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Indian J Endocrinol Metab. 2016 Jul-Aug; 20(4): 581–582.
PMCID: PMC4911858

Hyperparathyroidism in dentistry: Issues and challenges!!

Sir,

Endocrine system is responsible for many physiological activities and maintaining the homeostasis. Parathyroid hormone (PTH) is one of the important hormones. It has a key role in calcium and phosphorus metabolism and hence, has a great influence on bone and teeth mineralization.[1]

Disorder of the parathyroid gland may cause either hypersecretion or hyposecretion of PTH. It has diverse oral and extraoral manifestations. Hyperparathyroidism (HPT) is more of concern for an oral physician. Hence, it is important for an oral physician to be aware of the various oral and extraoral findings so that the disorder will be diagnosed correctly followed by a precise and prompt treatment.

Von Recklinghausen first described HPT in 1891. It affects around 0.05–0.1% of the general population. The prevalence is 1 in 400 women and 1 in 1000 men. It usually affects middle-aged persons.[2]

HPT is of three types according to the etiology as primary, secondary, and tertiary. Primary type occurs due to tumor of a gland or hyperplasia leading to increased secretion of PTH causing hypercalcemia and hypophosphatemia. Secondary type occurs due to stimulation of parathyroid glands to produce increased amounts of hormones to correct abnormally low serum calcium levels in different physiologic or pathologic conditions such as renal failure, intestinal malabsorption syndrome, decrease of Vitamin D production, thus resulting in parathyroid hyperplasia. Tertiary-type occurs due to long-standing secondary HPT.[3]

Osteoporosis is most common finding secondary to hypocalcaemia in HPT. Most commonly affected bones are ribs, clavicles, pelvic girdle, and mandible. A pathologic fracture may be the first symptom of the disease. Bone pain and joint stiffness may be present. Renal calculi are a common finding in this condition. Almost all patients with HPT have skeletal lesions in the advanced stages.

Intraoral manifestations are 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, periodontal ligament widening, teeth become sensitive to percussion and mastication, floating teeth delay or cessation of dental development, brown tumor, generalized bone ratification of jaw, soft tissue calcifications, caries, hypercalcemia may result in sialolithiasis mandibular tori, patient may complain of vague jaw bone pain.[4]

Brown tumor is tell-tale sign of HPT. It may be the earliest manifestation of this undiagnosed HPT in 6% of the cases it presents itself as a friable red-brown mass. Radiographically appears as an osteolytic radiolucent lesion. The other characteristic radiographic findings show a widespread loss of the lamina dura and changes in the pattern of the trabecular bone of the jaws. Long-standing lesion commonly produces a significant expansion of cortical bone, root resorption, and displacement of roots.[5]

The clinical management of these patients requires special consideration. We should know that there is a higher risk of bone fracture, so we must take precaution in surgical treatments. Before providing endodontic treatment, a thorough medical history taking is important as in some instances, these lesions appear as a radiolucency the periapical region of teeth and can lead to a misdiagnosis of a lesion of endodontic origin.[6]

Thus, an oral physician should have a thorough knowledge about the etiopathogenesis, clinical features and the diagnostic challenges in case of HPT as this entity shows its pathognomonic features intraorally. During management of this disease, a multidisciplinary approach will be helpful.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

REFERENCES

1. Zofkova L. Hypercalcaemia pathophysiological aspects. Physiol Res. 2015;65:1–10. [PubMed]
2. Wu JX, Yeh MW. Asymptomatic primary hyperparathyroidism: Diagnostic pitfalls and surgical intervention. Surg Oncol Clin N Am. 2016;25:77–90. [PubMed]
3. Machenahalli P, Shotliff K. Problem based review: The patient with hypercalcaemia. Acute Med. 2015;14:138–41. [PubMed]
4. Kakade SP, Gogri AA, Umarji HR, Kadam SG. Oral manifestations of secondary hyperparathyroidism: A case report. Contemp Clin Dent. 2015;6:552–8. [PMC free article] [PubMed]
5. Nair PP, Gharote HP, Thomas S, Guruprasad R, Singh N. Brown tumour of the jaw. BMJ Case Rep 2011. 2011:pii: Bcr0720114465. [PMC free article] [PubMed]
6. Venkatesh KV, Nandini VV. Periapical radiolucency not requiring endodontic therapy: An unusual case. Indian J Dent Res. 2009;20:126–8. [PubMed]

Articles from Indian Journal of Endocrinology and Metabolism are provided here courtesy of Wolters Kluwer -- Medknow Publications