This document discusses several diseases that can affect bone density and structure, including hyperparathyroidism, osteoporosis, osteomalacia, leukemia, Langerhans cell disease, Paget's disease, and multiple myeloma. It provides details on the clinical features, radiographic manifestations, differential diagnosis, and management of each condition. The document contains radiographic images showing examples of bone changes associated with some of the diseases.

2. SAADIA ASHRAF

3.  INTRODUCTION
 HYPERPARATHYROIDISM
 OSTEOPOROSIS
 OSTEOMALACIA
 LEUKEMIA
 LANGERHANS CELL DISEASE
 PAGETS DISEASE
 MULTIPLE MYELOMA
 RARITIES
 REFERENCE
CONTENTS

4. • Maintenance of normal bone density or mass requires normal
function and the interaction of a number of intricate and delicate
systems:osseous endocrine hematopoetic ,renal
gastrointestinal,nutritional and neurocirculatory.
• Radiographs reveal a considerable variation in the density of
normal jaw bones.
• All the rarefying diseases included here represent a disruption of
bone homeostasis that may result from an imbalance among the
factors noted or a direct influence of a disese process on the bone
itself.
INTRODUCTION

5. HYPERPARATHYROIDISM
Hyperparathyroidism is an endocrine abnormality in which there is
an excess of circulating parathyroid hormone(PTH).
TYPES
• Primary hyperparathyroidism
Results from hyperplasia or benign tumour of one of the four
parathyroid glands , resulting in production of excess PTH.
• Secondary hyperparathyroidism
This results from compensatory increase in the output of PTH in
response to hypocalcaemia.

6. Tertiary Hyperparathyroidism
Occasionally,the parathyroid tumour after long standing secondary
hyperparathyroidism may develop a condition called tertiary
hyperparathyroidism.
Ectopic hyperparathyroidism
Caused due to excessive parathyroid hormone synthesis in a patient
with malignant disease.

7. CLINICAL FEATURES
 More common in females
 Occurs mainly in 30-60 years of age
 Classis triad and signs of hyperparathyroidism are described as
having “stones , bones, and abdominal groans”
 Stones refers to the development of renal calculi (kidney
stones,nephrolithiasis) because of the elevated serum calcium levels
 Metastatic calcifications involving blood vessel walls,subcutaneous
soft tissues, sclera, dura and the regions around the jaws

8.  Bones refers to variety of osseous changes that may occur in conjunction
with hyperparathyroidism.
 Bone deformities such as bending of long bones,occasional pathologic
fractures,collapse of vertebrae and pigeon chest
 Loosening and drifting of teeth leading to malocclusion with diastema
formation.
 Abdominal groans refers to the tendency
for the development of duodenal ulcers.
 Palatal enlargement associated with
secondary hyperparathyroidism.

9. RADIOGRAPHIC FEATURES
Radigraphically observable changes are seen in 1 out of 5 patients
Earliest changes are subtle erosions of the bone from the periosteal
surfaces of the phalanges from hand
Overall demineralization of the skeleton resulting in overall grayness
and lack of normal contrast on the radiograph
Generalized osteoporosis
In prominent hyperparathyroidism ,the entire calvarium has a
granular appearance of the bone ,caused by loss of central trabeculae
and thinning of cortical tables

10.  Osteitis fibrosa cystica or osteitis fibrosa generalisata are localized regions
of bone loss produced by osteoclastic activity,resulting in loss of all
apparent bone structure. These appear cyst like on radiograph
 Brown tumor occur late in the disease .
 A change in normal trabecular pattern gives ground glass appearance of
numerous ,small , randomly oriented
trabeculae.
 Periapical radiographs reveal loss of lamina
dura.

