Journal of Oral Medicine and Pain

Korean Academy of Orofacial Pain and Oral Medicine (대한안면통증구강내과학회)
권호 표지
DOI QR코드

DOI QR Code

A Case Report : TMJ Osteoarthritis in a Patient with Renal Osteodystrophy

턱관절의 골관절염을 동반한 신성골이영양증 환자 증례보고

  • Lee, Gi-Ho (Department of Oral Medicine, School of Dentistry, Dankook University)
  • 이기호 (단국대학교 치과대학 구강내과학교실)
  • Received : 2013.06.22
  • Accepted : 2013.08.26
  • Published : 2013.09.30
Download PDF
⟨ Previous Next ⟩

Abstract

Renal osteodystrophy(RO) is characterized by skeletal changes in patients with renal disease and developed as a result of alterations in the metabolism of calcium, phosphate and secondary hyperparathyroidism. Bony changes in the craniofacial region include decreased bone density, radiolucent lesions(brown tumors), depletion of cortical bone and loss of lamina dura, but such changes rarely occur in the temporomandibular joint(TMJ). We report an uncommon case of bony changes and pain of both TMJs in a patient with RO. A 41-year-old man with RO came to our clinic due to TMJ pain and sounds. Occlusal change was also reported. Radiographs revealed degenerative changes of the both condyles. The patient had medical history of renal cancer therapy and hemodialysis. The patient was diagnosed with TMJ arthritis of RO and referred for systemic management through medication of calcium and vitamin D and parathyroidectomy. At 15-month follow-up, most of TMD symptoms disappeared and second radiographs revealed that bone density and cortical thickness of the mandible increased and the skeletal outline of the both condyles became relatively clear. As bony changes may begin in the early stage of the renal disease, dentists should be alert to detect the sign of the disease. In addition, it is important to differentiate TMJ arthritis of systemic cause because the treatment protocol is quite different.

신성골이영양증 (Renal osteodystrophy)은 만성 신질환 환자에서 관찰되는 골격성 변화를 특징으로 하는 질환으로 칼슘과 인 대사의 변화, 그리고 이차성 부갑상선 기능항진증의 결과로 나타난다. 방사선학적으로 지골의 말단, 장골과 악골 부위의 골막하 부위의 침식을 흔하게 관찰할 수 있다. 악안면 영역에서 골변화는 골밀도의 감소, 방사선 투과성 병소 (갈색 종양 : brown tumor), 피질골의 비박화와 치조백선의 소실을 보인다. 그러나 이러한 골변화가 악관절에 발생하는 것은 흔치 않은 일이다. 본 증례는 양측 하악 과두의 골변화를 보인 신성골이영양증 환자를 보고하고자 한다. 지난 10년 간 혈액 투석 치료와 3개월 전 신장암 수술 병력이 있는 41세 남자 환자가 좌측 턱의 통증을 주소로 2011년 2월 단국대학교 치과대학부속 치과병원 구강내과에 내원하였다. 양측 악관절의 골관절염과 유사한 방사선학적 소견을 보였고, 전치부 개방교합이 관찰되었다. CBCT를 이용한 방사선학적 특징과 생화학적 지표를 통해 신성골이영양증으로 인한 양측 턱관절의 골관절염으로 진단 되어 환자는 내과에서 신성골이영양증의 치료 방법의 하나인 칼슘 및 비타민 D 복용고 부갑상선 절제술을 시행 받았고, 그 동안 턱관절의 통증 조절을 위해 본원에서는 행동 요법과 약물 치료, 물리치료만 시행하였다. 약 1년 3개월 후 재검사에서 하악골의 골밀도와 피질골 두께가 증가하였고, 하악 과두 외형이 비교적 명확하게 바뀌었다. 골변화는 만성 신장 질환의 초기 단계부터 시작되므로 치과의사는 이러한 질환의 징후 및 가능성을 신속히 감별할 수 있어야 한다. 또한 골관절염과 신성골이영양증의 치료 프로토콜이 다르기 때문에 두 질환을 감별하는 것이 중요하다.

