Dental Roentgenologic Aspects of Systemic Disease

THE

ourna i A M E R I C A N

M A R C H 1950

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D E N T A L

V O L U M E 40

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OF T HE A S S O C I A T I O N

N UMBER 3

DENTAL R O EN TG EN O LO G IC A SP EC T S OF SYSTEM IC DISEASE

Edward C . Stafn e, D.D.S., Rochester, Minn.

use o f den tal r oen tg en olog y in the field o f m ed ica l diagnosis u p to the present tim e has been very lim ited , if its use in th e search fo r sources o f dental fo c a l in fe ctio n is e x clu d e d . H ow e v e r, it has lo n g been recog n ized by m an y that

T

these cases roen tgen ogram s m a d e o f the skull g av e n o ev id en ce o f this disease.

h e

It is the dentist w h o is associated w ith hospitals and m ed ica l units w h o obviou sly has the o p p o rtu n ity to observe a larger n u m b er o f cases in w h ich there are dental

m anifestation s o f n u m erou s system ic diseases in v olv e the ja w s. P articularly

r o e n tg e n o lo g ic m anifestations o f systemic disease. N o t on ly m ay the dental findings be o f v a lu e in m a k in g a differential diagnosis, b u t in som e instances, a b ­ n orm a l con d ition s o f patients w h o are u n d erg oin g a general physical ex a m i­ n a tion w o u ld rem ain u n d ia g n osed if it w ere n ot fo r a den tal roen tgen olog ic e x ­ am in ation w h ich gives a clu e to the c o r ­ rect diagnosis. T h is has been recog n ized by m a n y internists, and A lb rig h t and R eifen stein 2 stated that several cases o f

does this a p p ly to the skeletal diseases. W h ile referen ce is m a d e in th e m ed ica l literature to oral r o e n tg e n o lo g ic changes in system ic diseases, the freq u en cy o f o c cu rr e n ce o f these changes is n o t fu lly ap p recia ted . T h is is becau se the in cid en ce o f in v olv em en t o f th e ja w has n ot been studied ad equ ately an d such studies h ave n o t been based on ev id en ce revea led by the in traoral den tal roentgen ogram s. R oen tg en og ra m s o f th e h ead , w h ich are c o m m o n ly used in the d ifferen tia l d ia g ­ nosis o f skeletal disease, d o n o t offe r sat­ isfactory view s o f the ja w s a n d the teeth. A study by Stafne an d A u stin 1 based o n den tal roen tgen ogram s in a series o f cases o f P aget’ s disease revea led definite e v id en ce o f the disease in 17 p er cen t o f the cases, an a p p recia bly h igh er in cid en ce than

previously supposed.

In

som e

Read before the Section on Roentgenology and the Section on Orthodontics at the ninetieth annual session of the American Dental Association, San Francisco, October 1 9 , 1 9 4 9 . From the Section on Dental Surgery, Mayo Clinic, Rochester, Minn. 1. Stafne, E. C ., and Austin, L . T., A Study of Den­ tal Roentgenograms in Cases of Paget’s Disease (Oste­ itis Deformans), Osteitis Fibrosa Cystica and Osteoma. J .A .D .A . 25:1202 (Aug.) 1938. 2. Albright, Fuller, and Reifenstein, E. C ., The Parathyroid Glands and M etabolic Bone Disease; Se­ lected Studies. Baltimore: The Williams and Wilkins

of

Company, 1948, p. 57.

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266 h yp erp arath y roid ism in the series at the M assachusetts G en era l H osp ita l w ere p ick e d u p b y the den ta l d ep a rtm en t. In the case o f h yp erp arath y roid ism , as w ell as oth er diseases in w h ich th ere are skeletal m a n ifesta tion s, this statem ent c a n b e substantiated b y experien ces at the M a y o C lin ic. O f th e den tal specialties th e o r th o ­ dontists h a v e been p a rticu la rly interested in con d ition s w h ich in flu en ce th e skeletal d e v e lo p m e n t as w ell as in o th e r m e d ica l con d ition s o f th eir patients. T h is interest is e v id e n ce d by the in clu sion o f m an y v a lu a b le pa pers a n d abstracts o n the su b ject in the o r th o d o n tic literature. W h ile m a lo cclu sio n in m ost instances n o d o u b t is cau sed by lo ca l a n d gen etic factors, th ere are m a n y instances in w h ich m a lo cclu sio n a n d oth er den ta l a b n o rm a l­ ities are associated w ith skeletal m a n i­ festations o f system ic disease, diseases in w h ich o r th o d o n tic m easures instituted are usually n o t successful e x ce p t in the event that th e gen eral co n d itio n presen t ca n be treated successfully. B eck s,3 in evalu atin g rou tin e d e n to m e d ica l ex am in a tion s m a d e fo r a series o f o r th o d o n tic patients w ith a v iew to d eterm in in g g o o d a n d p o o r risks, fo u n d th at o f the gen eral con d ition s w h ich m ig h t in flu en ce treatm en t, end o c rin o p a th y a c c o u n te d f o r slightly m o re than h a lf. O th e r con d ition s n o te d w ere d ev elop m en ta l disturbances, dietary d e ­ ficien cy diseases, con g en ita l syphilis an d tuberculosis. I t w as also fo u n d th at delay in the tim e o f eru p tion o f teeth, p a rticu la rly u ntil late in life, w as suggestive o f system ic o r con stitu tion a l factors, w hereas in general, all classes o f m a lo cclu sio n are m ore fr e ­ q u en tly a c c o m p a n ie d b y early eru p tion o f teeth. O b v iou sly , diseases w ith skeletal m anifestation s, be th ey o f en d ocrin e, d e ­ v elo p m e n ta l, in fla m m a tory o r d ietary orig in , presen t a p r o b le m a n d are o f c o n ­ cern to the orth od on tist. T h e b ord erlin e co n d itio n s are o f p a rticu la r interest fo r th ey are m o r e d ifficu lt to recog n ize. In the con sid era tion o f the effects o f

The Journal of the American Dental Association system ic disease u p o n the teeth and their su p p ortin g osseous structures o r ja w s, the den ta l a n d ora l features w ill b e dealt w ith p rim a rily fr o m th e sta n d p oin t o f the d en ta l roentgen olog ist. To conserve space, on ly in traoral den ta l ro e n tg e n o ­ gram s are show n. In som e instances such roen tgen ogram s are a d e q u a te ; in others, su pplem en tary ex traorally p la ce d films w o u ld be necessary to ob ta in ro e n tg e n o ­ gram s that w o u ld sh ow all the b ou n daries o f the lesion. C on d ition s that w ill b e dis­ cussed briefly are som e o f those w h ich are associated w ith distu rban ces o f the e n d o cr in e glan ds, avitam inosis, skeletal d ev elop m en ta l distu rban ces, in fla m m a ­ tory diseases o f the b on e, P ag et’s disease, m u ltip le m y elom a , ecto d e rm a l dyplasia a n d acrosclerosis. I n m a n y con d ition s the d en ta l roen tg en og ra m presents a c h a r­ acteristic p ictu re w h ich , o f course, m ay vary w ith the stage at w h ich the disease is observed. A ch a ra cteristic roen tg e n o g ra p h ic p ictu re of the disease m a y h a v e b een greatly altered as a result o f th era p eu tic m easures that m a y already h a v e b een instituted, an d r o e n tg e n o lo g ic e v id en ce o f the disease is n o t always presen t in the teeth an d ja w s, alth ou g h present in oth er bon es o f the skeleton.

Endocrine' Disturbances T h e en d o crin e glan ds are ductless g lan ds that p r o d u c e h orm on es w h ich are secreted in to the b lo o d stream a n d play the role o f catalyzers a n d regu late c e ll­ u lar processes such as g ro w th a n d m e ta b ­ olism . T h e e n d o crin e g lan ds w h ich are k n ow n to h a v e an in flu en ce u p o n the skeleton are the pituitary, sex, th yroid , ad ren al a n d p a ra th yroid glan ds, a n d any d istu rb an ce w h ich is cau sed b y a qu a n tita ­ tive ch a n g e in the h orm on es, be it o v e r ­ p r o d u c tio n o r u n d e r p r o d u c tio n , m a y p r o -

3. Becks, Hermann, Orthodontic Prognosis: Evalua­ tion of Routine Dentomedical Examinations to Deter­ mine “ Good and Poor Risks.” Am . J. Orthodontics 2 5 : 6 io (July) 1939.

