Systemic Diseases Manifestation the Jaws based on chapter25 Oral Radiology P R I N C I P L E S a n d I N T E R P R E T A T I O N Sixth Edition White and pharoah

1. Systemic Diseases Manifested
in the Jaws
C H A P T E R 25
Oral Radiology
P R I N C I P L E S
a n d I N T E R P R E T A T I O N Sixth Edition
White and pharoah
Seyed vahid malek hosseini

2. Systemic Diseases Manifested
in 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.

3. 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

4. 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.

5. 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.

6. 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.

7. • 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

8. 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

9. 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

10. Radiographic Features of the Teeth and Associated
Structures
• loss of the lamina dura that may give the root a tapered appearance
because of loss of image contrast.

12. loss of bone and lamina dura and
the granular texture of the bone

13. subperiosteal erosion in hyperparathyroidism

14. Hyperparathyroidism

15. HYPOPARATHYROIDISM AND
PSEUDOHYPOPARATHYROIDISM
• 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

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

17. HYPERPITUITARISM
Acromegaly and giantism
• increases the production of growth hormone
• causes overgrowth of all tissues in the body

18. • 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

19. 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

20. 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.

21. 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

22. HYPERTHYROIDISM
Thyrotoxicosis 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.

23. HYPOTHYROIDISM
Myxedema 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.

24. DIABETES MELLITUS
• no characteristic radiographic features
• Periodontal disease associated with diabetes is radiographically
indistinguishable

25. 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

26. Cushing ’ s syndrome manifested in the jaws as
thinning
of the lamina dura

27. Metabolic Bone Diseases 461

28. 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

29. 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

30. Osteoporosis evident as a loss of the normal
thickness and
density of the inferior cortex of the mandible.

31. 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

32. 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

33. 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.

34. 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

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

36. 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

37. large pulp chambers in the deciduous dentition
and the premature loss of the mandibular incisors

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

39. 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

40. areas of radiolucency
corresponding to loss of bone mass, loss of
distinct lamina dura, and a sclerotic bone pattern
around the roots of the teeth

41. diffuse sclerotic (radiopaque) bone
pattern throughout the jaws. Note the loss of a
distinct inferior cortex of the mandible resulting
from an increase in the radiopacity of the internal
aspect of the bone.

42. HYPOPHOSPHATEMIA
Vitamin D – resistant rickets and hypophosphatemic rickets
• conditions that produce renal tubular disorders resulting in excessive
loss of phosphorus.

43. 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

44. radiolucent appearance of the
jaws and hence the lack of bone density and the
large pulp chambers

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

46. OSTEOPETROSIS
Albers-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

47. dense calcification of all the bones.

48. 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

49. 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.

50. an unusual pattern of mandibular erosions at
regions of muscle attachment such as the angles,
coronoid process, digastric region, or condyles

51. 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.

52. widening of the periodontal
membrane space around some of the teeth.

53. 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.

54. Radiographic Features of the Jaws
• general osteoporosis
• bone marrow hyperplasia may cause enlargement and protrusion of
the maxillary alveolar ridge

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

56. hair-on-end bone pattern

57. 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

58. 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.

59. granular appearance of
the skull and thickening of the diploic space

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

61. thickened body of the mandible
and the sparse trabeculae and lack of maxillary
antra

62. thick trabeculae
and large
bone marrow spaces