anemia) (hereditary Hb synthesis defect involve α-/β-globulin genes) (resultant RBC: Hb content, thin, life span) (heterozygous form: thalassemia minor, is mild; homozygous form (thalassemia major), severe; thalassemia intermedia) Radiographic Appearance of the Jaws Thick trabeculae & large bone marrow spaces Ref. 1

Radiologic Changes in Bone Observed in Systemic Diseases Summaries Radiologic Changes in Bone Observed in Systemic Diseases Ref. 1

Effects on Teeth and Associated Structures Summaries Effects on Teeth and Associated Structures Ref. 1