Panoramic radiography and its role in the diagnosis of systemic disorders

This article presents a case report in which a systemic disease was first suspected by viewing a panoramic radiograph. A 49-year-old man sought prosthetic rehabilitation with implants. Panoramic radiography revealed an osteolysis of poorly defined limits in the apical region of teeth No. 26 to 28. The patient's medical history included the recent removal of a giant cell lesion from the left tibia. During palpation of the neck, a fixed nodule was detected on the superior portion of the left thyroid gland. Biochemical tests showed elevated levels of serum alkaline osphatase, serum calcium, and parathyroid hormone. As the serum phosphate was low, the final diagnosis was primary hyperparathyroidism. A CT scan showed a hypodense lesion involving teeth No. 26 to 28, with preserved cortical bone. A whole-body bone scintigraphy showed lesions in the mandible and other long bones. A high radiopharmaceutical capitation was present in the left parathyroid gland. The patient was referred to a head and neck surgeon, who removed the left thyroid lobule and the parathyroid gland. The microscopic diagnosis was parathyroid carcinoma. After eight months of follow-up, the mandibular lesion disappeared.