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Year : 2012  |  Volume : 23  |  Issue : 3  |  Page : 384-387
Oro-mandibular manifestations of primary hyperparathyroidism

1 Oral Health Sciences Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
3 Bone and Mineral Research Laboratory, Henry Ford Hospital, Detroit, Michigan, USA

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Date of Submission05-Nov-2010
Date of Decision12-May-2011
Date of Acceptance13-Aug-2011
Date of Web Publication11-Oct-2012


Aims and Objective : To determine the effects of Primary Hyperparathyroidism on oral cavity in a symptomatic contemporary Indian population by taking note of the following parameters: (1) Radiological alteration of lamina dura, (2) mandibular cortical width, (3) prevalence of brown tumor, and (4) mandibular tori.
Study Design : Twenty-six patients of Primary Hyperparathyroidism were examined clinically and radiologically for extra- and intraoral abnormalities. Loss of lamina dura, mandibular cortical width, presence of mandibular tori, and brown tumors were assessed and correlated with serum Calcium, Phosphate, Parathormone, and Alkaline phosphatase. The results were compared with twenty-six age- and gender-matched control subjects. The data was expressed as mean ± SD, and a probability (p) value of < 0.05 was considered significant. Pearson's statistical method was used to assess the significant correlation between radiological measurements and biochemical values.
Results : Generalized absence of the lamina dura was the most consistent finding and there was a significant correlation between its loss and altered parathormone, alkaline phosphatase, and inorganic phosphate, but not with serum calcium or the duration of the disease. Mean values (in mm) for the cortical indices were significantly lower in the patients compared to the controls and correlated significantly with parathormone and alkaline phosphatase. None of the patients had mandibular tori and only one patient had a brown tumor.
Conclusion : Loss of lamina dura, ground glass appearance, and mandibular cortical width reduction are common findings in primary hyperparathyroidism and these are significantly correlated with elevated parathormone and alkaline phosphatase. However, the presence of brown tumors and oral tori are less commonly encountered features.

Keywords: Alkaline phosphatase, hyperparathyroidism, lamina dura, mandibular tori, parathyroid hormone

How to cite this article:
Rai S, Bhadada SK, Rattan V, Bhansali A, Rao D S, Shah V. Oro-mandibular manifestations of primary hyperparathyroidism. Indian J Dent Res 2012;23:384-7

How to cite this URL:
Rai S, Bhadada SK, Rattan V, Bhansali A, Rao D S, Shah V. Oro-mandibular manifestations of primary hyperparathyroidism. Indian J Dent Res [serial online] 2012 [cited 2019 Nov 14];23:384-7. Available from:
Primary hyperparathyroidism (PHPT) is the third most common endocrine disorder, [1] with varying clinical presentations, ranging from asymptomatic hypercalcemia detected during a routine biochemical testing to classic manifestations traditionally associated with the disease. [2] PHPT affects many organs, including bone, kidneys, soft tissues, the gastrointestinal tract, and the central nervous system. [3] As a part of systemic manifestation, the odontogenic tissue and the jaw bones are also affected; this can be detected on conventional radiographs. Complete or partial loss of lamina dura (LD) and ground glass appearance of the jaw bones are the most common findings [4] [Figure 1] and [Figure 2]. Of late, a high prevalence of mandibular tori (60 - 70%) has been reported in patients with mild PHPT. [5] Rarely, lytic lesions in the jaws may present as reparative giant cell granulomas referred to as brown tumors. [6],[7] The main objective of the present study was, therefore, to determine the effects of moderate-to-severe PHPT on oral cavity as assessed by the presence or absence of LD on intra-oral periapical ((IOPA) radiographs, altered mandibular cortical width on an orthopantomogram (OPG), and the prevalence of mandibular tori and brown tumors.
Figure 1: An IOPA radiograph showing complete loss of LD in a PHPT patient

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Figure 2: An OPG showing reduced cortical width of the mandible and a ground glass appear ance in a PHPT patient

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   Materials and Methods Top

Patients: Twenty-six consecutive patients with PHPT referred from the Department of Endocrinology were examined between January 2004 and December 2006 at the Oral Health Sciences Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India. The Institute's Ethics Committee approved the study and a written informed consent was obtained from each patient. A diagnosis of PHPT was confirmed by elevated or non-suppressed serum PTH levels, with or without increased serum albumin-adjusted serum calcium levels, and subsequently at surgery by removal of a single parathyroid adenoma.

