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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 30  |  Issue : 2  |  Page : 181-184

Oral manifestation of hyperparathyroidism: A report of two cases


1 Department of Medicine and Radiology, Faculty of Dental Sciences, Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
2 Department of Oral and Maxillofacial Surgery, Faculty of Dental Sciences, Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
3 Department of Oral Medicine and Radiology, Babu Banarasi Das College of Dental Sciences, Lucknow, Uttar Pradesh, India

Date of Submission19-May-2018
Date of Acceptance07-Jun-2018
Date of Web Publication16-Jul-2018

Correspondence Address:
Dr. Adit Srivastava
Unit of Oral Medicine and Radiology, Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_88_18

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   Abstract 


Hyperparathyroidism is a common endocrine disorder affecting multiple vital organs. The three types of hyperparathyroidism show oral as well as systemic manifestations, including brown tumor, neurological disorders, nephrolithiasis, and pancreatitis. Oral manifestations form an integral part in diagnosing the underlying parathyroid pathology, which is presented in this case series.

Keywords: Hyperparathyroidism, oral manifestations, osteolytic lesions


How to cite this article:
Srivastava A, Verma N, Singh AK, Shivakumar G C. Oral manifestation of hyperparathyroidism: A report of two cases. J Indian Acad Oral Med Radiol 2018;30:181-4

How to cite this URL:
Srivastava A, Verma N, Singh AK, Shivakumar G C. Oral manifestation of hyperparathyroidism: A report of two cases. J Indian Acad Oral Med Radiol [serial online] 2018 [cited 2020 Jan 19];30:181-4. Available from: http://www.jiaomr.in/text.asp?2018/30/2/181/236740




   Introduction Top


Hyperparathyroidism is an endocrinal disorder having various systemic complications. Raised parathormonelevels in hyperparathyroidism causean increase in osteooclastic activity andperitrabecular fibrosis.[1] Hyperparathyroidism is of three types, namely, primary, secondary, and tertiary. Primary hyperparathyroidism is caused bypathology in parathyroid glands most commonly being adenomas or carcinomas. Secondary hyperparathyroidism is in response to hypocalcemiacaused by chronic renal disease, liver disease, intestinal disease, and vitamin D deficiency; and tertiary hyperparathyroidism is a result of long-standing case of secondary hyperparathyroidism. Clinical manifestations of primary hyperparathyroidism include pain, fatigue, and muscular weakness; cortices of bones are more affected with associated subperiosteal bone resorption.[2]

Here, we present case series of two cases of primary hyperparathyroidism with their oral manifestations.


   Case Reports Top


Case report 1

A 21-year-old female reported in the department of oral medicine with swelling in the left mandibular region for3months. Onexamination, a hard, nontender swelling was notedinvolving the mandible region extending from the left posterior molar region to the left posterior mandible ramus involving coronoid and condyle. There was obliteration of buccal vestibule on the left mandibular region [Figure 1]. Orthopantomogram showed multilocular radiolucencies extending from 48 to 38 involving the mandibular condyle and coronoid. Expansion of cortices with thinning of mandibular cortical bone was seen. There was generalized loss of lamina dura [Figure 2]. Skeletal radiographs showed multiple cystic lesions in bones [Figure 3]. Computed tomographyrevealed expansile multiple osteolytic lesion involving the maxilla and mandible and includingthe left coronoid and condyle [Figure 4] and [Figure 5]. Patient had raised parathormone 109 pg/ml (Normal: 10–60pg/ml) and serum alkaline phosphatase levels 600IU/L (Normal: 30–120U/L) with normal serum calcium level 9.5ml/dl (Normal: 8.5–10.5 ml/dl). On further investigation, she was diagnosed with right parathyroid gland adenoma and was planned for parathyroidectomy. After right lower parathyroidectomy, oral lesions showed regression.
Figure 1: Case 1: Diffuse swelling present on left side of face

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Figure 2: Case 1: Multilocular radiolucencies extending from 48 to 38 involving mandibular condyle and coronoid

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Figure 3: Case 1: Multiple cystic lesion seen in skeletal radiograph of hands

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Figure 4: Case 1: CT axial view showing expansile multiple osteolytic lesion involving maxilla and mandible

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Figure 5: Case 1: 3D reconstruction showing extensive osteolytic lesions involving maxilla and mandible

