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Disorders of parathyroid gland

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This presentation is about Parathyroid Disorders which are hypo and hyperparathyroidism and their relationship to teeth and oral cavity including oral and dental manifestation of these disorders , and correct management patients seeking dental care with these disorders.

This presentation is about Parathyroid Disorders which are hypo and hyperparathyroidism and their relationship to teeth and oral cavity including oral and dental manifestation of these disorders , and correct management patients seeking dental care with these disorders.

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Disorders of parathyroid gland

  1. 1. University Of Sulaimani Faculty Of Medical Sciences School Of Dentistry Oral Diagnosis Department Disorders of Parathyroid glands By: Garmyan Yawar 2015/2016
  2. 2. 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
  3. 3. Parathyroid gland
  4. 4. 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).
  5. 5. Disorders of Parathyroid Hormone Hyperparathyroidism Hypoparathyroidism
  6. 6. • 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
  7. 7. • 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
  8. 8. Signs and Symptoms Symptoms 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
  9. 9. Hyperparathyroidism Hyperparathyroidism Primary Parathyroid hyperplasia Parathyroid adenoma Parathyroid carcinoma Secondary Parathyroid hyperplasia Tertiary Autonomous nodule on top of hyperplasia
  10. 10. 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
  11. 11. 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
  12. 12. k subperiosteal resorption of the phalanges of the index and middle fingers
  13. 13. • 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
  14. 14. Tertiary hypoparathyroidism • Tertiary When long-standing secondary hyperplasia becomes autonomous in spite of correction of the underlying stimulant (renal transplant).
  15. 15. 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
  16. 16. This case shows the decreased bone trabeculation giving it a ‘ground-glass’ or granular appearance
  17. 17. 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.
  18. 18. 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.
  19. 19. Oral Manifestations Dental 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
  20. 20. 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
  21. 21. 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.
  22. 22. • 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.
  23. 23. 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.
  24. 24. Etiology It 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.
  25. 25. • 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
  26. 26. • Patchy hair loss, such as thinning of your eyebrows • Dry, coarse skin • Brittle nails • Headaches • Depression, mood swings • Memory problems
  27. 27. 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
  28. 28. 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
  29. 29. • Delay or cessation of dental development • Dental malocclusion • Caries • Chronic candidiasis • Paresthesia of the tongue or lips • Alteration in facial muscles
  30. 30. 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.
  31. 31. • 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.
  32. 32. 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
  33. 33. • (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

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