Oral cavity evaluation

A complete oral cavity examination was performed with specific attention paid to the presence of mandibular torus (tori) and intra-oral brown tumors. The mandibular tori are bony protuberances in or along the lingual border of the mandible, in the premolar region. Edentulous patients were excluded from the study. A similar assessment was done on 26 age- and gender-matched control group. The subjects in the control group were randomly selected from the dental outpatient department seeking routine dental treatment and had no apparent history of metabolic bone disorders, pathological fractures or drug intake in the recent past, known to affect bone and mineral metabolism.

Assessment of lamina dura

Full mouth standardized Intra Oral Periapical (IOPA) radiographs were performed for detailed assessment of LD. Each root was divided into a cervical third, middle third, and apical third on both the mesial and distal surfaces, with each division noted as one unit. Thus, every single-rooted tooth has six units and every two- and three-rooted tooth has twelve and eighteen units, respectively [Figure 3]. On account of the two-dimensional view in conventional radiography, there were certain limitations that were taken into account while assessing the IOPA radiographs. The root surfaces overlapped by another root or crown were not considered. For e.g. the palatal root of a maxillary bicuspid is overlapped by the buccal root, hence was excluded. The presence or absence of LD was ascertained for each unit. The total number of units was counted for each patient and the percentage of the missing LD was calculated.
Figure 3: Method of measurement of LD by division of single root into six units on an IOPA radiograph

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Assessment of mandibular cortex

A standardized OPG was taken on a single machine (Kodak 8000C). Three mandibular cortical indices (MCI) - the Gonial Index (GI), Antigonial Index (AI), and the Mental Index (MI) - were measured in the standard manner [8],[9] [Figure 4]. All the measurements were done by a single blinded observer repeated over a period of one month. The effect of PHPT on the mandibular cortical indices was determined by correlating GI, AI, and MI with the indices of the disease (calcium, alkaline phosphatase, intact parathormone).
Figure 4: An OPG showing the method of measurement of mandibular (GI, AI, MI) cortical indices

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Laboratory methods

Serum Ca (reference range: 8.5 - 10.2 mg / dl), phosphate (reference range: 3.5 - 5 mg / dl), and alkaline phosphatase (AP; reference range 3 - 13 KAU) were measured by the standard methods in the hospital laboratory. Serum PTH (reference range: 10 - 69 pg / ml), and 25-hydroxyvitamin D (25-OHD) were measured by the chemiluminescence's assay using commercially available kits (DiaSorin Inc, Stillwater, Minnesota, USA).

Statistical analysis

All analyses were performed using SPSS (Release 10.01, pc windows; SPSS Inc, Chicago, IL). Data was expressed as mean ± SD, unless otherwise specified. A probability (p) value of < 0.05 was considered significant. The Pearson's statistical method was used to assess the significant correlations between indices measurements on x-rays and the indices of the diseases.

   Results Top

The mean ± SD age of the patient and control groups was comparable (31.7 ± 13.07 vs. 30.7 ±13.57 years), and there were 12 males and 14 females in each group. The mean ± SD duration of the PHPT symptoms was 28 ± 26 months (range: 1 month to 10 years). More than half of the patients had either a pathological fracture of the long bones or pelvis as the presenting complain whereas only one patient presented with a brown tumor (3.8%) as an intraoral expansile painless lesion. The mean ± SD albumin adjusted serum Ca was 10.2 ± 0.8 mg / dl (range: 8.5 - 12.5), serum phosphate was 3.3 ± 0.3 mg / dl, serum AP was 38.5 ± 36.6 (range 35 - 99 KAU), and serum PTH was 769 ± 751 pg / ml (range 123 to 2139 pg / ml).