J.A .D .A ., V ol. 40, March 1950 . . . 267

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d u ce a d istu rb an ce o f g row th a n d m e ta b ­ olism o f bones. S ch o u r a n d M assler4 stated that th e teeth a n d ja w s reflect en d o crin e d y sfu n ction ju st as d o oth er organs a n d tissues. T h e y g o on to say that teeth, becau se o f h igh ly sp ecialized struc­ tures, are v a lu a b le f o r analysis o f en ­ d o c rin e fu n c tio n an d th at th ey o fte n re­ flect effects w ith k y m og ra p h ic accu racy. Pituitary G la n d .— T h e p itu itary g la n d is situated w ith in the sella tu rcica at the base o f th e skull a n d has an an terior and a p osterior lob e. T h e g la n d secretes several h orm on es, som e o f w h ich in flu en ce the secretion o f h orm on es b y oth er e n d ocrin e glands. T h e an terior lo b e o f th e g la n d p rod u ces those h orm on es w h ic h in flu en ce the skeleton, in clu d in g its grow th . A d eficien cy in th e secretion o f the g row th h o rm o n e o f th e pituitary g la n d results in a decrease in the g row th o f all tissues, soft a n d skeletal, a n d is ca lle d h y­ p opitu ita rism . W h e n it occu rs early in life the result is the p itu itary d w a rf. S in ce the n erv ou s system d ev elop s early, the m en ta l age is w ell a b o v e th e d e v e lo p ­ m en ta l age. T h e e ffe ct u p o n the g ro w th o f the ja w s is sim ilar to th at u p o n the rest o f th e skeleton. T h o u g h the size o f the teeth is n o t a ffected , in terferen ce w ith n orm a l osseous d e v e lo p m e n t results in re­ ta rd ed d e v e lo p m e n t o f th e roots an d re­ ta rd ed e ru p tion o f the teeth .5 O v e r p r o d u c tio n o f th e g row th h o rm o n e fr o m th e pituitary g la n d p ro d u ce s an ov e rg ro w th o f those parts o f the b o d y w h ich are still ca p a b le o f g row th at the tim e o f onset o f h ypersecretion . T h is c o n ­ d itio n is ca lle d hyperpituitarism . I f onset is p r io r to 5 o r 6 years o f age w h en all structures are u n d e rg o in g a ctive g row th th ere is a u n ifo r m o v e rg ro w th o f all parts o f th e b od y . T h e result is a person w h o is fa irly w ell p r o p o rtio n e d a n d o f a b n orm a lly large stature; th e c o n d itio n is referred to as giantism . T h e on set o f h ypersecretion d u rin g the ju v e n ile p e rio d also p ro d u ce s gian tism b u t d is p rop ortion o f g row th , since som e structures m a y h a v e

a tta in ed a d u lt p rop ortion s p r io r to the onset. O n e o f the parts w h ich u n d erg o d isp rop ortion an d excessive g ro w th is the m a n d ib le, a n d th e result is progn ath ism . I n a crom eg a ly o r h yperpitu itarism in th e ad u lt, ov e rg ro w th occu rs in those parts in w h ich g ro w th persists in the a d u lt: th e term inal parts o f the b od y , toes, fingers, nose a n d skull. A c c o r d in g to W e in m a n n a n d S ich er,6 the central fea tu re o f a c r o m e g a lic ch a n g e in the skull is the en orm ou s en largem en t o f th e m a n ­ dib le. C ellu la r activity ap pears to be g rea ter at th e sites o f fo r m a tio n o f e n d o ­ ch o n d ra l b on e, an d since th e m a n d ib le g row s b y e n d o ch o n d ra l ossification at the con d y le , th ere is a grea t in crease in h eigh t o f the ram us. T h is leads to c o n ­ tin u ed o r su praeru p tion o f the teeth, fo l­ lo w e d b y an a p p osition o f b o n e at the a lv eola r crest w h ich increases th e h eigh t o f th e m a n d ib u la r b o d y . T h e result is d e c id e d p rogn ath ism . C h an ges in o c c lu ­ sion m a y vary con sid erably, a n d a c c o r d ­ in g to K o rk h a u s7 th e fo r m a tio n o f spaces betw een the teeth a n d th eir ou tw a rd tiltin g are a m o n g th e m ost reliab le sym p­ tom s o f acrom eg a ly , a n d serve to d iffe r ­ en tiate it fr o m a n om a lou s m a n d ib u la r protrusion s w h ich are o f defin ite gen etic a n d h ered itary origin . H e is o f the o p in ­ io n th at th e sp a cin g an d tiltin g w h ich occu rs in b o th ja w s in a crom eg a ly is p r o d u c e d b y a b n orm a l stress a n d pressure o f m acroglossia. T h e ro e n tg e n o g ra p h ic a p p ea ra n ce o f b o n e in t h e , a cro m e g a lic ja w is n o t alt­ e r e d ; th erefore, the den ta l ro e n tg e n o ­ g ra m is o f d ia g n ostic v a lu e on ly in that it serves to rule ou t P aget’ s disease and

4. Schour, Isaac, and Massler, Maury, Endocrines and Dentistry. J. A . D . A . 30:595 (April); 763 (May); 943 (June) 1943 . 5. Cohen, M . M ., and Wagner, Richard, Dental De­ velopment in Pituitary Dwarfism. / . D . Res. 27:445 (Aug.) 1948. 6. Weinmann, J. P., and Sicher, Harry, Bone and B ones; Fundamentals of Bone Biology. St. Louis: The C. V . Mosby Company, 1947, pp. 188-206. 7. Korkhaus, Gustav, The Changes in the Form of the Jaws and in the Position of the Teeth Produced by Acromegaly. Internet. J. Orthodontia 19 :160 (Feb.)

1933.

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The Jo u rn al of the A m erican Dental A ssociation

oth er deform ities that d o p rod u ce a b ­ n orm a l changes.

cid u ou s teeth is d ela yed an d eru p tion o f the perm a n en t teeth is retarded. T h e d e ­

Thyroid D isease.— T h e th y roid g lan d p r o ­

v e lo p m e n t o f the roots o f th e teeth is greatly retarded, alth ou g h the teeth them selves are n o t d w a rfed .

du ces th yroxin , a h o rm o n e w h ich regu ­ lates the basal m eta b olic rate, w h ich in turn has an e ffe ct u p o n g row th an d d e ­ v elop m en t.

T h e den tal roen tgen ogram s o f a girl 13J/2 years o f age in w h ose case a d ia g n o ­ sis o f cretinism h a d been m a d e are sh ow n in F ig u re 1. T h e y revea led reta rd a tion in d ev e lo p m e n t o f the perm a n en t teeth. T h e

In h y p oth y roid ism there is a deficien cy in the secretion o f th yroxin w h ich results in retard a tion o f grow th , the degree o f w h ich is largely d ep en d en t u p o n the tim e o f onset an d d eg ree o f lack o f the h o r ­ m on e. H y p oth yroid ism is d iv id ed in to th ree ty p e s: cretinism , w h en it is present

m a tely six years b eh in d the c h r o n o lo g ic age. T h e c o n d itio n h a d been recog n ized

at b irth ; ju v e n ile m y x ed em a , w h en it occu rs d u rin g in fa n cy and c h ild h o o d ; ad u lt m y x ed em a, w h en the on set is a fter

early, a n d the th erapy instituted m a y h a v e altered the degree o f d e v e lo p m e n t ap p recia bly .

pu berty, in w h ich case n o gross changes in the skeleton are p ro d u ce d . W h e n h ypoth y roid ism occu rs at birth or d u rin g the first years o f life, g ro w th alm ost stops in n early all tissues, an d the result is a

