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Metabolic Conditions
Metabolic Conditions
Metabolic Conditions
Classically, dental patients who wear complete dentures may complain of newly acquired
poor prosthetic adaptation and function as the maxilla symmetrically enlarges. The
alveolar ridge ultimately widens, with relative flattening of the palatal vault. When teeth
are present, increased spacing, as well as loosening, is noted. In severe cases, continued
enlargement of the maxilla or mandible can make closure of the lips difficult or
impossible. Classic radiographic findings in the late stage of Paget’s disease are due to
bony sclerosis providing a patchy radiopaque pattern described as resembling cotton or
wool. In the jaws, this pattern of bone change may be associated with hypercementosis or
resorption of tooth roots, loss of lamina dura, and obliteration of the periodontal ligament
space (Figures 15-2 and 15-3).
Histopathology. In the initial resorptive phase, random overactive osteoclastic bone
resorption is evident. Resorbed bone is replaced by vascularized connective tissue in
company with prominent osteolysis and osteogenesis. Bone eventually develops a dense
mosaic pattern as a result of reversal lines in increasingly sclerotic bone, as osteoclasts
give way to osteoblasts (Figures 15-4 and 15-5). The laboratory can provide important
information about the diagnosis of Paget’s disease. Serum calcium and serum phosphate
levels are normal in the presence of markedly elevated alkaline phosphatase levels. The
intense osteoblastic activity in this metabolically active bone is believed to be responsible
for the elevated alkaline phosphatase levels. The amount of bone resorption may be
correlated with increases in urinary calcium and hydroxyproline levels.
Treatment. The primary indicator for therapeutic intervention is patient discomfort.
Elevation of alkaline phosphatase levels to twice normal levels is also an indication for
treatment. Therapy has been directed at controlling osteoclast formation and function.
The use of calcitonin and bisphosphonate has been effective. Both suppress bone
resorption and deposition, as reflected in a reduction in the biochemical indices, including
alkaline phosphatase and urinary hydroxyproline levels. A 50% reduction in either index
constitutes a good therapeutic response (see Chapter 13 for complications of
bisphosphonate therapy). Paget’s disease is a slowly progressive disorder, but it is seldom
fatal. Relief of symptoms, particularly bone pain, with oral or intravenous
bisphosphonates is beneficial.
Complications include skeletal deformity, weakened bones, neurologic deficits, and
pathologic fracture. Heart failure may also be an important complication of Paget’s
disease as a consequence of the hypervascular bone. In the early vascular phase, bleeding
following any type of bone surgery (e.g., tooth extraction) can be problematic. In a small
percentage of cases, malignant transformation into osteosarcoma may occur. Depending
on the series reported, this has ranged from 1% to 15%.