The most common radiographic finding was the generalized absence of LD. Fifteen of the 26 patients (58%) had complete or partial loss of LD. In these 15 patients, 11 (42%) had complete absence, while four (15%) had partially missing LD. In the control group, only eight of the 26 subjects (31%) had partial loss, while intact LD was present in the remaining 18 (69.2%) patients [Table 1], [Table 2]. The mean ± SD presence of LD in the percentage was 51.82 ± 49.05 in the patient group and 96.62 ± 5.54 in the control group, with P <.05. The single patient with the mandibular brown tumor also had multiple lytic lesions in the maxilla, frontal bone, and the femur. None of the patients or the matched control group subjects had mandibular tori. A significant correlation was found between the loss of lamina dura and serum PTH levels (r = 0.74, P < 0.01). The percentage of loss of LD also correlated significantly with AP (P < 0.003) and inorganic phosphate (P < 0.001), but not with serum Ca or duration of the disease.
Table 1: Presence of lamina dura in patient and control groups in percentage

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Table 2: Mandibular cortical indices in patients and controls

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   Discussion Top

To the best of our knowledge and literature search, this is the first comprehensive Asian study of intra-oral clinical and radiological findings in symptomatic PHPT patients. In addition, we found that both the loss of lamina dura and mandibular cortical thickness indices correlated significantly with the serum PTH and AP. However, these changes occurred at high PTH levels. Patients with high PTH and AP, uniformly showed loss of LD and thinning of MCI. Mandibular tori were not found in any of the patients in either group.

In the previous studies [10],[11],[12] loss of LD and ground glass appearance in the jaw bones was the most consistent finding with regard to the odontogenic changes in PHPT. In our study LD was missing in more than half (52%) of the PHPT patients examined, which was related to the severity of PHPT. With high PTH and AP values, absence of LD was more frequent. A moderate rise in PTH or AP did not alter the odontogenic tissue, and thus it appeared that the odontogenic signs and symptoms were manifestation of the advanced stages of PHPT.

One out of the twenty-six patients showed complete loss of MI, AI, and GI, whereas, the rest showed mild alteration in the form of the cortical width. These reduced values of cortical width were statistically significant when compared to patients in the control group, who had no apparent history of any bone disease. A significant difference was noted in the indices, but there was no correlation of age, sex or duration of the disease with the increased levels of PTH and AP. The results of this study demonstrated that panoramic radiograph indices could be suggestive of osseous alteration and might be useful as a method of risk assessment, when combined with other factors.

In the context of PHPT, a maxillofacial brown tumor is a rare finding and is only seen in the advanced stages of the disease. In our series of 26 patients, only one patient had such lesion. Interestingly, in contrast to the report by Padbury et al., [5] none of our patients with moderate-to-severe PHPT had mandibular tori. Mandibular torus is determined by multiple factors like genetic and environmental factors, including an occlusal (biting) force. Another recently proposed mechanism for oral tori is in combination with the biomechanical forces, particularly to the oral cavity; cortical bone loss and trabecular expansion result in an increased incidence of mandibular tori. This preferential loss of cortical bone and increased formation of trabecular bone usually occurs in the early stage of PHPT (asymptomatic). Absence of mandibular tori in our study is possibly due to the young age of the patients and moderate-to-severe PHPT, where loss of both the cortical as well as trabecular bone takes place. Our further search on the incidence of mandibular tori in different populations led us to a few large sample size studies. [13],[14],[15] Possibly, race, age, and gender play an important role in the determination of mandibular tori and must definitely be considered while conducting similar studies. The mandibular tori would probably have been an incidental finding in the previous study and the hypothesis of mandibular tori formation must be confirmed in a larger sample size.

The authors were aware of the limitations of this study. The measurements of LD and MCI were done in a subjective way by a single blinded observer. We tried to reproduce the method and minimize the error by repeating the measurements again by the same observer after a month. It would have been interesting to compare the mandibular tori and cortical indices with dual-energy x-ray absorptiometry (DEXA). Due to the non-availability of DEXA in all patients, we were unable to do this. Other possible limitations of this study were that the serum PTH was not obtained in healthy controls and the sample size was small.