H y p e rfu n c tio n o f th e th y roid g la n d , o r h yperth yroidism , w h en it occu rs in c h il­ dren m ay, in contrast to h y p o fu n ctio n , a ccelera te skeletal g row th , in clu d in g d e ­ v e lo p m e n t an d eru p tion o f teeth. T h e re

d isp rop ortion a tely fo r m e d d w a r f k n ow n

m a y also b e an osteoporosis. A case o f h y ­

as a cretin . T h e ja w s are sm all and u n ­ d erd ev elop ed . T h e sh eddin g o f the d e ­

p erth yroidism in a ch ild 5 years o f age in w h ich the d en tition co rresp on d ed to that

d e v e lo p m e n t o f the bon es o f the wrists an d h an ds w as w ell b eh in d the c h r o n ­ o lo g ic a g e ; the d en tition w as a p p ro x i­

Fig. —Cretinism. The permanent mandibular central incisors and first molars have recently erupted. The remaining permanent teeth which remain unerupted show retardation of develop­ ment as evidenced by the short roots with wide-open root canals

Stafne

J .A .D .A ., Vol. 40, M arch 1950 . . . 269

Fig. 2 .— Hyperthyroidism. Roentgenograms showing definite osteoporosis. The teeth erupted prematurely, and there was malocclusion o f a ch ild 9 years o f age w as rep orted by W e lti.8 T h e d e cid u ou s teeth h a d begun to shed at 3J/2 years o f age and the skeletal age w as that o f a ch ild 10 to 12 years old . M id d le b u r g h 9 also reported early eru p tion o f teeth in a case o f h yper­ th yroidism in w h ich the m axillary first m olars a n d m a n d ib u la r incisors had eru pted at 4 years an d 11 m on th s o f age. T h e den tal roen tgen ogram s o f a girl 12 years o f a g e w h o h a d h yperth yroidism are sh ow n in F igu re 2. T h e y revealed a defin ite osteoporosis. T h e teeth h a d eru p ­ ted prem atu rely, a n d th ere w as m a lo c ­ clusion w ith m a lp osition o f the m a n d ib u ­ lar incisors. I n v ie w o f th e osteoporosis present, progn osis fo r successful o rth o ­ d o n tic treatm en t w o u ld b e d o u b tfu l until the general c o n d itio n h a d been treated successfully. T o x ic g oiter m a y, in the ad u lt, also p r o d u c e osteoporosis. A t th e clin ic, w h ere a large n u m b e r o f cases o f tox ic g oiter are en cou n tered , an a ttem pt has been m a d e to evalu ate th e deg ree o f osteop or­ osis present in such cases o n the basis o f ev id en ce revea led b y den ta l roen tgen o­ gram s. H o w e v e r, th e d eg ree o f osteop or­ osis present as e v id e n ce d by the dental roen tgen ogra m does n o t vary sufficiently fr o m that o f m a n y patients in w h o m the g en eral ph ysical ex a m in a tion gives essen­ tially n orm a l results to b e o f diagn ostic value.

Parathyroid D isease.— T h e h o rm o n e se­ creted by the p a ra th yroid glands has a d e c id e d e ffe ct o n th e m etab olism o f ca lciu m an d p h osp h oru s and, in directly o r directly, o n the m etab olism o f b on e. H y p op a ra th y roid ism results in h y p o ­ ca lcem ia w h ich p ro d u ce s n eu rom u scu lar excitability, tetan y a n d even gen eral c o n ­ vulsions. It m a y b e cau sed by accid en tal rem ov a l o f o r d a m a g e to the glands in the cou rse o f th y roid ectom y , an d it m ay b e id io p a th ic. H e r e it is o f interest to note K r o n fe ld ’s10 c o m m e n t that the ev id en ce o f relation sh ip betw een the pa ra th yroid glands, tetany an d con vu lsion s a n d h y ­ p op la sia o f en am el is rath er con clu sive. A lb r ig h t a n d S trock 11 h a v e ob served that w h en h yp op a ra th yroid ism has d ev elop ed p rior to co m p le tio n o f d ev elop m en t o f the teeth, aplasia o r h yp op lasia occu rs at that p o in t in th eir d ev e lo p m e n t at w h ich the h y p op a ra th y roid ism w as first e x p e r­ ien ced . In th e even t that it occu rs p rior to co m p le te form a tion o f the enam el,

8. Welti, H ., quoted by Schour, Isaac, and Massler, Maury.4 9. Middleburgh, H ., Hyperthyroidism and Early Eruption of Teeth. Am . ] . Orthodontics (Abstr.) 2 5 : 597 (June) 193910. Kronfeld, Rudolf, Histopathology of the Teeth and Their Surrounding Structures, ed. 2. Philadelphia: Lea and Febiger, 1939, p. 43 * 1 1 . Albright, Fuller, and Strock, M . S., The Associa­ tion of Acalcification of Dentine With Hypoparathy­ roidism in Rats and the Cure of Same With Parathor­ mone, With Some Correlated Observations in Man. (Abstr.) / . Clin. Investigation 12:9 74 , 1933*

270

h yp op lasia o f th e en am el w ill result. I f the cro w n has alrea dy fo rm e d , the h y p o ­ plasia m a y b e e v id e n ce d by short, u n d er­ d e v e lo p e d roots. D en ta l roentgen ogram s in a case o f id io p a th ic h y p op a ra th y roid ­ ism rep orted b y L o v e ste d t12 are show n in F igu re 3. T h e y revea led h ypoplasia o f en am el o f the p rem ola r, a n d the secon d an d th ird m o la r teeth. T h e patien t w as a girl 15 years o f ag e w h en first seen, w h o h a d h a d con v u lsiv e seizures w ith spasms

The Jo u rn a l of the A m erican Dental A ssociation

presen t th e sym ptom s refera ble to the ja w s are sim ilar in b o th p rim a ry an d secon d a ry types. W h e n all th e bon es o f the b o d y are in v o lv e d , the c o n d itio n is d esign ated “ osteitis fibrosa cystica g en eralisata.” In recen t years, there has prob a b ly been greater interest by the internist in the den tal an d oral m anifestations o f h yp erp a ra th y roid ism th an in those o f any oth er disease, fo r often th e earliest ev i­

Fig. 3 .— Hypoparathyroidism. Roentgenograms revealing enamel hypoplasia of the premolars and of the unerupted second and third molar teeth. The dental defects present suggest that the onset of the disease occurred approximately between 2 and 3 years of age

o f the han ds at the ag e o f 3 years. T h e d ev e lo p m e n t o f the b o n e w as com p a ra b le to that o f an 11 year o ld ch ild . C a lcifica ­ tion o f the cereb ra l basal gan glia, w h ich a ccord in g to C a m p 13 is significant in the diagnosis o f p a ra th yroid insufficiency, was also present. T h e den ta l roen tgen ogram s sh ow n in F ig u re 3 w ere m a d e w hen the patien t w as 17 years o f age. In h yp erp arath y roid ism there is an in ­ creased secretion o f pa ra th yroid h o r ­ m on e. P rim ary h yperparath yroidism is p r o d u c e d w h en m o r e pa ra th yroid h o r­ m o n e is secreted than th e b o d y requires. S econ d a ry h yperp arath y roid ism occu rs w h en an in creased p r o d u c tio n o f p ara­ th yroid h o rm o n e ap pears to be a secon d ­ ary response to som e oth er con d ition . D isease o f b o n e is n o t essential bu t w hen the skeletal features o f the disease are

d en ce o f osseous degen eration appears in the ja w s. K e a tin g 14 is o f the op in ion that den ta l roen tgen ogra m s h ave a special v a lu e, p a rticu la rly in the recog n ition o f the disease in cases in w h ich there is m in im a l disease o f th e b on e, an d goes on to say, “ T h e tech n ica l su periority o f roen tgen ogram s o f the b o n e su rrou nd ing the teeth p lu s the special ad va n tage p r o ­ v id e d b y the u n in v olv ed teeth as a gau ge o f density m a ke den ta l roen tgen ogram s pa rticu la rly u sefu l in the recog n ition o f m ild degrees o f skeletal in volvem en t.