12. Brown tumour

13. DIFFERENTIAL DIAGNOSIS
UNILOCULAR
 Post extraction socket
 Primordial bone cyst
MULTILOCULAR
 Pagets disease
 Ameloblastoma
 Central giant cell granuloma
 Cherubism
 Aneurysmal bone cyst
 Osteomalacia
 Fibrous dysplasia
 Multiple myeloma

14. MANAGEMENT
• After successful surgical removal of the causative factor,almost all
radiographic changes revert to normal,except for brown tumours
which heals with bone that is radigraphically more sclerotic than
normal

15. OSTEOPOROSIS
Osteoporosis is defined as “ a disease characterized by low bone mass
and micro architectural deterioration of bone tissue leading to
enhanced bone fragility and an increase in fracture risk.
There are 2 types:
1. primary
• Associated with aging process
2. Secondary
• Results from nutritional deficiencies,hormonal
imbalance,inactivity or corticosteroid or heparin therapy.

16. CLINICAL FEATURES
• Post menopausal women are at risk
• Bones are fragile and succeptible to fractures
• Congenital form is inherited as an autosomal recessive disorder which is
fatal in early life due to massive haemorrhage, anemia and rampant
bone infections occurring due to progressive loss of bone marrow and
their cellular products
• They may notice a gradual loss of height due to shortening of trunk,
characterized by attacks of severe pain, aggrevated by movements

17. • Percussion over the affected vertebrae is painful
• Bone becomes succeptible to osteomyelitis
• Fracture of the jaws is common during tooth extraction with common
occurrence of osteomyelitis
• Teeth may show delayed eruption, early loss of teeth, arrested root
formation, enamel hypoplasia and are more prone to caries due to poor
calcification
• Patients have anemia due to replacement of hemolytic marrow by bone.
(RBC count below 1,000,000 per cumm)

18. RADIOGRAPHIC FEATURES
• Results in overall reduction in bone density,which may be observed in
the jaws by using the unaltered density of the teeth in comparison.
• Thinning of the cortical boundaries of the inferior mandibular cortex
• Reduction in the volume of cancellous bone
• Lamina dura appear thinner than normal
• Anatomical shadows such as the nasal fossa and maxillary sinus are
less distinct
• Wedge shaped appearance of the effected vertebrae

19. Wedge shaped fracture
of vertebrae
Panoramic view showing
generalized granular appearance of
the trabeculae involving the entire
maxilla and mandible.

20. DIFFERENTIAL DIAGNOSIS
Infantile cortical hyperostosis
MANAGEMENT
• Estrogen , calcium and vitaminD supplement after
menopause
• Weight-bearing exercise programs are also effective

21. OSTEOMALACIA
• “Rickets” in children and “osteomalacia” in adults embrace a
group of disorders characterized by an accumulation of osteoid
in place of mineralized bone.
• They are caused by deficiency of calcium.
• It may be a result of 1 or a combination of the following:
• Vitamin D Deficiency
• Calcium malabsorption
• Liver and renal disorders
• Prolonged anticonvulsive drug therapy
• Hypophosphatemic rickets

22. CLINICAL FEATURES
RICKETS
• In the 1st 6 months of life,tetany and convulsions are the
clinical problems resulting due to hypocalcaemia
• This may be followed with swelling of the wrist and ankles
• Craniotabes .a softening of the posterior of the parietal
bones may be the initial sign of the disease
• Short stature and deformity of the extremities are common
• Development of dentition is delayed ,

23. OSTEOMALACIA
• Patient will have bone pain and muscle weakness
• Pelvic deformities are common in females
• They have a peculiar waddling or penguin gait ,tetany and green
stick(incomplete) bone fractures.
• Dental abnormalities are rarely seen ,there may be incidence of
periodontitis.

24. RADIOGRAPHIC FEATURES
General radiographic features
• Widening and fraying of the epiphyses of the long
bones
• Bowing of the weight bearing bones
• Bone cortex may be thin
• Pseudofractures occurs most commonly in the ribs,pelvis and weight
bearing bones.

