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Secondary Hyperparathyroidism: A Case Report
JOURNAL OF ENDODONTICS Copyright © 2003 by The American Association of Endodontists
Printed in U.S.A. VOL. 29, NO. 4, APRIL 2003
CASE REPORT Secondary Hyperparathyroidism: A Case Report Robert J. Loushine, DDS, R. Norman Weller, DMD, MS, W. Frank Kimbrough, DDS, MS, and Frederick R. Liewehr, DDS, MS
The origin of periapical radiolucent lesions is most often due to the apical extension of pulpal pathosis; however, many other nonodontogenic conditions can cause periapical radiolucencies (1). One major organ system that has a significant impact on bone mineralization is the kidney (2). The following case report presents a clinical situation in which a patient was referred for endodontic treatment based on a single radiograph showing a tooth with a periapical radiolucency. The case was ultimately diagnosed as osteolytic lesions resulting from end-stage renal disease (ESRD) and a subsequent secondary hyperparathyroidism.
origin was made. During the medical history phase of the endodontic evaluation, the patient revealed that she had diabetes and was undergoing dialysis. The past dental history revealed that teeth #19 and #30 were extracted approximately 5 yr ago because of nonrestorable caries. The patient reported no history of trauma to the area but for the past 2 days she has had mild tenderness to chewing on her right side. The extraoral examination revealed tenderness in the right temporomandibular joint area with no swelling or asymmetry present. The intraoral examination and vitality testing resulted in normal findings. A panoramic radiograph (Fig. 1) demonstrated an unusual bone pattern in the mandible and confirmed the referring dentist’s finding of a radiolucency associated with tooth #31. A periapical radiograph of the mandibular anterior teeth (Fig. 2) also showed multiple periapical radiolucencies; however, the teeth had normal responses to vitality testing. Based on the clinical findings endodontic therapy was not indicated. After a limited occlusal adjustment of tooth #31 the patient’s pain on chewing disappeared within a week. Along with the occlusal adjustment, the patient’s physician was consulted and subsequent laboratory tests revealed the following serum levels: alkaline phosphatase 80 units/L (normal ⫽ 35–115 units/L), calcium 8.6 mg/dL (normal ⫽ 8.5–10.5 mg/dL), phosphorus 5.2 mg/dL (normal ⫽ 2.5– 4.5 mg/dL), and parathyroid hormone 8140 Eq/mL (normal ⫽ 10 – 80 Eq/mL). Based on the laboratory results and the clinical findings, a diagnosis of secondary hyperparathyroidism with periapical osteolytic lesions was made. The patient was unable to return for the 1-yr follow-up appointment because of a work-related transfer to another part of the country. However, she returned 7 yr after the initial evaluation. Her current medical history revealed that she had a kidney transplant 5 yr ago and that her laboratory serum levels were now in the normal range. The clinical examination and diagnostic testing showed normal findings. A current panoramic radiograph (Fig. 3) shows the changes in the bony appearance from the original radiograph (Fig. 1).
CASE REPORT
DISCUSSION
A 32-yr-old female patient was referred to the endodontic department with a chief complaint of chewing pain on the mandibular right side. The referring dentist’s radiographic examination revealed a periapical radiolucency associated with tooth #31, and an initial diagnosis of a lesion of endodontic
End-stage renal disease affects over 200,000 patients who are undergoing dialysis and over 70,000 patients with kidney transplants (3). The underlying pathologic process for renal failure is the deterioration and ultimate destruction of functioning nephrons. Diabetes is the leading cause of ESRD with 32% of newly diag-
A thorough diagnostic examination is essential before providing endodontic treatment. The sequence of diagnostic procedures must begin with a wellorganized review of the medical history. In the early screening process, a health history that reveals a systemic disorder must be investigated further because it may have a significant impact on the dental diagnosis and ultimate endodontic treatment. There are a number of systemic diseases that can cause bone lesions throughout the body. Chronic renal failure is one disorder that may stimulate a secondary hyperparathyroidism that can cause a variety of bone lesions. In some instances these lesions appear in the periapical region of teeth and can lead to a misdiagnosis of a lesion of endodontic origin. The following case report of a patient referred for endodontic treatment demonstrates the importance of understanding the effects of end-stage renal disease on the dental structures.
