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牙科放射線學 (2)
Radiologic Interpretation ofSystemic DiseasesManifested 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 [email protected]
• Know how to interpret radiographic findings of systemic diseases manifested in jaws
學 習 目 標
1. Stuart C. White, and Michael J. Pharoah : Oral Radiology - Principles and Interpretation, 6th edition, 2009, Chapter 252. http://uwmsk.org/residentprojects/hpth.html3. path.upmc.edu4. Kunihiko Miyashta. Contemporary Cephalometric Radiography, 1st
edition, 1996, frontpage
References
General radiographic findings of systemic diseases manifested in jaws
1. A change in bone size & shape2. A change in trabeculae no., size, & orientation3. 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 eruption2. Enamel hypoplasia3. Enamel hypocalcification4. Loss of lamina dura
Ref. 4
Endocrine Disorders
Radiographic Features~1/5 patients: radiographically observable bone changes
General Radiographic Features1. The earliest & most reliable changes: bone erosions from subperiosteal surfaces of phalanges of hands
Ref. 2
HYPERPARATHYROIDISM( circulating PTH- serum calcium level)
Endocrine Disorders
General Radiographic Features (continue)2. Demineralization of the skeleton radiolucence3. Osteitis fibrosa cystica: localized regions of bone loss produced by osteoclastic activity loss of all apparent bone structure4. Brown tumors: occur late in the disease (~10% of cases) These peripheral/central bone tumors: radiolucent Gross specimen: brown or reddish-brown color5. Pathologic calcifications in soft tissues: a punctate/ nodular appearance & occur in kidneys & joints
HYPERPARATHYROIDISM( circulating PTH- serum calcium level)
Endocrine Disorders
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
Ref. 1A, Axial, B, sagittal CT images of a case of secondary hyperparathyroidism
HYPERPARATHYROIDISM( circulating PTH- serum calcium level)
Ref. 1
Endocrine Disorders
Radiographic Features of the Jaws
A, Bone loss results radiopaque teeth standing out in contrast to the radiolucent jaws
HYPERPARATHYROIDISM( circulating PTH- serum calcium level)
B, loss of lamina dura & granular texture of bone
Refs. 1, 3
Endocrine Disorders
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.
Radiographic Features of the Jaws
HYPERPARATHYROIDISM( circulating PTH- serum calcium level)
Endocrine Disorders
Radiographic Changes of the Teeth & Associated Structures
A & B, Characteristic granular bone pattern Loss of lamina dura & floor of maxillary antrum
Ref. 1
HYPERPARATHYROIDISM( circulating PTH- serum calcium level)
C, The same case reveals a brown tumor in the apical region of the second & third molars.
Ref. 1
Endocrine Disorders
Radiographic Features
Dental anomalies: enamel hypoplasia, external root resorption, delayed eruption, or root dilaceration
HYPOPARATHYROIDISM( secretion of PTH)
Endocrine Disorders
A case of acromegaly manifesting as excessive growth of mandible class III skeletal relationship of jaw Ref. 1
Radiographic Features of the Jaws
HYPERPITUITARISM(acromegaly-adult & giantism-child)
( anterior lobe of the pituitary gland, growth hormone)
The same patient: enlargement of sella turcica
Endocrine Disorders
Radiographic Changes of the TeethA, Tooth crown: normal in sizeB, Roots of posterior teeth: hypercementosis, the result of functional & structural demands on teeth instead of a secondary hormonal effectC, Supereruption of posterior teeth: attempt to compensate for the growth of mandible
HYPERPITUITARISM(acromegaly-adult & giantism-child)
( anterior lobe of the pituitary gland, growth hormone)
Endocrine Disorders
Radiographic FeaturesA, Primary dentition: erupt at normal time, but delayed exfoliation by several yearsB, Crowns of permanent teeth: form normally, but delayed eruption by several yearsC, Third molar buds: completely absentD, Jaws (esp. mandible): small crowding & malocclusion
HYPOPITUITARISM( secretion of pituitary hormones)
Endocrine Disorders
HYPERTHYROIDISM(thyrotoxicosis & Graves’ disease)
( production of thyroxin in thyroid gland)
Radiographic FeaturesA, Results in an advanced rate of dental development & early eruption, with premature loss of primary teethB, Adults: bone density/loss of some areas of edentulous alveolar bone
Endocrine Disorders
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 duraC, Jaws: relatively smallD, Adults: periodontal disease, tooth loss, tooth separation of as a result of tongue enlargement & external root resorption
Radiographic Features
HYPOTHYROIDISM(myxedema & cretinism)
( secretion of thyroxine by thyroid glandsdespite the presence of TSH)
Endocrine Disorders
Radiographic FeaturesA, Jaws/teeth: no characteristic radiographic featuresB, Periodontal disease associated with DM is indistinguishable radiographically from periodontal disease without DM
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)
Ref. 1
Endocrine Disorders
Radiographic Features of the JawsA, Generalized osteoporosis, which may have a granular bone pattern This demineralization may result in pathologic fractures.B, Skull: diffuse thinning accompanied by a mottled appearanceC, Teeth: premature eruption & partial loss of lamina dura
CUSHING’ S SYNDROME( secretion of glucocorticoid of adrenal gland)
Ref. 1
Metabolic Bone Disorders
Radiographic Features of the Jaws
Loss of normal thickness & density of inferior cortex of mandible
OSTEOPOROSIS( bone mass but normal bone histology)
Metabolic Bone Disorders