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Case report 2

A 16-year-old female reported in the department with a swelling in the right maxillary region. On intraoral examination, a well-defined reddish swelling was present involving the alveolar ridge extending from 17 to maxillary tuberosity and buccal vestibule of the same region measuring approximately 3 × 3.5cm, with well-defined margins and a smooth surface. It was firm in consistency and tender on palpation [Figure 6]. Orthopantomogram showed bone loss wrt 17 and generalized loss of lamina dura [Figure 7]. Skeletal radiograph of the hand showed multiple cystic lesions in bone. Computed tomography (CT) showed multiple subcentimeterosteolytic lesions showing expansion with soft tissue component andinternal ground glass matrix in bilateral maxilla and mandible [Figure 8] and [Figure 9]. Her serum chemistry showed normal calcium level 10.3ml/dl (Normal: 8.5–10.5 ml/dl) and serum alkaline phosphatase levels 87 IU/L (Normal: 30–120U/L); however, she showed raised parathormone 68 pg/ml (Normal: 10–60pg/ml). Patient was referred to the department of general medicine for evaluation. Ultrasonography showed presence of parathyroid adenoma, inferior to the left thyroid lobe [Figure 10]. Patient was diagnosed with primary hyperparathyroidism and underwent left lower parathyroidectomy. Shewas reviewed after 3 weeks for oral examination. The lesion showed regression from its previous size [Figure 11].
Figure 6: Case 2: Well defined reddish swelling involving alveolar ridge extending from 17 to maxillary tuberosity

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Figure 7: Case 2: Orthopantomogram showing interdental bone loss wrt 17 and generalized loss of lamina dura

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Figure 8: Case 2: CT axial view showing multiple subcentimetre osteolytic lesion with expansion and soft tissue component

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Figure 9: Case 2: 3D CT image showing multiple osteolytic lesions involving maxilla and mandible

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Figure 10: Case 2: USG of neck showing well defined hypoechoic lesion inferior to left thyroid gland

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Figure 11: Case 2: Regression of oral lesion after Parathyroidectomy

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   Discussion Top


Primary hyperparathyroidism is a prevalent endocrine pathology affecting 2–7% of population.[3] In 70–80% of the cases the underlying pathology is adenoma in parathyroid glands, whereas the remaining cases could be due to hyperplasia of all glands. Primary hyperparathyroidism affects age group of 40–80 years with a female predilection ratio of3:1;[4] however, both the above reported cases were females of younger age group of (16–21 years). There is increased osteoclastic activity in bone leading to bone resorption with fibrous replacement and reactive bone formation. There can be microfractures with hemorrhage and fibrous tissue growth resulting in mass called as brown tumor due to its brown color, which is result of vascular factors and blood;[4] the above mentioned cases showed presence of brown tumors in jaws. Hypercalcemia due to increased serum calcium leads to nephrolithiasis andnephrological, as well asneurological changes and pancreatitis,[5],[6],[7] which were absent in above reported patients. Both the patientshad normal calcium levels with elevated parathormone and serum alkaline phosphatase levels.


   Conclusion Top


Hyperparathyroidism is a difficult diagnosis presenting with a plethora of signs and symptoms affecting multiple organs of the body. Dentist can often recognize the condition early and report the condition for prompt intervention and treatment, reinforcing the saying that mouth is the mirror of your health.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Can Ö, Boynueǧri B, Gökçe AM, Özdemir E, Ferhatoǧlu F, Canbakan M, et al. Brown Tumors: A Case Report and Review of the Literature. Case Rep Nephrol Dial 2016;6:46-52.  Back to cited text no. 1
    
2.
Mackenzie-Feder J, Sirrs S, Anderson D, Sharif J, Khan A. Primary Hyperparathyroidism: An Overview. Int J Endocrinol 2011;2011:251410.  Back to cited text no. 2
    
3.
Yeh MW, Ituarte PH, Zhou HC, Nishimoto S, Liu IL, Harari A,et al. Incidence and Prevalence of Primary Hyperparathyroidism in a Racially Mixed Population. J Clin Endocrinol Metab 2013;98:1122-9.  Back to cited text no. 3
    
4.
Sharma P, Parikh K, Chhabra AP, Kapadia B, Vorha PA, Verma S. Classical case of primary hyperparathyroidism. Indian J Radiol Imaging 2005;15:485-7  Back to cited text no. 4
    
5.
Matheson N. The parathyroid and adrenal glands. In: Mann CP, Russel RC, editors. Bailey and Love's Short practice of Surgery. 21st ed. London: Chapman & Hall; 1991. pp 769-75.  Back to cited text no. 5
    
6.
Yousem DM, Scheff AM. Thyroid and Parathyroid. In: Son PM, Curtin HD, editors. Head and neck imaging. 3rd ed. Vol 2. St. Louis: Mosby; 1996. pp 952-75.  Back to cited text no. 6
    
7.
Resnick D, Niwayama G Parathyroid disorders and renal osteodystrophies In: Resnick D, editor. Diagnosis of bone and joint disorders. 3rd ed. Philadelphia: WB Saunders; 1995. pp 2012-75.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]



 

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