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Vol. 29, No. 4, April 2003
Secondary Hyperparathyroidism
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FIG 1. Panoramic radiograph, showing unusual mandibular bone pattern and periapical radiolucencies. FIG 3. Panoramic radiograph taken 5 yr after a successful kidney transplant. Note the changes in the bony appearance compared with the original radiograph.
FIG 2. Periapical radiograph, showing periapical radiolucencies associated with the mandibular anterior teeth.
nosed cases. The other major primary disease contributors are hypertension and glomerulonephritis (3). A variety of bone disorders known as renal osteodystrophy can result from ESRD (4). As nephron function decreases, glomerular filtration decreases resulting in an increased serum phosphate level. This excess phosphate causes serum calcium to be deposited into bone because the phosphate level has a regulating effect on bone mineralization. The resulting low serum calcium stimulates the parathyroid glands and causes a secondary hyperparathyroidism resulting in increased parathormone excretion, which mobilizes calcium from the bone. Another effect of failing kidneys is the inability to produce the active
metabolite of vitamin D (1,25-dihydroxycholecalciferol) (4). The result is a decreased intestinal absorption of calcium and a continued secretion of parathyroid hormone, which besides mobilizing calcium from bone also promotes phosphate excretion. This entire process leads to varying bone disorders including: osteitis fibrosa generalisata (resorption lesions), osteomalacia (increased unmineralized bone matrix), and osteosclerosis (enhanced bone density) (4 – 6). Additional cases in the literature of ESRD have reported other bone changes such as a ground-glass appearance, the complete loss of the lamina dura around all the teeth and the existence of giant cell lesions (6, 7). The initial blood serum laboratory results showed a parathyroid hormone level of 8140 Eq/mL. The normal level for this hormone ranges from 10 to 80 Eq/mL (mean ⫽ 33). Because the calcium level was 8.6 mg/dL, which is within the normal range of 8.5 to 10.5 mg/dL (3), the diagnosis was secondary hyperparathyroidism rather than primary hyperparathyroidism. Primary hyperparathyroidism is most commonly caused by a benign adenoma of the parathyroid gland (6). The main changes in the laboratory blood values for primary hyperparathyroidism are an increased serum calcium level (10.5–14.0 mg/dL) along with a frequently elevated serum alkaline phosphatase (⬎115 units/L). After the successful kidney transplant (8), the patient’s laboratory values returned to normal levels and the original radiolucent areas have shown some recalcification. The endodontic diagnostic testing resulted in normal findings. This case report demonstrates the effects of end-stage renal disease on the dental structures and the possibility of a misdiagnosis if an inadequate medical history and incomplete diagnostic testing are performed. Dr. Loushine is associate professor and program director, Postgraduate Endodontics, Dr. Weller is professor and chairman, and Dr. Kimbrough is associate professor, Department of Endodontics, School of Dentistry, Medical College of Georgia, Augusta, GA. Dr. Liewehr is director, Army Endodontic Residency Program, Fort Gordon, GA. Address requests for reprints to Robert J. Loushine, DDS, Program Director, Postgraduate Endodontics, Department of Endodontics, School of Dentistry, Medical College of Georgia, Augusta, GA 30912-1244.
References 1. Wood NK, Goaz PW. Differential diagnosis of oral and maxillofacial lesions. 5th ed. St. Louis: CV Mosby, 1997:392– 413. 2. Seltzer S. Endodontology. 2nd ed. Philadelphia: Lea & Febiger, 1988: 81–117.
274
Loushine et al.
3. Beers MH, Berkow R. The Merck manual. 17th ed. West Point, PA: Merck & Co., Inc., 1999:2526 – 43. 4. Little JW, Falace DA, Miller CS, Rhodus NL. Dental management of the medically compromised patient. 5th ed. St. Louis: CV Mosby, 1997: 260 –73. 5. Fletcher PD, Scopp IW, Hersh RA. Oral manifestations of secondary hyperparathyroidism related to long-term hemodialysis therapy. Oral Surg Oral Med Oral Pathol 1977;43:218 –26.
Journal of Endodontics 6. Walsh RF, Karmiol M. Oral roentgenographic findings in osteitis fibrosa generalisata associated with chronic renal disease. Oral Surg Oral Med Oral Pathol 1969;28:273– 81. 7. Kaffee I, Tamse A, Schwartz Y, Buchner A, Littner M. Changes in the lamina dura as a manifestation of systemic diseases: report of a case and review of the literature. J Endodon 1982;8:467–70. 8. Rhodus NL, Little JW. Dental management of the renal transplantation patient. Comp Cont Educ Dent 1993;14:518 –32.
