|Year : 2015 | Volume
| Issue : 1 | Page : 115-118
Hyperparathyroidism and thalassemia trait in a patient with impacted teeth: A case report revealing the importance of detailed history taking and investigations
Vinod Vijay Chandar, Shailaja Sankireddy, Sridevi Koduri, Akshika Sharma
Department of Oral Medicine and Radiology, Faculty of Dental Sciences, SGT University, Gurgaon, Haryana, India
|Date of Submission||15-Feb-2015|
|Date of Acceptance||24-Jun-2015|
|Date of Web Publication||12-Oct-2015|
Department of Oral Medicine and Radiology, Faculty of Dental Sciences, SGT University, Gurgaon - 122 505, Haryana
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Among the eruption disorders, the most common developmental dental anomalies encountered are the retention or impaction of teeth. Impaction of multiple teeth is a common finding associated with some syndromes or systemic disorders. This is a report of a female aged 18 years with normal serum calcium and unusual oral manifestations where in the diagnosis of underlying hyperparathyroidism and thalassemia trait came to light.
Keywords: Impacted teeth, parathormone, root resorption, thalassemia trait
|How to cite this article:|
Chandar VV, Sankireddy S, Koduri S, Sharma A. Hyperparathyroidism and thalassemia trait in a patient with impacted teeth: A case report revealing the importance of detailed history taking and investigations. J Indian Acad Oral Med Radiol 2015;27:115-8
|How to cite this URL:|
Chandar VV, Sankireddy S, Koduri S, Sharma A. Hyperparathyroidism and thalassemia trait in a patient with impacted teeth: A case report revealing the importance of detailed history taking and investigations. J Indian Acad Oral Med Radiol [serial online] 2015 [cited 2022 Jan 24];27:115-8. Available from: https://www.jiaomr.in/text.asp?2015/27/1/115/167129
| Introduction|| |
In a normal eruption scenario, permanent teeth erupt uneventfully and replace their primary predecessors. However, sometimes teeth fail to erupt. Most of these unerupted teeth are deviated or angulated aberrantly and eventually lose their potential to erupt and be referred to as impacted teeth. A commonly observed finding is impaction involving a single tooth; however, impaction of multiple teeth is an uncommon finding.  This delayed or arrested eruption may probably be caused due to diminished resorption of bone and of primary teeth, and sometimes due to the presence of multiple supernumerary teeth. In other cases, the normal number of permanent teeth are present and the failure to erupt is caused by loss or lack of eruptive force (Sivakumar et al., 2007). Conditions which cause the lack of eruptive force include general, endocrinal, neurogenic, and mucosal or bone disorders. Here we present a case of impacted second premolar in the first quadrant and all four permanent second molars in an 18-year-old female in whom an in-depth elicitation of the history and a series of investigations led to the diagnosis of hyperparathyroidism (HPT) and thalassemia trait, of which the patient was completely unaware of. To the best of our knowledge, no similar case has been reported earlier in literature.
| Case Report|| |
A female patient aged 18 years reported to the department with the complaint of forwardly placed upper front teeth and increase in spaces between the teeth since 7-8 years. The patient had an attack of tetany almost 2 years ago for which she was hospitalized and had taken calcium supplements for treatment of the same. The patient disclosed a late menarche around the age of 15 years and irregular menstrual cycle since 2-3 months. No significant family history was present.
No significant extraoral finding was present except an incompetent lip seal [Figure 1]. Intraoral examination revealed a black-colored macule on the right buccal mucosa near 46, retained deciduous second molar in the first quadrant (55) and missing four permanent second molars, clinically. Loss of contact was present between 11 and 12, and 21 and 22 [Figure 2]. A provisional diagnosis of oligodontia (with respect to 15, 17, 27, 37 and 47) and retained 55 was made. A differential diagnosis of delayed eruption secondary to hypothyroidism, considering the late menarche milestone was made. The patient was advised an orthopantomograph (OPG) along with complete blood profile tests including calcium analysis. The OPG revealed impacted 15, 17, 27, 37, and 47, and permanent tooth buds of 28, 38, and 48. Resorption of roots was seen in relation to 11, 12, 13, 14, 55, 21, 33, 34, 35 and 44 [Figure 3]. The blood picture showed a decreased hemoglobin and a microcytic profile. The patient was then advised calcium, phosphorus, uric acid, vitamin D, thyroid and parathyroid hormone level tests. The investigations revealed normal levels of calcium, phosphorus, vitamin D and alkaline phosphate, but the uric acid level was reduced. Although there were normal levels of the thyroid hormone, the parathyroid hormone level was raised to 176.9 pg/ml. Hand-wrist radiographs were taken which showed no bony abnormality. Considering the microcytic blood picture, the patient was further evaluated for thalassemia following which hemoglobin chromatography showed the patient to be positive for thalassemia trait.
|Figure 2: Intraoral appearance showing interdental spacing in relation to anterior teeth|
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|Figure 3: OPG depicting impacted teeth, hypoplastic mandible and root resorption|
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| Discussion|| |
Out of the several developmental anomalies in humans, dental agenesis is one of the most common anomaly which presents a significant clinical problem. It is classified according to the number of missing permanent teeth excluding the third molars. A condition with one to five missing teeth is referred to as hypodontia.  Incidence of missing permanent teeth has been reported to vary from 2.6 to 11.3%, depending on the demographic and geographic profile. 
