牙科放射線學 (2)

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


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


Ref. 1

Endocrine Disorders

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

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.



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


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


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


Loss of normal thickness & density of inferior cortex of mandible

OSTEOPOROSIS( bone mass but normal bone histology)


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


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


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



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



A diffuse sclerotic (radiopaque) bone pattern throughout the jawsInferior cortex of mandible: indistinct resulting from radiopacity of internal aspect of bone



Ref. 1


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



Ref. 1



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



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


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


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


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




Ref. 1

Other Systemic Diseases


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



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



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



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



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


Radiographic Appearance of the Jaws

Thickened mandibular body & sparse trabeculae & lack of maxillary antra



(heterozygous form: thalassemia minor, is mild; homozygous form (thalassemia major), is severe; thalassemia intermedia)

Ref. 1


Radiographic Appearance of the JawsThick trabeculae & large bone marrow spaces



(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

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牙科放射線學 (2)