Printed in U.S.A. VOL. 29, NO. 4, APRIL 2003
CASE REPORT Secondary Hyperparathyroidism: A Case Report Robert J. Loushine, DDS, R. Norman Weller, DMD, MS, W. Frank Kimbrough, DDS, MS, and Frederick R. Liewehr, DDS, MS
The origin of periapical radiolucent lesions is most often due to the apical extension of pulpal pathosis; however, many other nonodontogenic conditions can cause periapical radiolucencies (1). One major organ system that has a significant impact on bone mineralization is the kidney (2). The following case report presents a clinical situation in which a patient was referred for endodontic treatment based on a single radiograph showing a tooth with a periapical radiolucency. The case was ultimately diagnosed as osteolytic lesions resulting from end-stage renal disease (ESRD) and a subsequent secondary hyperparathyroidism.
origin was made. During the medical history phase of the endodontic evaluation, the patient revealed that she had diabetes and was undergoing dialysis. The past dental history revealed that teeth #19 and #30 were extracted approximately 5 yr ago because of nonrestorable caries. The patient reported no history of trauma to the area but for the past 2 days she has had mild tenderness to chewing on her right side. The extraoral examination revealed tenderness in the right temporomandibular joint area with no swelling or asymmetry present. The intraoral examination and vitality testing resulted in normal findings. A panoramic radiograph (Fig. 1) demonstrated an unusual bone pattern in the mandible and confirmed the referring dentist’s finding of a radiolucency associated with tooth #31. A periapical radiograph of the mandibular anterior teeth (Fig. 2) also showed multiple periapical radiolucencies; however, the teeth had normal responses to vitality testing. Based on the clinical findings endodontic therapy was not indicated. After a limited occlusal adjustment of tooth #31 the patient’s pain on chewing disappeared within a week. Along with the occlusal adjustment, the patient’s physician was consulted and subsequent laboratory tests revealed the following serum levels: alkaline phosphatase 80 units/L (normal ⫽ 35–115 units/L), calcium 8.6 mg/dL (normal ⫽ 8.5–10.5 mg/dL), phosphorus 5.2 mg/dL (normal ⫽ 2.5– 4.5 mg/dL), and parathyroid hormone 8140 Eq/mL (normal ⫽ 10 – 80 Eq/mL). Based on the laboratory results and the clinical findings, a diagnosis of secondary hyperparathyroidism with periapical osteolytic lesions was made. The patient was unable to return for the 1-yr follow-up appointment because of a work-related transfer to another part of the country. However, she returned 7 yr after the initial evaluation. Her current medical history revealed that she had a kidney transplant 5 yr ago and that her laboratory serum levels were now in the normal range. The clinical examination and diagnostic testing showed normal findings. A current panoramic radiograph (Fig. 3) shows the changes in the bony appearance from the original radiograph (Fig. 1).
CASE REPORT
DISCUSSION
A 32-yr-old female patient was referred to the endodontic department with a chief complaint of chewing pain on the mandibular right side. The referring dentist’s radiographic examination revealed a periapical radiolucency associated with tooth #31, and an initial diagnosis of a lesion of endodontic
End-stage renal disease affects over 200,000 patients who are undergoing dialysis and over 70,000 patients with kidney transplants (3). The underlying pathologic process for renal failure is the deterioration and ultimate destruction of functioning nephrons. Diabetes is the leading cause of ESRD with 32% of newly diag-
A thorough diagnostic examination is essential before providing endodontic treatment. The sequence of diagnostic procedures must begin with a wellorganized review of the medical history. In the early screening process, a health history that reveals a systemic disorder must be investigated further because it may have a significant impact on the dental diagnosis and ultimate endodontic treatment. There are a number of systemic diseases that can cause bone lesions throughout the body. Chronic renal failure is one disorder that may stimulate a secondary hyperparathyroidism that can cause a variety of bone lesions. In some instances these lesions appear in the periapical region of teeth and can lead to a misdiagnosis of a lesion of endodontic origin. The following case report of a patient referred for endodontic treatment demonstrates the importance of understanding the effects of end-stage renal disease on the dental structures.
272
Vol. 29, No. 4, April 2003
Secondary Hyperparathyroidism
273
FIG 1. Panoramic radiograph, showing unusual mandibular bone pattern and periapical radiolucencies. FIG 3. Panoramic radiograph taken 5 yr after a successful kidney transplant. Note the changes in the bony appearance compared with the original radiograph.