12. Lovestedt, S. A ., The Dental Picture of Spon­ taneous Parathyroid Insufficiency. (Unpublished data.) 13. Camp, J . D ., Symmetrical Calcification of the Cerebral Basal Ganglia; Its Roentgenologic Significance in the Diagnosis of Parathyroid Insufficiency. Radiology 49:568 (Nov.) 1947. 14. Keating, F. R ., Jr., Hyperparathyroidism. Am . J. Orthodontics (Oral Sure• S ect,) 33 : n o (Feb.) 1947.

J .A .D .A ., Vol. 40. March

Fig. ^ — Hyperparathyroidism. A : Pronounced osteoporosis of both jaws, absence of the lamina dura, and teeth which appear dense by contrast but which are of normal radiopacity. B : Six months after surgical treatment. With the exception of a few regions, the bone has returned to normal appearance and the lamina dura has reappeared

Stafne 1950 . . . 271

272

M ild demineralization, early distortion of the trabecular pattern, and disappear­ ance of the lamina dura sometimes pro­ vide more specific clues to the diagnosis than do changes elsewhere in the skele­ ton.” T h e disease as seen in the dental roent­ genogram is evidenced by the abnormal radiolucency of bone, and a transforma­ tion of this bone into finely meshed, lace­ like trabeculae that have a ground-glass appearance. Areas of fibrosis where the trabeculae of the bone are mostly de­ stroyed will appear cystlike, and in some regions where the areas of radiolucence are more circumscribed, actual tumor formation m ay be present. T h e lamina dura may be partially or completely absent, depending on the severity of the disease, and the teeth in which there is no alteration in the content of min­ eral salt stand out in contrast to the dark-appearing osteoporotic bone. T h e teeth, although not necessarily loose in their sockets, may be very motile, par­ ticularly in cases of advanced disease, largely because of the softness of bone, and there m ay be malocclusion and re­ sorption of the roots of the teeth in re­ gions of cyst formation. There is a definite predilection to tumor formation in the jaws, and Strock,15 who studied dental roentgenograms in 4 5 cases of hyperparathyroidism, noted that about half of them showed evidence of giant cell tumors. A s time goes on and as the disease is recognized more often in the earlier stages, the incidence of tumor formatio'n will no doubt be decreased. While all giant cell tumors of the jaws are by no means associated with hyper­ parathyroidism, their occurrence in the jaws should suggest the possibility of the presence of the disease. Operation on giant cell tumors of the jaw s on the premise that they were merely local lesions has been done. Following successful treatment of the disease, there is a decided change in the roentgenographic appearance of the bone

The Journal of the American Dental Association

of the jaws, as well as bones elsewhere. Bone in which fibrosis has not been too extensive will return to normal, leaving no evidence as to w hat has taken place. Regions in which the trabeculae have been extensively or completely destroyed m ay be replaced by sclerotic bone which is denser and more radiopaque than normal bone. T h e picture is one which often permits a diagnosis of successfully treated hyperparathyroidism to be made from the roentgenographic evidence. T h e dental roentgenograms shown in Figure 4 A were made of a male patient 20 years of age who had prim ary hyper­ parathyroidism, produced by an adenoma of the parathyroid gland. T h e bone of both jaw s was osteoporotic and the al­ veolar portion so soft that in the anterior regions it could be moved by pressure of the fingers. There is considerable radio­ lucency of the bone in contrast to the un­ affected teeth. Roentgenograms made six months after surgical treatment revealed a decided increase in radiographic density of the bone (Fig. 4 B ) .

Disease o f the G ona ds .— Besides func­ tioning as organs of reproduction, the gonads also secrete a hormone which con­ trols the development and growth of the sex organs, affects skeletal maturation and causes eventual cessation of osseous growth. In hypogonadism the appearance of the secondary sex characteristics is de­ layed. M aturation of some of the parts of the skeleton is also delayed and as a result there is an overgrowth of bones, including the bones of the jaws. T h e teeth undergo normal development, but are prone to erupt prematurely. In virilism or precocious puberty, which is sometimes secondary to adrenal cortical tumor, there is an overproduction of male hormones which causes an early appearance of sex characteristics and, 15. Strock, M . S., The Mouth in Hyperparathyroid­ ism. N ew England J. M ed. 2 2 4 :ioig (June is) 1941.

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J .A .D .A ., V ol. 40, M arch 1950 . . . 273

Fig. s.-—Diabetes (juvenile). Roentgenograms showing destruction of the alveolus and bone to the extent that many of the teeth remained unsupported by bone. Some teeth had been exfoliated; many of those remaining were fairly firmly fixed in soft tissue

a m o n g oth er things, an early a n d a c c e l­

roen tg en olog ic studies in d ia b etic c h il­

erated m a tu ra tion o f the skeleton. Early d e v e lo p m e n t a n d eru p tion o f the teeth m a y o ccu r. W h ite 16 has rep o rte d a case in w h ich the d ecid u ou s d en tition was co m p le te d at the age o f i year, a n d the secon d deten tion at the age o f 3 years.

dren, fo u n d a h igh in cid e n ce o f alveola r a trop h y an d em phasized that in such

D isease of the Pan creas.— T h e pancreas has b o th e n d o crin e an d ex ocrin fu n c ­ tions. T h e islands o f L an gerh an s secrete insulin w h ich serves to m a in tain the n orm a l level o f b lo o d sugar. A n u n d er­ p r o d u c tio n o f insulin p rod u ces diabetes m ellitus (h y p o in s u lin is m ). It has lon g been gen erally th ou g h t that p e riod on ta l disease is associated w ith and even con sid ered a p a th o g n o m o n ic sym p­ to m o f diabetes, a lth ou g h this has often been qu estion ed, p rob a b ly becau se d ia ­ betes occu rs m ost o fte n in o ld e r persons an d at a tim e w h en p eriod on ta l disease is also prevalen t a m o n g all persons. H o w ­ ever, L ov ested t a n d A u stin ,17 a m o n g others, h a v e fo u n d that the in cid e n ce o f active an d a d v a n ce d p e riod on tocla sia or periodon tosis is slightly greater a m on g d ia b etic patients than a m on g n on d ia b etic patients. O bservation s m a d e in ju v e n ile diabetes sh ou ld be o f greater v alu e, h ow ev er, fo r period on tosis is n ot c o m m o n in children . R u tle d g e ,18 w h o m a d e clin ica l an d dental

studies it was very im p orta n t to know' w h eth er the d ia b etic c o n d itio n was b ein g con trolled . P eriod on tal lesions are by n o m eans a constan t fea tu re in ju v e n ile diabetes, yet o n occa sion such striking a n d m a rk ed destruction o f alveola r b o n e occu rs that it w o u ld be difficu lt to exp lain its pres­ en ce o n the basis o f c o in c id e n c e on ly. T h e den ta l roen tgen ogram s in su ch a case are sh ow n in F igu re 5. T h e patien t w as a b oy 18 years o f age w h o h a d a history o f diabetes fo r 12 years. I t is d o u b tfu l w h eth er the d ia b etic con d ition h a d b een kept u n der co n tro l, fo r the patien t h ad n ot been to o c o o p e ra tiv e in fo llo w in g the dietary regim en, or in the taking o f insulin. T h e a m ou n t o f d estru c­ tion o f alveola r b on e as revea led b y the roen tgen ogram s was fa r greater than w o u ld be e x p ected fr o m the results o f the clin ical exam in a tion , a n d surprisingly

16 . W hite, A ., Q uoted by T hom a, K . H ., Oral Pathology. St. L o u is: T h e C . V . M osby Com pany, 19 4 1, p. 1 7 1. 17 . Lovestedt, S. A ., and Austin, L . T ., Periodonto­ clasia in Diabetes M ellitus. J . A . D . A . 3 0 :2 7 3 (F eb .) 194318. R utledge, C . E ., O ral and R oentgenographic As­ pects of the T eeth and Jaw s o f Ju ven ile Diabetics. J . A . D . A . 2 7 :17 4 0 (N o v.) 1940.