In conclusion, patients with moderate-to-severe PHPT demonstrated significant loss of LD and decreased MCI, due to high PTH, compared to the age- and gender-matched controls. However, incidence of mandibular tori was not increased as was reported by others. This was probably a reflection of multiple risk factors for the development of tori, including severity of disease, race, and age. The presence of tori should not be attributed to PHPT till studies with a large sample size are available. Brown tumors may rarely be the first presenting symptom, and finally, osseous and odontogenic changes in the orofacial region are still prominent in moderate-to-severe PHPT.

   References Top

1.Rao DS, Rao SD. Treatment of primary hyperparathyroidism. Curr Opin Endocrinol Diabetes 2003;10:394-9.  Back to cited text no. 1
2.Mithal A, Bandeira F, Meng X, Rao DS. Clinical presentation of primary hyperparathyroidism in India, Brazil and China. In: Bilzeikian JP, Levine MA, Marcus R, editors. San Diego, CA: The Parathyroid Academic Press; 2001. p. 375-6.  Back to cited text no. 2
3.Ahmad R, Hammond JM. Primary, secondary, and tertiary hyperparathyroidism. Otolaryngol Clin North Am 2004;37:701-3.  Back to cited text no. 3
4.Stafne EC. Roentgenologic manifestations of systemic disease in dentistry. Oral Surg Oral Med Oral Pathol 1953;6:483-4.  Back to cited text no. 4
5.Padbury AD, Tozum TF, Taba M, Ealba EL, West BT, Burney RE, et al. The impact of primary hyperthyroidism on the oral cavity. J Clin Endocrinol Metab 2006;9:3439-45.  Back to cited text no. 5
6.Martinez-Gavidia EM, Bagan, Milian-Masanet MA, Lloria de ME, Perez Valles A. Highly aggressive brown tumour of the maxilla as first manifestation of primary hyperparathyroidism. Int J Oral Maxillofac Surg 2000;29:447-9.  Back to cited text no. 6
7.Daniels S. Primary hyperparathyroidism presenting as a palatal brown tumor. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;98:409- 13.  Back to cited text no. 7
8.Ledgerton D, Horner K, Devlin H, Worthington H. Panoramic mandibular index as a radiomorphometric tool: A study in precision. Dentomaxillofac Radiol 1997;26:95-100.  Back to cited text no. 8
9.Bras J, van Ooij CP, Abraham-Inpijin L, Kusen GJ, Wilmink JM. Radiographic interpretation of the mandibular angular cortex: A diagnostic tool in metabolic bone loss, Part I: Normal bone. Oral Surg Oral Med Oral Pathol 1982;53:541-5.  Back to cited text no. 9
10.Rosenberg EH, Guralnick WC. Hyperparathyroidism: A review of 220 proven cases, with special emphasis on findings in the jaws. Oral Surg Oral Med Oral Pathol 1962;15:84.  Back to cited text no. 10
11.Silverman S, Gordan G, Grant T, Stienbach H, Eisenberg E, Manson R. The dental structures in Primary Hyperparathyroidism. Oral Surg Oral Med Oral Pathol 1962;15:426.  Back to cited text no. 11
12.Keating FR Jr. Clinical and laboratory aspects of the diagnosis of Primary Hyperparathyroidism. J Am Med Assoc 1961;178:547.  Back to cited text no. 12
13.Reichart PA, Neuhaus F, Sookasem M. Prevalence of torus palatinus and torus mandibularis in Germans and Thai. Community Dent Oral Epidemiol 1988;16:61-4.  Back to cited text no. 13
14.Jainkittivong A, Apinhasmit W, Swasdison S. Prevalence and clinical characteristics of oral tori in 1,520 Chulalongkorn University Dental School patients. Surg Radiol Anat 2007;29:125  Back to cited text no. 14
15.Yildiz E, Denaz M, Ceyhan O. Prevalence of torus palatinus in Turkish Schoolchildren. Surg Radiol Anat 2005;27:36.  Back to cited text no. 15

Correspondence Address:
Sachin Rai
Oral Health Sciences Centre, Postgraduate Institute of Medical Education and Research, Chandigarh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-9290.102236

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2]

This article has been cited by
1 Giant Cell Lesions Associated with Primary Hyperparathyroidism
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[Pubmed] | [DOI]


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