FIG 2. Periapical radiograph, showing periapical radiolucencies associated with the mandibular anterior teeth.
nosed cases. The other major primary disease contributors are hypertension and glomerulonephritis (3). A variety of bone disorders known as renal osteodystrophy can result from ESRD (4). As nephron function decreases, glomerular filtration decreases resulting in an increased serum phosphate level. This excess phosphate causes serum calcium to be deposited into bone because the phosphate level has a regulating effect on bone mineralization. The resulting low serum calcium stimulates the parathyroid glands and causes a secondary hyperparathyroidism resulting in increased parathormone excretion, which mobilizes calcium from the bone. Another effect of failing kidneys is the inability to produce the active
metabolite of vitamin D (1,25-dihydroxycholecalciferol) (4). The result is a decreased intestinal absorption of calcium and a continued secretion of parathyroid hormone, which besides mobilizing calcium from bone also promotes phosphate excretion. This entire process leads to varying bone disorders including: osteitis fibrosa generalisata (resorption lesions), osteomalacia (increased unmineralized bone matrix), and osteosclerosis (enhanced bone density) (4 – 6). Additional cases in the literature of ESRD have reported other bone changes such as a ground-glass appearance, the complete loss of the lamina dura around all the teeth and the existence of giant cell lesions (6, 7). The initial blood serum laboratory results showed a parathyroid hormone level of 8140 Eq/mL. The normal level for this hormone ranges from 10 to 80 Eq/mL (mean ⫽ 33). Because the calcium level was 8.6 mg/dL, which is within the normal range of 8.5 to 10.5 mg/dL (3), the diagnosis was secondary hyperparathyroidism rather than primary hyperparathyroidism. Primary hyperparathyroidism is most commonly caused by a benign adenoma of the parathyroid gland (6). The main changes in the laboratory blood values for primary hyperparathyroidism are an increased serum calcium level (10.5–14.0 mg/dL) along with a frequently elevated serum alkaline phosphatase (⬎115 units/L). After the successful kidney transplant (8), the patient’s laboratory values returned to normal levels and the original radiolucent areas have shown some recalcification. The endodontic diagnostic testing resulted in normal findings. This case report demonstrates the effects of end-stage renal disease on the dental structures and the possibility of a misdiagnosis if an inadequate medical history and incomplete diagnostic testing are performed. Dr. Loushine is associate professor and program director, Postgraduate Endodontics, Dr. Weller is professor and chairman, and Dr. Kimbrough is associate professor, Department of Endodontics, School of Dentistry, Medical College of Georgia, Augusta, GA. Dr. Liewehr is director, Army Endodontic Residency Program, Fort Gordon, GA. Address requests for reprints to Robert J. Loushine, DDS, Program Director, Postgraduate Endodontics, Department of Endodontics, School of Dentistry, Medical College of Georgia, Augusta, GA 30912-1244.
References 1. Wood NK, Goaz PW. Differential diagnosis of oral and maxillofacial lesions. 5th ed. St. Louis: CV Mosby, 1997:392– 413. 2. Seltzer S. Endodontology. 2nd ed. Philadelphia: Lea & Febiger, 1988: 81–117.
274
Loushine et al.
3. Beers MH, Berkow R. The Merck manual. 17th ed. West Point, PA: Merck & Co., Inc., 1999:2526 – 43. 4. Little JW, Falace DA, Miller CS, Rhodus NL. Dental management of the medically compromised patient. 5th ed. St. Louis: CV Mosby, 1997: 260 –73. 5. Fletcher PD, Scopp IW, Hersh RA. Oral manifestations of secondary hyperparathyroidism related to long-term hemodialysis therapy. Oral Surg Oral Med Oral Pathol 1977;43:218 –26.
Journal of Endodontics 6. Walsh RF, Karmiol M. Oral roentgenographic findings in osteitis fibrosa generalisata associated with chronic renal disease. Oral Surg Oral Med Oral Pathol 1969;28:273– 81. 7. Kaffee I, Tamse A, Schwartz Y, Buchner A, Littner M. Changes in the lamina dura as a manifestation of systemic diseases: report of a case and review of the literature. J Endodon 1982;8:467–70. 8. Rhodus NL, Little JW. Dental management of the renal transplantation patient. Comp Cont Educ Dent 1993;14:518 –32.