274

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m a n y o f the teeth w ere firm ly fix ed in soft tissue even th ou gh all o f th eir su p­ p ortin g b o n e h a d been destroyed.

Avitaminosis V itam in s h ave an a ction sim ilar to that o f h orm on es a n d are d eriv ed fr o m fo o d s that are ingested. A d eficien cy o f som e vitam ins in the diet is k n ow n to h a v e an in flu en ce u p o n skeletal d ev elop m en t, in ­ c lu d in g d ev elop m en t o f the teeth. T h e oral m anifestation s o f pellag ra in vitam in B c o m p le x d eficien cy an d o f scu rvy in v ita m in C d eficien cy are w ell k n ow n . T h e e ffe ct o f v ita m in D d eficien cy u p o n the teeth a n d their su p p ortin g osseous structures has p rob a b ly receiv ed the m ost atten tion in the den tal field. Vitamin D Deficiency.— T h e role o f v ita ­ m in D in m etab olism is to m a in tain the level o f ca lciu m an d p h osp h oru s a n d the n orm a l ratio o f these tw o substances. A d eficien cy o f v ita m in D causes rickets in c h ild h o o d an d osteom a lacia in the adult. R ick ets affects prim a rily th e g row in g

skeleton, largely th rou g h a fa ilu re o f the osteoid tissue to u n d e rg o ca lcifica tion prop erly, w ith the result that th e bones rem ain soft, b en d an d b e c o m e d eform ed . Follis, Jackson, E liot an d P ark19 h ave sh ow n by m icr o s c o p ic ex a m in a tion that th ere is a h igh in cid e n c e o f rickets, p a r­ ticu larly in ch ild ren w h o are ill, an d w h ile they d o u b t if a slight d eg ree o f rickets interferes w ith d ev elop m en t, the severer form s d o . T h e disease is m ost preva len t fr o m 3 m on th s to 3 years o f a g e ; th erefore, rickets is associated w ith a relatively h ig h in cid e n ce o f h yp op la sia o f the en am el o f th e teeth. I n severe cases the ja w s are u n d e rd e v e lo p e d an d there is retarda tion in the sh ed d in g o f the d e cid u ou s teeth, as w ell as in eru p tion o f the perm a n en t teeth. I n late rickets, w h ich occu rs a fter 6 years o f age, the den tal distu rb an ce is less severe. T h e effects o f p rim a ry rickets u p o n th e den tal system h a v e been d ea lt w ith extensively in the den tal literature. 19. Follis, R . H ., Jr ., Jackson, Deborah? Eliot, Martha M ., and Park, E . A ., Prevalence of Rickets in Children Between Two and Fourteen Years of Age. Am . J. Dis. Child. 66: i (July) 1943-

Fig. 6.— Renal rickets. Roentgenograms show absence of normal bone cancellations giving a wooly, ground-glass appearance. There is absence of lamina dura, and retarded development of the roots of the teeth

Stafno

Renal rickets is a form of disturbed calcium-phosphorus balance which is secondary to chronic nephritis; it may cause skeletal deformity and disturbed development of the jaws and teeth. T h e jaws áre osteoporotic and underdevel­ oped, and the eruption of the permanent teeth is retarded. Pancoast, Pendergrass and Schaeffer20 stated that as a rule the roentgenographic appearance of the bones is one of greater translucency and sponginess than is that of rickets due to vitamin D deficiency. Dental roentgenograms of a boy 14 years of age, who had all the criteria for renal rickets and renal dwarfism, are shown in Figure 6. There was a trans­ formation of bone cancellations through­ out both jaws, giving a wooly appearance, and there was an absence of lamina dura. T h e roentgenographic appearance was very similar to that seen in hyperpara­ thyroidism. T h e bone was more radio­ paque than is usual, probably as a result of treatment which had been followed by improvement in the patient’s general con­ dition. T h e teeth were fully erupted, al­ though the patient gave a history of hav­ ing the first permanent tooth erupt at the age of 9 years. Several teeth were malposed. Completion of calcification of the roots of the teeth was retarded as evi­ denced by wide-open apical foramens on the second bicuspids and second molars. A mesiodens was present, w hich was erupting on the palatal surface. W hile renal rickets is discussed in this paper under the heading, “ Avitaminosis,” it should be pointed out that the disease m ay actually be a form of hyperparathy­ roidism.

Developmental Disturbances of the Skeleton Inheritance factors play an important part in m any of the developmental dis­ turbances of the skeleton. In some in­ stances the symptoms m ay be present at birth; in others they m ay develop during

J.A .D .A ., Vol. 40, March 19 5 0 .. . 275

childhood or adolescence. Am ong these skeletal diseases are Albers-Schônberg disease (marble bone), osteogenesis im ­ perfecta, achondroplasia and cleidocran­ ial dysostosis.

Albers-Schonberg Disease. — AlbersSchonberg disease is hereditary, and while usually congenital, it m ay also de­ velop in postnatal life, in which event it is usually less severe. There is a general­ ized osteosclerosis and elimination of bone marrow caused by a reduction in osteoclastic activity. T h e sclerotic bone is of poor quality, and although it is re­ ferred to as “ marble bone,” in reality it cuts like chalk and is very fragile. F rac­ tures are, therefore, not uncommon. There is also decreased resistance to infection, and several cases of osteomyelitis of the jaw s have been reported. As in other bones, the jaw s show a great increase in roentgenographic den­ sity in the disease. There may be delayed eruption of the teeth and early elimina­ tion of the pulp chamber by a formation of secondary dentin. Norm al develop­ ment of the teeth may also be interfered with. T h e dental roentgenograms of a male 28 years of age who had Albers-Schon­ berg disease are shown in Figure 7. T h e roentgenograms revealed a pronounced increase in radiographic density of bone and underdevelopment of the roots of the teeth. A diagnosis of the condition had not been m ade prior to roentgenographic examination, and roentgenograms of other bones revealed marked density. A brother also had the same condition and apparently a similar anomaly of the teeth, for the teeth had been lost early and were said to have had no roots. Achondroplasia. — Achondroplasia is a hereditary disease in which a disturbance 20. Pancoast, H . K ., Pendergrass, E. P., and Schaef­ fer, J. P., The H ead and N eck in Roentgen Diagnosis. Springfield, Illinois: Charles C Thomas, 1940.

276

o f the fo r m a tio n an d d ev elop m en t o f cartila ge is the essential feature. V e r y lit­ tle g ro w th takes p la ce at the epiphysis o f the lo n g bon es, a n d the result is a d w a rf w h ose extrem ities are very short in c o m ­ p arison to the torso. O th e r characteristics are a p rom in en t foreh ea d , saddle nose, retru d ed u p p e r ja w an d p rogn ath ou s

The Jo u rn al of the A m erican D ental A ssociation

Cleidocranial Dysostosis. — C leid ocra n ia l dysostosis is usually o f h ereditary trans­ m ission. A n instance in w h ich a fath er an d three ch ild ren w ere afflicted is re­ p o rte d b y H e u p e l.22 I t is ch a ra cterized by c o m p le te o r in com p lete aplasia o f the clavicles, d ela yed ossification o f the fo n ­ tanels an d d ela yed eru ption an d n o n ­

7*— Albers-Schdnberg disease. Roentgenograms showing bone of increased roentgenographic density, absence of narrow spaces, underdeveloped roots and reduction in size of the pulp chambers lo w e r ja w . W h ile the teeth u n d erg o n orm a l d ev elop m en t, there m ay, in som e

eru p tion o f th e teeth. A lth o u g h it has g enerally b een assum ed that the distu rb­

instances, b e a distu rban ce in their eru p ­ tion. M ille r 21 rep orted on the den tal c o n ­ d itio n o f a p a tien t 13 years o f age “ w h o

a n ce is co n fin e d to the m em bran ou s bon es, oth er bon es m a y be in v o lv e d as w ell, a n d the co n d itio n is m o re g en era l­ ized th an w as form erly su pposed. T h e r e is u n d erd ev elop m en t o f th e m a xilla w h ich results in a relatively p rogn a th ou s

h a d a ch on d rop la sia ” an d fo u n d that the b icu sp id teeth a n d secon d m olars in b o th ja w s w ere u nerup ted. 8,

