University Of Sulaimani

Faculty Of Medical Sciences

School Of Dentistry
Oral Diagnosis Department

Parathyroid
Disordorders

By: Garmyan Yawar

2015/2016
 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
Parathyroid gland
 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).
Disorders of Parathyroid Hormone

Hyperparathyroidism

Hypoparathyroidism
• 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
• 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
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
 Hyperparathyroidism

Hyperparathyroidism

Primary Secondary Tertiary

Parathyroid Parathyroid Parathyroid Autonomous

Parathyroid
nodule on top of
hyperplasia adenoma carcinoma hyperplasia hyperplasia
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
(4)
or normal serum phosphate level. Kidney stones

• (4) Hyperparathyroidism-jaw tumour syndrome detected by aggressive generalized osteitis fibrosa cystica
• Alae Guerrouani, Abdelkader Rzin, and Karim El Khatib
 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

k

subperiosteal resorption of the phalanges of the

index and middle fingers
Secondary Hyperparathyroidism
• 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.
 Tertiary hypoparathyroidism
• Tertiary When long-standing secondary
hyperplasia becomes autonomous in spite of
correction of the underlying stimulant (renal
transplant).
 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
This case shows the decreased bone trabeculation giving it a
‘ground-glass’ or granular appearance
 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 .
 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.
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
 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
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.
• 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.
 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.
 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.
• 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
• Patchy hair loss, such as thinning of your eyebrows
• Dry, coarse skin
• Brittle nails
• Headaches
• Depression, mood swings
• Memory problems
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
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
• Delay or cessation of dental development
• Dental malocclusion
• Caries
• Chronic candidiasis
• Paresthesia of the tongue or lips
• Alteration in facial muscles
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.
• 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.
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
• (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