25. Radiographic features of the jaws
• The jaws cortical structures , such as the inferior mandibular border ,
follicular walls of the developing teeth and lamina dura are thinned or
missing
• Within the cancellous portion of the jaw,the trabeculae become reduced
in density ,number and thickness
Radiographic features associated with teeth
• Teeth may be poorly formed,with thin enamel caps and large pulp
chamber and root canals.
• Periapical and periodontal abscess occur frequently

26. Thinning or decreased mineralization of
the enamel seen in bitewing view.
Large pulp chamber

27. DIFFERENTIAL DIAGNOSIS
• Hyperparathyriodism
• Rheumatoid arthritis
• Muscle strain
MANAGEMENT
Dietary enrichment of vitamin D and calcium

28. LEUKEMIA
Definition
Leukemia is a malignant tumour of hematopoietic stem cells.
These malignant cells displace normal bone marrow constituents and spill
out into the peripheral blood.

29. CLASSIFICATION
ACUTE
Acute lymphoblastic leukemia
L1 : acute lymphoblastic (primarily paediatric)
L2 : acute lymphoblastic (primarily adults)
L3 : Burkitt’s
Acute nonlymphoblastic or myeloid leukemia
M1 : myeloblastic (without maturation)
M2 : myeloblastic (with maturation)
M3 : promyelocytic
M4 : myelomonocytic
M5 : monocytic , promonocytes or undifferentiated blast
M6 : erythroleukemia
M7 : megakaryocytic

30. CHRONIC
Chronic lymphatic leukemia involving lymphocytes
series
Chronic myeloid leukemia involving granulocyte
series

31. CLINICAL FEATURES
 ACUTE LEUKEMIA
• More common in young and adult males
• Onset is usually abrupt,with pyrexia and enlargement of spleen
• Patient may complaint weakness ,fever ,headache ,vomiting ,generalized
swelling of lymph nodes ,petechae or hemorrhage in the skin and mucous
membrane
• Recurrent infection of the lungs,urinary tract,skin mouth rectum and upper
respiratory tract.

32. • Localized tumours consisting of leukemic cells called chloroma,whose
surface turns green when exposed to light are seen.
• Oral cavity shows pallor,ulceration with necrosis petechiae and
bleeding
• Gingiva appears boggy,hypertrophic with cyanotic discoloration
• Paresthesia of the lower lip and chin with toothache due to leukemic
cell infiltration of the dental pulp.
• There may be associated normochromic anemia ,thrombocytopenia
and decrease in the normal functioning of the neutrophils.

33. CHRONIC LEUKEMIA
• Usually occurs in the older age group
• No presenting signs or complaints
• Patient may complaint of acute left upper abdominal pain ,weakness ,
fatigue and dyspnea on exertion ,petechiae , ecchymosis and hemorrhage
on the skin and mucous membrane
• Oral findings are-hypertrophy of the gingiva, with ulceration , necrosis
and dark gangrenous degeneration. Swollen tongue.,loosening of the
teeth,regional lymphadenopathy
• Shows presence of normocytic and normochromic anemia.

34. Extensive hemorrhagic enlargement of
the maxillary and mandibular gingiva.
The ulcerated soft tissue nodule of the
hard palate represents leukemc cells that
have proliferated in this area

35. RADIOGRAPHIC FEATURES
• The lesions are seen as patchy areas of radiolucency which may later coalesce
to form generalized areas of ill-defined radiolucency of the bone
• The lesions are usually bilaterally present
• Foci of leukemic cells may be present as a mass (chloroma) which may
behave like a localized malignant tumor. These are rare in the jaws
• Developing teeth in their crypts and teeth undergoing eruption may be
displaced in the occlusal direction or into the oral cavity before root
development resulting in the premature loss of teeth
• If the lesion involves periodontal structures, the crestal bone may also be lost

36. Periapical radiographs of left mandible illustrating multi focal areas of bone destruction
and widening of portions of periodontal ligament space.