T h e den ta l roen tgen ogram s in F igure m a d e o f a typical ach on d rop la stic

d w a r f at the age o f 30 years, revea led 24 e m b e d d e d teeth, in clu d in g 5 d ecid u ou s m olars that h a d u n d erg on e alm ost c o m ­ plete resorption . It is d o u b tfu l if the d e ­ cid u ou s teeth h a d ever been erupted. W ith the e x ce p tio n o f n on eru p tion o f the d ecid u ou s teeth, the co n d itio n w as very sim ilar to that seen in cleid ocra n ia l dysostosis. T h e r e w as a history o f early onset a n d a fam ilia l ten den cy. T h e teeth w ere o f n orm a l size, w ith the ex ce p tio n o f a ru d im en tary righ t m axillary th ird m olar.

m a n d ible. A b n orm a lities o f the teeth an d ja w are alm ost a con stan t feature. T h ese h ave been w ell described in the den ta l litera­ ture. M illh o n an d A u stin 23 rep orted 4 cases, in 1 o f w h ich o r th o d o n tic m easures h a d been attem p ted to c o rr e ct the a b ­ n orm alities present. T h e c o n d itio n is

21. Miller, H . A ., Dental Abnormalities in a Patient With Achondroplasia. Internal. J. Orthodontia 23:296 (March) 1937. 22. Heupel, R . G ., Cleidocranial Dysostosis. (Abstr.) /. D . Res. 1 5 :186 (June-Aug.) 1935. 23. Millhon, J . A ., and Austin, L . T ., Dental Find­ ings in Four Cases of Cleidocranial Dysostosis. Am . J. Orthodontics (Oral Surg. Sect.) 30 :30 (Jan .) 1944-

J .A .D .A ., V ol. 40, M arch 19 5 0 . . . 277

Stafne

ch a ra cterized chiefly by u n d e rd e v e lo p ­ m en t o f the m axilla, p ro lo n g e d retention o f the d ecid u ou s teeth, n on eru p tion o f the perm a n en t teeth an d the form a tion o f su pernu m erary den tal structures. F ail­ ure o f the d ecid u ou s teeth to shed an d o f the perm a n en t teeth to erupt is p rob a b ly d u e to the ch a ra cter o f the b on e. T h e b on e is u n a b le to p r o d u c e resorption o f the roots o f the d e cid u ou s teeth an d also fails to resorb in response to the eruptive fo rce o f the p erm a n en t teeth. In cases in w h ich a large n u m b er o f u n eru p ted teeth an d also su pernum erary den tal structures are observed, the presence o f c le id o c ra n ia l dysostosis should be suspected. A case in p o in t is th at o f a b oy 9 years o ld fo r w h o m the dental roen tgen ogram s sh ow n in F igu re 9 w ere m ade. A ll the d ecid u ou s teeth w ere still present an d th ere w as n o ev id en ce that the roots o f these teeth h a d b eg u n to u n d erg o resorption . T h e den tal d e v e lo p ­ m en t in gen eral w as retarded. T h e pres­

clavicles w ere absent also. It sh ou ld be kept in m in d that the diagnosis dep en d s largely on the r o e n tg e n o lo g ic ex a m in a ­ tion, an d su ch an ex am in a tion is essential in establishing a fa m ilia l relationship.

H and-Schiiller-Christian's Disease H a n d -S ch iiller-C h ristia n ’s disease is a d istu rban ce o f th e reticu lo-en d oth elia l system. T h e disease occu rs m ost often early in life, and com b in es d efects in b on e, ex op h th a lm os an d diabetes in sip­ idus, a lth ou g h the triad o f sym ptom s m ay n o t be presen t in all cases. T h e d efects in b o n e are p r o d u c e d b y gra n u lom a -lik e a ccu m u la tion s o f co n n e ctiv e tissue in w h ich th ere m a y b e a large n u m b er o f fo a m cells lo a d e d w ith fat. T h e osseous defects o c c u r m ost freq u en tly in the c a l­ varía, ja w s, scapula, pelvis a n d ribs, an d in som e instances the first sym ptom s o f the disease m a y o c c u r in th e ja w s. I n ­ v olv e m e n t o f the jaw s is c o m m o n . K e n -

Fig. 8.— Achondroplasia. Roentgenograms revealed noneruption of 20 permanent teeth and of the mandibular deciduous molars which had undergone resorption

en ce o f a n om a lou s an d m a lfo rm e d su per­ n um erary teeth in all lateral in cisor regions, an d p r o lo n g e d reten tion o f the d ecid u ou s teeth suggested c leid ocra n ia l dysostosis. O n in vestigation , a r oen tg en o­ gra m revea led the ab sen ce o f b o th cla v ­ icles, a n d a roen tg en og ra m m a d e o f the b oy ’s fa th er revea led th at b o th

o f his

n ed y 24 re p orted 8 cases in 5 o f w h ich the ja w s w ere in v olv ed . S ch a efer an d W il­ liam s25 a n d A u stin 26 h ave rep orted cases 24.. Kennedy, R . L . J ., Xanthomatosis: SchiillerChristian’s Disease. Proc. Staff M e et., M ayo Clin. 1 3 : 776 (Dec. 7) 1938. 25. Schaefer, J . E. and Williams, P. E ., Xanthoma­ tosis (Schiiller-Christian’s Disease). D en. Cosmos 7 4 : 879 (Sept.) 1932.

278

in w h ich the ja w s h a v e been in volved . T h e ro e n tg e n o g ra p h ic a p p ea ra n ce o f the lesions in b on es, particu la rly those o f the skull, is distin ctive a n d diagn ostic, an d th at o f the ja w s, w h en the disease occu rs in ch ild ren , is p ro b a b ly even m ore so. In the ja w s o f ch ild ren , the pads o f g ra n u lom a tou s tissue h ave a p red ilection f o r fo r m in g in the p eria p ica l region s o f the teeth. W ith ex p an sion o f the lesions the sockets are destroyed a n d the d e c id ­ u ou s as w ell as d e v e lo p in g perm a n en t teeth are fo r c e d fr o m th eir origin a l p osi­ tions an d e x folia ted . W ith th e b o n e sur­ ro u n d in g the teeth destroyed, the ro e n t­ gen ogram s g iv e th e a p p ea ra n ce th at the ex folia tin g teeth are floa tin g in space. F igure i o show s th e typical r oen tg en o­ g ra p h ic a p p ea ra n ce o f H a n d -S ch ü lle rC h ristian ’ s disease o f the ja w s in a b o y 8 years o f age. T h e first lesion h a d a p p a r­ ently o c cu rr e d in th e ca lv a riu m fo u r years previously. O n e y ea r p r io r to the tim e the roen tgen ogram s w ere m a d e, the right m axillary d e cid u ou s cu sp id a n d m ola r teeth an d th e tw o m a n d ib u la r d ecid u ou s secon d m olars h a d b e c o m e loose an d w ere lost. T h is w as fo llo w e d b y e x folia tion o f

The Jo u rn a l of the A m erican Dental A ssociation

the tw o m a n d ib u la r bicu spids on the left an d th e secon d b icu sp id o n the right. T h e roen tgen ogra m s reveal extensive d e ­ stru ction o f b o n e in the p osterior regions o f the m a n d ib le an d the righ t m axilla, w h ich m eans that the right m axillary lateral in cisor an d bicu spids an d the re­ m a in in g m a n d ib u la r posterior teeth w ill be lost. I f th e in v o lv e m e n t o f the ja w is r e c­ og n iz ed early, roen tgen th erapy m ay, in a m easu re, p rev en t extensive loss o f teeth, since it has p r o v e d to be a successful m eans o f destroyin g th e lesions w h ich o c ­ cu r in o th e r bon es. A t present I h ave u n d er ob serv a tion a p a tien t w ith an early lesion o f the ja w s that has been treated by roen tgen rays, a n d w hile the o u tc o m e is u n certain , the results h ave been en co u r­ agin g.