Radiographic Features of the JawsA, In rickets, mandibular border/walls of IAN canal: thinB, Changes in jaws occur after changes in ribs & long bonesC, Trabeculae within cancellous portion of jaws: density, no. & thicknessD, Severe cases: jaws appear so radiolucent that the teeth appear to be bereft of bony support
A, Osteomalacia (Most) : no radiographic manifestations in jawsB, Radiographic manifestations: an overall radiolucence & sparse trabeculae
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)
Ref. 1
Metabolic Bone Disorders
B, Early rickets: retarded tooth eruptionC, Lamina dura & cortical boundary of tooth follicles: thin or missing
Radiographic Changes Associated with the TeethA, Enamel hypoplasia & hypocalcification
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)
Ref. 1
Metabolic Bone Disorders
Radiographic Features of the JawsA, Mandible & maxilla: generalized radiolucencyB, Cortical bone & lamina dura: thinC, 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
HYPOPHOSPHATASIA(inherited disorder- production/defective function of
alkaline phosphatase)
Ref. 1
Metabolic Bone Disorders
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
RENAL OSTEODYSTROPHY(Renal rickets)
(kidney disease interferes with hydroxylation of25(OH)D into 1,25(OH)2D, which normally occurs in kidney)
Ref. 1
Metabolic Bone Disorders
Radiographic Features of the Jaws
A diffuse sclerotic (radiopaque) bone pattern throughout the jawsInferior cortex of mandible: indistinct resulting from radiopacity of internal aspect of bone
RENAL OSTEODYSTROPHY(Renal rickets)
(kidney disease interferes with hydroxylation of25(OH)D into 1,25(OH)2D, which normally occurs in kidney)
Ref. 1
Metabolic Bone Disorders
Radiographic Changes Associated with the TeethA, Enamel hypoplasia & hypocalcification loss of radiographic evidence of enamel
B, Lamina dura: absent or less apparent in instances of bone sclerosis
RENAL OSTEODYSTROPHY(Renal rickets)
(kidney disease interferes with hydroxylation of25(OH)D into 1,25(OH)2D, which normally occurs in kidney)
Ref. 1
Metabolic Bone Disorders
Radiographic Features of the Jaws
Radiolucence of jaws & hence lack of bone density & large pulp chambers
HYPOPHOSPHATEMIA(vitamin D-resistant rickets & hypophosphatemic rickets)
(distal renal tubules fail to reabsorb phosphorus serum phosphorus- hypophosphatemia)
(Multiple myeloma 2nd damage to kidney hypophosphatemia)
Ref. 1
Metabolic Bone Disorders
Radiographic Changes Associated with the Teeth
Bone loss around the teeth, a granular bone pattern, large pulp chambers & external root resorption
HYPOPHOSPHATEMIA(vitamin D-resistant rickets & hypophosphatemic rickets)
(distal renal tubules fail to reabsorb phosphorus serum phosphorus- hypophosphatemia)
(Multiple myeloma 2nd damage to kidney hypophosphatemia)
Ref. 1
Metabolic Bone Disorders
General Radiographic Features
Dense calcification of skull & facial bones Dense calcification of chest, pelvis &
femurs (fracture of the proximal right femur)
OSTEOPETROSIS(Albers-Schönberg & marble bone disease)
( normal function osteoclast bone mass)(autosomal recessive type-osteopetrosis congenita;
autosomal dominant type-osteopetrosis tarda)
Ref. 1
Metabolic Bone Disorders
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)
OSTEOPETROSIS(Albers-Schönberg & marble bone disease)
( normal function osteoclast bone mass)(autosomal recessive type-osteopetrosis congenita;
autosomal dominant type-osteopetrosis tarda)
Ref. 1
Metabolic Bone Disorders
Radiographic Changes Associated with the TeethA, Delayed eruption, early tooth loss, missing teeth, malformed roots & crowns, & teeth that are poorly calcified & prone to cariesB, Bone density/ankylosis: delayed eruption of the primary & secondaryC, Lamina dura & cortical border: thicker than normal
OSTEOPETROSIS(Albers-Schönberg & marble bone disease)
( normal function osteoclast bone mass)(autosomal recessive type-osteopetrosis congenita;
autosomal dominant type-osteopetrosis tarda)
Ref. 1
Other Systemic Diseases
Radiographic Features of the Jaws
Loss of bone in mandibular angle (arrows) & the right coronoid process (arrow), which are locations of muscle attachments
PROGRESSIVE SYSTEMIC SCLEROSIS(Scleroderma)
(a generalized connective tissue disease: collagen deposition hardening of skin & other tissues)
Ref. 1
Other Systemic Diseases
Radiographic Changes Associated with the Teeth
Widening of periodontal membrane space around some of the teeth
PROGRESSIVE SYSTEMIC SCLEROSIS(Scleroderma)
(a generalized connective tissue disease: collagen deposition hardening of skin & other tissues)
Ref. 1
Other Systemic Diseases
General Radiographic Features
Thickened diploic space & thinning of skull cortex
Skull showing hair-on-end bone pattern
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)
Ref. 1
Other Systemic Diseases
Radiographic Features of the Jaws
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)
A, Osteoporosis because of volume of trabecular boneB, Thinning of cortical plates
Ref. 1
Other Systemic Diseases
General Radiographic Features
Granular appearance of skull & thickening of the diploic space
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)
Ref. 1
Other Systemic Diseases
Radiographic Appearance of the Jaws
Thickened mandibular body & sparse trabeculae & lack of maxillary antra
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)
Ref. 1
Other Systemic Diseases
Radiographic Appearance of the JawsThick trabeculae & large bone marrow spaces
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)
SummariesRadiologic Changes in Bone Observed in Systemic Diseases
Ref. 1
SummariesEffects on Teeth and Associated Structures
Ref. 1