37. Occlusal displacement of
developing mandibular
second molar out of its
follicle.

38. DIFFERENTIAL DIAGNOSIS
• Metabolic disorders : these cause generalized rarefaction of the bone.
May be differentiated on the basis of the blood picture
• Lymphoma, neuroblastoma : the clinical presentation is different and it
may be differentiated on the basis of the blood picture
• Rarefying osteitis : careful clinical and radiological examination will
show no apparent cause for the same in case of leukemia

39. MANAGEMENT
Leukemia is primarily treated with a combination of chemotherapy
with or without allogenic or autologous bone marrow
transplantation

40. LANGERHAN’S CELL DISEASE
Definition
Disorders included in this category are abnormalities that result from the
abnormal proliferation of langerhan’s cells or their precursers.
These are classified into 3 distinct clinical forms :
1. Eosinophilic granuloma (solitary)
2. Hand-Schuller-Christian disease (chronic disseminated)
3. Letterer-Siwe disease (acute disseminated)
The acute disseminated form ; the most aggressive and lethal can produce a
generalized rarefactions of the bones

41. CLINICAL FEATURES
• Often occurs in infants below 3 years of age
• Initial onset is manifested as skin rash involving the trunk,scalp and extremities.
• The rash may be erythematous,purpuric and ecchymotic and sometimes it may
be ulcerative.
• Soft tissue and bony granulomatous lesions are disseminated through out the
body.
• Oral cavity is affected with multiple ulcers and enlargement of gingival tissues.
• Diffuse destruction of maxilla and mandible leading to loosening and
premature loss of teeth.

42. RADIOGRAPHIC FEATURES
• Rarified appearance of jaw bones closely mimic leukemic changes.
• Bone destruction in Langerhans cell disease commences at alveolar crest .
• Extrusion of teeth , thinning of the cortices, and lamina dura and crypt
and tooth involvement may be present in Langerhans cell disease.
• New bone formation in the form of proliferative periostitis is commonly
seen in juvenile cases.

43. Marked bone loss resulting in
“floating-in-air “ appearance
Severe bone loss that resemble advanced
periodontitis.

44. DIFFERENTIAL DIAGNOSIS
 Periodontal disease
 Traumatic bone cyst
 Cherubism
 leukemia
 Multiple myloma
MANAGEMENT
Surgical curettage and limited radiation therapy.disseminated disease is
treated with chemotherapy.

45. PAGETS DISEASE
DEFINITION
This is a condition of resorption and apposition of osseous tissue in one or
more than one bone simultaneously
CLINICAL FEATURES
• Disease of later middle and old age, more in males
• It affects the maxilla more than the mandible and the disease is bilateral
• The affected bone is usually enlarged and commonly deformed resulting in
bowing of the legs ,curvature of the spine and enlargement of skull.

46. • When affected the jaws also enlarge,with increase in alveolar width. Mouth
remain open as lips are too small to cover the jaws.
• Movement and migration of the affected teeth,malocclusion
and in edentulous cases poor fit of the denture
• Bone pain,more often in the weight bearing bones
• Extraction sites heal slowly.
• Associated complications are osteogenic sarcoma ,osteomylelitis ,giant cell
tumour,carcinoma of overlying mucosa and maxillary antrum,pathological
fractures and facial paralysis.
• Elevated levels of serum alkaline phosphatase.

48. RADIOGRAPHIC FEATURES
It has 3 radiographic stages.
An early radiolucent resorptive stage
• In the mandible,the inferior cortex appears osteoporotic and has a
laminated structure
• Trabeculae may be altered in shape and decreased in number ,they
may be long and align themselves in a horizontal linear pattern.
• Root resorption may be seen
• In the skull the early lytic lesion may be seen as discrete radiolucent
area termed as osteoporosis circumscripta.

49. A granular or ground glass second stage:
• The trabeculae become short,with random orientation and have a
granular pattern
• There are rounded patches of abnormal bone of greater density ,within the
radiolucent bone.
A denser more radiopaque appositional stage:
• The trabeculae may be more organized into rounded radiopaque patches
of abnormal bone ,creating a cotton wool appearance.
• Bone is enlarged and nearly 4 times its normal thickness on the lateral
radiographs.