M ultiple M yelom a A m y e lo m a is a n eoplasm fo r m e d fr o m b o n e m a rro w cells w h ich b e lo n g to the 26. Austin, L . T ., Xanthomatosis (Schüller-Christian’s Disease): Report of Dental Findings in One Case. J. O. S. 4:209 (July) 1946.

Fig. 9.— Cleidocranial dysostosis. Roentgenograms showing nonresorption of the roots of the deciduous teeth and supernumerary dental structures in the lateral incisor regions of both jaws

Stafn

J .A .D .A ., Vol. 40, M arch 19 5 0 . . . 279

Fig. io .— Hand-Schuller-Christian’s disease. Roentgenograms showing pronounced destruction of bone in the right maxilla and posterior regions of the mandible. The teeth in the regions of destruction are being exfoliated, including some of those which are still undergoing development

plasm a cell series. M u ltip le tu m ors w h ich destroy b o n e m a y b e w id ely distributed, pa rticu la rly in the spinal c o lu m n , cla v ­ icles, sternum , ribs an d skull. T h e p r o g ­ nosis is very p o o r in this c o n d itio n , and

diagn ostic. T h e lesions in this disease m ay sim ulate gian t cell tu m or, a n d a m e lo ­ blastom a an d oth er tum ors. In som e in ­

life ex p ecta n cy is on ly a fe w years.

w ere lo ca l lesions.

T h e general r oen tg en og ra p h ic a p ­ pea ra n ce has been d escribed by Pancoast, Pendergrass a n d S ch a effer.20 I n th e early

D en ta l roen tgen ogram s o f a w o m a n 57 years o f age, w h o w as su fferin g fr o m ex ­ tensive m u ltip le m y elom a , are sh ow n in F igure 11. T h e y revea led extensive d e ­ stru ction o f b o n e in b o th sides o f the m a n ­ d ib le, p a rticu la rly a lon g the lo w e r b o rd e r an d also ex ten d in g up in to the eden tu lou s spaces. T h e re w ere m ijltilocu la r cystic spaces, very sim ilar roen tgen ogra p h ica lly to those seen in am eloblastom a.

stages, sm all ra d iolu cen t regions are c o n ­ fined to the b o n e m a rrow . As these b e ­ co m e m o re n um erou s, they coa lesce to fo r m larger lesions w h ich are seen as large, irregu larly defin ed region s o f ra d iolu cen ce. I n the jaw s, roen tg en og ra p h ic ev id en ce o f m u ltip le m y elom a is m ost o ften seen in the m a n d ib le, w h ere it follow s a pa ttern sim ilar to that described fo r oth er bones. E v id e n ce o f the initial lesion usually appears in the posterior region s w h ere the m a rrow spaces are largest an d tend to exten d a lon g an d b e ­ low the m a n d ib u la r can al. T h e disease process also tends to exten d tow a rd the a lveola r crest in eden tu lou s spaces, an d in on e instance the earliest roen tg en og ra p h ic ev id en ce o f tu m o r fo rm a tio n w as o b ­ served in an eden tu lou s space. T h e roen t­ g e n o g ra p h ic a p p ea ra n ce o f m u ltip le m y elom a as seen in the ja w s is n ot

stances su rgical p roced u res h a v e been p e r fo rm e d o n the assum ption that th e)’

P a g e t's Disease P aget’ s disease is a disease o f the skeleton w h ich occu rs m ost o fte n after m id d le life. It m ay b e lim ited to on e b on e, o r in som e instances m a n y bon es m a y be in v olv ed . T h e cause o f the disease is u n k n ow n , an d the fa c t that it is n ot gen eralized suggests that it is p rob a b ly n ot a result o f a m e ta b o lic o r e n d ocrin e disorder. T h e initial lesion is o n e o f d e ­ stru ction b y resorption . T h is is later fo llo w e d b y d ep osition o f an excessive

280

The Jo u rn al of fhe A m erican D en ial A ssociation

Fig. i i . — M ultiple myeloma. There is extensive bilateral destruction of bone along the inferior border of the mandible and extending upward into the edentulous spaces

am ou n t o f b o n e o f in ferior qu ality to p r o d u c e d isfigu ration an d d eform ity. T h e ja w s are in v o lv e d in a relatively h ig h p er­ cen tage o f cases. T h e in cid e n ce is greater in the m a xilla th an in the m a n d ib le, and in rare instances b o th ja w s are in v o lv e d .27 T h e p rim a ry lesion m a y o c c u r in the jaw s. T h e ro e n tg e n o g ra p h ic a p p ea ra n ce is d ep en d en t u p o n the stage at w h ich the disease is seen. I n the early or resorptive stage, ev id en ce o f th e lesion is seen as a ra d iolu cen t region w h ich has the ap p ea r­ an ce o f a pseudocyst, w h ich m ost often en croa ch es u p o n the roots o f the teeth. As the disease progresses an d d ep osition o f b o n e takes p la ce , there are region s o f in ­ creased roen tg en og ra p h ic density p r e ­ senting a b n orm a l can cellou s b o n e o f a

v aried pattern. B ecause o f th e d ifferen ce in degree o f osteoclastic a n d osteoblastic activity, there are altern a tin g areas o f osteoporosis a n d sclerosis p resen tin g a coarsely m o th -ea ten a p p e a ra n ce . T h e r e is an absence o f la m in a d u ra in th e in v olv ed regions. In a d v a n ce d stages a large deposition of p o o rly d ifferen tia ted hyperplastic cem en tu m m a y o c c u r o n th e roots o f the teeth in the in v olv ed regions. T h is form o f cem en tu m , w h ic h m a y b e p re ce d e d by resorption o f roots, has been d escrib ed by R u sh to n .28 T h is h ypercem en tosis is p e c ­ 27. Stafne, E. C ., Paget’s Disease Involving the Maxilla and the Mandible: Report of a Case. /. O. S. 4 : 1 1 4 (April) 1946. 28. Rushton, M . A ., The Dental Tissues in Osteitis Deformans. Guy’ s Hosp. R ep. 8 8 :16 3 (April) 1938.

Fig. is . — Paget’s disease involving both jaws. There are alternating regions of osteoporosis and sclerosis of bone, and there is deposition of hyperplastic cementum on the roots of several teeth

Stafne

J .A .D .A ., V ol. 40, M arch 19 5 0 . . . 2 8 1

u lia r to P aget’ s disease an d, w h en p r e ­ sent, is o f valu e n o t on ly in arrivin g at a diagnosis o f P aget’s disease b u t also in differen tia tin g it fr o m oth er osseous lesions w h ich m ay in volve the m a xilla an d m a n d ible. T h e den tal roen tgen ogram s in a case o f P aget’ s disease in v olv in g b oth jaw s in a patien t 47 years o f age sh ow som e o f the ch aracteristic r o e n tg e n o lo g ic features (F ig . 1 2 ).

g ra p h ic a p p ea ra n ce o f senile eden tu lou s ja w s in w h ich the alveola r ridges had

Ectoderm al Dysplasia

u n d erg on e extensive resorption . T h e case o f a m a n 18 years o f age w h o h a d on ly