Impacted teeth fail to erupt fully into the oral cavity within the expected time due to any interference with the jaw bone, adjacent tooth or even the gums. Several local and systemic factors contribute to non-eruption or impaction of teeth. Among local factors, lack of adequate dental arch length and the space for eruption are the main reasons.  Other reasons could be palatal clefts, developmental abnormities of tooth germs, growth disharmony between pre-maxilla and maxilla, maxillary brachygnathia, and transversal growth deficiency of the anterior maxilla (Mc Connelt, 1996). Systemic factors include endocrinological abnormalities and irradiation. Multiple impactions may be associated with syndromes like cleidocranial dysostosis and Gardner's syndrome. The present case did not show any features attributable to the stated syndromes.
The classic order of frequency of impaction of permanent teeth can be summarized as follows: Lower third molars, upper third molars, upper canines, upper and lower premolars, upper incisors, lower canines, lower incisors, upper and lower first molars, and upper and lower second molars.  In this case, all the permanent second molars were impacted, which is in contrast to the frequency of impaction. The impaction can be attributed to lack of eruptive forces, which could be a result of the hormonal imbalance in the patient. The loss of tooth contact in between 11 and 12, and 21 and 22, in the reported case could be the result of reduced bone density of the supporting alveolar bone.
Hyperparathyroidism is a metabolic disorder characterized by increased production of parathormone (PTH). It is the most common cause of hypercalcemia in non-hospitalized patients; however, patients with hyperparathyroidism may have low, normal, or high serum calcium levels, mostly depending on the renal function. It occurs in 1 of 1,200 adults, more commonly in women. Secondary HPT is normally related to patients with intestinal malabsorption syndrome or chronic renal failure, occurring in decreased vitamin D production or with hypocalcemia causing the glands to produce a high quantity of PTH. There is also hyperphosphatemia.  In the reported case, although the present serum calcium levels were not altered to a considerable extent, a past history of decreased calcium may have contributed to a secondary rise in PTH.
Dental abnormalities in HPT are widened pulp chambers, development defects, alterations in dental eruption, and malocclusion. However, in the present case, widening of pulp chambers was absent. There was external root resorption which is not a common finding in either hyperparathyroidism or thalassemia trait; but, its presence could be attributed to the fact that bone remodeling changes occurring during HPT, which usually involves osteoclasts, might have influenced odontoclasts in the process resulting in root resorption. 
Hyperparathyroidism should be suspected when there is an increase in serum calcium levels and should be confirmed by the increase in PTH. In our case though the calcium levels were normal at the time of presentation, the patient revealed a history of calcium deficiency 2 years back which could be one of the reason for the increased parathyroid hormone levels. One of the main clinical manifestations of hyperparathyroidism is reduction in bone density. Mandible is one of the commonly involved bone, which was seen in this case. In the oral cavity, the most common clinical manifestations of HPT are brown tumor, loss of bone density, hypoplastic teeth, malocclusion, soft tissue calcifications, and dental abnormalities such development defects, alterations in dental eruption and widened pulp chambers.  In our case, however, the patient demonstrated only delayed eruption of the permanent second molars.
According to previous studies, it has been seen that PTH has an opposite effect as that of estrogen. Therefore, a late menarche in our patient can be correlated to a raised parathyroid hormone level that could have led to low estrogen levels.  The patient, at the time of reporting to the department, was totally unaware of the clinical conditions, but it was the alertness and curiosity of oral physician which led to the aforementioned investigations and finally to the diagnosis of hyperparathyroidism and positive thalassemia trait.
| Conclusion|| |
Through this case report we want to put emphasis on the significance of a complete and in-depth case history, an observant eye of the oral physician, correlation of various clinical findings and the appropriate investigations which would lead to a correct diagnosis of underlying systemic conditions of which the patient is usually unaware. The systemic conditions might not be manifesting or of any primary concern for the patient at the time of presentation; however, they could be of significance in future, as in the present case scenario, the hyperparathyroidism and positive thalassemia trait could be a matter of concern in a female of this age group.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]