50. Periapical film showing
“cotton wool” appearance of
the bone
Lateral skull film shows
marked enlargement of the
cranium.

51. • Irregular enlargement of the alveolar process,which become prominent
and bulge.
• Pagets disease in the maxilla may encroach the maxillary sinus
• Hypercementosis is seen on the involved teeth and the lamina dura and
periodontal ligament space is obliterated around the hypercementosed
and normal roots resulting in ankylosis.
• Development of osteogenic sarcoma may produce frank dissolution or
destruction of the bone

52. DIFFERENTIAL DIAGNOSIS
Early stage ( radiolucent appearance):
• Giant cell lesions of hyperparathyroidism
• Osteoporosis
• Osteomalacia
• Multiple myeloma
Second stage(mixed radiolucent radiopaque appearance)
• Osteogenic sarcoma
• Cementifying and ossifying fibroma
• Fibrous dysplasia
• Osteoblastic metastatic carcinoma

53. • Chondroma and chondrosarcoma
• Metabolic disease
Advanced stage(purely radiopaque appearance)
• Florid osseous dysplasia
• Tori
• Osteoma

54. MANAGEMENT
• managed medically by using either calcitonin or sodium etidronate.
• Surgery may be required to correct the deformities of the bone
• Complications of the disease treated with radiotherapy

55. MULTIPLE MYELOMA
DEFINITION
It is a malignant neoplasm of plasma cells of the bone marrow with
widespread involvement of the skeletal system including the skull and jaws.

56. CLINICAL FEATURES
• Common in men between the age of 35 and 70 years.
• Mandible is more commonly involved than the maxilla
• Patient will complain of-fatigue,weight loss,fever,bone pain(lower back
pain) and anemia. Hypercalcemia is also seen.
• Intraoral swelling is usually tender and elicite egg shell cracking,tends to be
ulcerated and bluish red.
• Intraoral hemorrhage and susceptibility to infection may also be present.
• Oral amyloidosis is a complication of this disease.

57. RADIOGRAPHIC FEATURES
• Lesions are bilateral,well-defined but not corticated radiolucencies,with an
oval or a cystic shape –punched out appearance. It may appear ragged and
even infiltrative.
• The inferior alveolar canal looses its cortical boundary. The mandibular
lesions cause thinning of lower border of mandible or endosteal scalloping.

58. Multiple circular radiolucent
lesions in the skull
Panoramic image depicting
multiple areas of well-defined
bone destruction lacking any
cortical boundary.
Cropped panoramic image
shows a solitary lesion in
the condylar neck region
and a pathologic fracture

59. DIFFERENTIAL DIAGNOSIS
 Metastatic carcinoma
 Simple bone cyst
 Hyperparathyroidism
MANAGEMENT
• Chemotherapy with or without autologous or allogenic bone
marrow transplantation.
• Radiation therapy may be used.

60. RARITIES
• Acromegaly
• Agranulocytosis
• Burkitts lymphoma
• Central cavernous hemangioma
• Congenital heart disease
• Cyclic neutropenia
• Diabetes
• Down syndrome
• Erythroblastosis foetalis
• Gauchers disease
• Hypoparathyroidism
• Hypophosphatemia
• Hypovitaminosis C
These diseases may produce generalized rarefactions of the skeleton . Either these diseases
occur rarely or they seldom produce rarefactions of the jaws or bones

61. Differential diagnosis of oral and maxillofacial lesions-5th edition -
NORMAN K WOOD & PAUL W GOAZ
Oral radiology-principles and interpretation
STUART C WHITE & MICHAEL J PHAROAH
 Burket’s oral medicine – MICHAEL GLICK
 Essentials of oral and maxillofacial radiology -FRENY R KARJODKAR
 Oral and maxillofacial pathology-Neville , damm, allen , bouquot
REFERENCE