E ctod erm a l dysplasia is a disease o f h ereditary ten d en cy ch a ra cterized by scantiness o r absen ce o f sw eat glands, partial or total ab sen ce o f hair, fau lty fingernails and partial o r co m p le te a b ­ sence o f teeth. T h e deg ree o f in v olv em en t o f the teeth, as w ell as o f oth er e c to ­ d erm al structures, p ro b a b ly d ep en d s u p on the tim e o f onset o f the distu rban ce. I f the distu rban ce occu rs early in feta l life, there m a y b e a co m p le te ab sen ce o f te e th ; if in the latter part, the d ecid u ou s teeth m a y h ave fo r m e d , b u t a fe w o r all o f the perm a n en t teeth m a y fa il to d e ­ v elo p . O f the p erm a n en t teeth, those fo r w h ich the an lage is first laid d o w n , that is, the first m olars, incisors an d cuspids, are m ost ap t to rem ain u n a ffected . O n e o f the earliest cases o f e ctod erm a l

dysplasia in w h ich there w as co m p le te a n od on tia w as rep orted by G u ilfo r d ,29 a dentist, in 1883. T h o m a a n d A lle n 30 re­ p orted a case o f co m p le te a n o d o n tia in a b o y 5 years o f age a n d a sim ilar case w as rep orted b y L ov ested t31 in a m a n 23 years o f age. B ecause o f fa ilu re o f the teeth to form , the m a xilla an d m a n d ib le w ere u n ­ d erd ev elop ed and h a d the r oen tg en o­

fo u r perm a n en t teeth w as rep orted by C o o k .32 T h ese w ere tw o m a xilla ry cuspids an d tw o m a xilla ry m olars. T h e den tal roen tgen ogram s in F igure 13 w ere m a d e o f a b o y 10 years o f age. T h e y revea led con g en ita l absen ce o f the m axillary lateral incisors an d bicu spids, the m a n d ib u la r central a n d lateral in ­ cisors, bicu spids and secon d m olars. T h e p erm a n en t m a xilla ry cen tra l incisors, the fo u r cuspids an d the first m olars w ere pres­ ent an d u n d erg oin g n o rm a l d ev elop m en t. 29. Guilford, S. H ., A Dental Anomaly. D en. Cosmos (M ar.) 1883. 30. Thoma, K . H ., and Allen, F . W., Anodontia in Ectodermal Dysplasia. Am . J. Orthodontics 26:503 (May) 1940. 3 1. Lovestedt, S. A ., Examples of Dental Dysplasia. Am . J. Orthodontics (Oral Stirg. S ect.) 33:6 25 (Aug.) 194732. Cook, T . J . , Hereditary Ectodermal Dysplasia of the Anhidrotic Type. Am . J. Orthodontics 2 5 :1008 (Oct.) 1939.

2 5 :113

Fig. 13 .— Ectodermal dysplasia. There is prolonged retention of six deciduous incisors, the canines and the molars, and congenital absence of permanent maxillary lateral incisors and pre­ molars and of the mandibular incisors, premolars and second molars

282

The Jo u rn al of the A m erican D ental A ssociation

Fig. 14.— Acrosclerosis. An abnormal increase in the width of the periodontal membrane space of the six left molars is evident. The space is fairly uniform in width and tends to sur­ round the entire root

P hysical e x a m in a tion revea led a scarcity o f h air o n the legs, arm s a n d b o d y , an d a dry skin w h ich w as sensitive to sun an d fr o m w h ich th ere was very little sw eat­ ing. S light d efects w ere present in the fingernails. In this instance the onset o f the e ctod erm a l d istu rb an ce p rob a b ly o c ­ cu rred late in fe ta l life as e v id e n ce d by the c h r o n o lo g ic age at w h ich den ta l d e ­ v e lo p m e n t w as in terfered w ith an d by the m ild degree o f ectod erm a l sym ptom s present.

Acrosclerosis A crosclerosis

is

a

disease

in

w h ich

scleroderm a in volves ch iefly the fingers, sh ou lder girdle, u p p e r p a rt o f the th orax, fa c e an d som etim es the m u cou s m e m ­ branes o f the ora l cavity. W h e n the fa ce is in v olv ed there m a y b e inability to op en the m ou th n orm ally. A crosclerosis o ften is associated w ith R a y n a u d ’ s disease. A c o m m o n den tal ro e n tg en og ra p h ic fin din g, w h ich appears to b e p ecu lia r on ly to patients su ffering fr o m acros­ clerosis, is e v id en ce o f an a b n orm a l in ­ crease in the w id th o f the p eriod on ta l m em b ra n e space, w h ich seems to h ave a

p red ilection fo r the p osterior teeth. T h e en larged sp ace w h ich has b e e n crea ted is alm ost u n iform in w id th , su rrou nds the entire ro o t o f the tooth a n d gives th e a p ­ p ea ra n ce o f a tooth w h ich is b e in g ex ­ truded rap id ly fr o m its socket. T h e in ­ creased size o f the p eriod on ta l m em b ra n e space is crea ted, h ow ev er, a t th e expense o f the alveola r socket. T h e r e is roen t­ g en og ra p h ic ev id en ce o f a ctiv e resorption a n d destruction o f the la m in a du ra. T h is is fo llo w e d b y sclerotic ch a n g es in the walls as e v id en ced b y a w id e r a d io p a q u e lin e w h ich ou tlin es the lim its o f th e en ­ larged socket. M ic r o s c o p ic exam in a tion o f the p eriod on ta l m em bran e reveals an increase in the n u m ber an d size o f the collag en ou s fibers an d th ick e n in g o f the walls o f the vessel, w h ich suggest changes sim ilar to the cutan eous signs o f the disease.33 D en ta l roen tgen ogram s illustrating the typical w id en in g o f the p e r io d o n ta l m e m ­ bran e space a b ou t the le ft m o la r teeth o f a w om a n 23 years o f age are sh ow n in

33. Stafne, E . C., and Austin, L. T., A Characteris­ tic Dental Finding in Acrosclerosis and Diffuse Sclero­ derma. Am . J. Orthodontics ( Oral Surg. S ect.) 30 :25 (Jan.) 1944.

J.A .D .A ., Vol. 40, M«rch 1 9 5 0 ... 283

Stafne

Figure 14. The periodontal membrane space about the molar teeth on the right showed similar changes. Comment

The conditions referred to in this re­ port by no means include all the oral manifestations of systemic disease that may be revealed by dental roentgeno­ grams. Evidence of osteoporosis and ne­ crosis caused by heavy metals such as arsenic, lead and radium may be present, and roentgenographic evidence of lesions of bone produced by syphilis, tuberculosis and conditions of obscure etiology such as polyostotic fibrous dysplasia are to be found in the jaws. There is at present an enlarging field of opportunity for the dentist not only in the study, but also in rendering valuable service in the field, of general diagnosis. Other than medical clinics that have dental departments as part of their specialty services, an increasing number

of hospitals now include among their de­ partment a hospital dental service. The dentist who is engaged in such service should not limit himself to treatment only, but should think more in terms of diagnosis, both general and dental. In diagnosis the general roentgenologist can be of invaluable aid, and full co­ operation with him will prove to be of mutual benefit to both. Members of the dental staff of hospital dental services in hospitals that offer dental internships also have a teaching obligation which not only includes the teaching that concerns problems which are primarily dental, but must include attendance of and partici­ pation in meetings and conferences of the medical staffs of the hospitals. ' A knowledge of the dental and osseous manifestations of systemic disease opens a field in dental roentgenology that is a broad and difficult one, and yet it is one in which addition of knowledge and further development are largely the re­ sponsibility of the dentist.

A Growth o f Science.— When science began and man was discovering simple machines— like the wheel, the lever, the screw and the inclined plane— the only special tools required fo r research and development were a good p air of eyes and a knack for elemental reasoning. D uring the industrial revolution, when scientists were developing electricity, steam po.wer, chemistry and internal combustion, research required more tools and more knowledge: but seldom more tools than an inventor could afford ; seldom more knowledge than he could acquire. T h e doctor of the past operated and served his patient with his own skill, his own knowledge, and his own two hands. Nowadays he uses the service of the m any hands— the specialist and the hospital. So it is in m anufacture. In the past the ingenuity and skill of an individual could solve the immediate problem. T o d ay the com plexity and knowledge demands the cooperation of m any minds, skills and techniques of the modern highly specialized research laboratory.—

Henry Butler Allen, “Introduction," The Franklin Institute Laboratories for Research and Development. Philadelphia: Franklin Institute, J949 -