Keywords

References

  1. Syrjanen S, Lampainen E. Mandibular changes in panoramic radiographs of patients with end stage renal disease. Dentomaxillofac Radiol 1983;12:51-56. https://doi.org/10.1259/dmfr.1983.0010
  2. Kanis J.A., Cundy T.F., Hamdy N.A.T. Renal osteodystrophy. Bailliere's Clinical Endocrinology and Metabolism 1988;2:193-241. https://doi.org/10.1016/S0950-351X(88)80013-2
  3. John E.Z., Caner, John L. Decker. Recurrent acute (? Gouty) arthritis in chronic renal failure treated with periodic hemodialysis. Am J Med 1964;36:571-582. https://doi.org/10.1016/0002-9343(64)90105-6
  4. Fishman MC. Medicine. 4th ed. Philadelphia, 1996, Lippincott. Raven Publishers; pp 187-196.
  5. Koch Nogueira PC, David L, Cochat P. Evolution ofsecondary hyperparathyroidism after renal transplantation. Pediatr Nephrol 2000;14:342-346. https://doi.org/10.1007/s004670050772
  6. Drueke TB. The pathogenesis of parathyroid gland hyperplasia in chronic renal failure. Kidney Int 1995;48:259-272. https://doi.org/10.1038/ki.1995.292
  7. Spolnik KJ, Maxwell DR, Patterson SS, Kleit SA, Cockerill EM, Dental radiographic manifestations of end-stage renal disease. Dent Radiogr 1981;54:21-31.
  8. Eastwood JB. Renal osteodystrophy: a radiological review. CRC Crit Rev Diagn Imaging 1977;9:77-104.
  9. Silverman S, Gordan G, Grant T, et al. The dental structures in primary hyperparathyroidism: studies in 42 consecutive dentulous patients. Oral Surg Oral Med Oral Pathol 1962;15:426-436. https://doi.org/10.1016/0030-4220(62)90375-4
  10. John R, Timothy L. : Oral manifestations of renal osteodystrophy : case report and review of the literature. Spec Care Dentist 2003;23:28-34. https://doi.org/10.1111/j.1754-4505.2003.tb00286.x
  11. Johnson, C., Benjamin Graham, C., Kingsbury Curtis, F. Roentgenographic manifestations of chronic renal disease treated by periodic haemodialysis. American Journal of Roentgenology 1967;101:915-926. https://doi.org/10.2214/ajr.101.4.915
  12. A.J. Sidebottom, R. Salha. Management of the temporomandibular joint in rheumatoid disorders. Br J oral Maxillofac Surg 2013;51:191-198. https://doi.org/10.1016/j.bjoms.2012.04.271
  13. L Lamazza, F Guerra, M Pezza, AM Messina, A Galluccio, M Spink, A De Biase. The use of etanercept as a non-surgical treatment for temporomandibular joint psoriatric arthritis: a case report. Australian Dental Journal 2009;54:161-165. https://doi.org/10.1111/j.1834-7819.2009.01110.x
  14. Roland Jonsson, Ann-Marie Lindvall, Gudrun Nyberg. Temporomandibular joint involvement in systemic lupus erythematosus. Arthritis and Rheumatism 1983;26:1506-1510. https://doi.org/10.1002/art.1780261213
  15. Ferit Tovi, Albert Gatot, Dan Fliss. Temporomandibular arthritis in familial mediterranean fever. HEAD & NECK 1992;14:492-495. https://doi.org/10.1002/hed.2880140613
  16. Zsuzsanna Suba, Daniel Takacs, Szabolcs Gyulai Gaal et al. Tophaceous gout of the temporomandibular joint: A report of 2 cases, J Oral Maxilofac Surg 2009;67:1526-1530. https://doi.org/10.1016/j.joms.2008.12.019
  17. Vivino FB, Katz WA. Sjogren's syndrome: clinical picture and diagnostic tests. J Musc Med 1995;12: 40-52.
  18. Al-Hashimi I, Khuder S, Haghighat N, Zipp M. Frequency and predictive value of the clinical manifestations in Sjogren's syndrome. J Oral Pathol Med 2001;30:1-6. https://doi.org/10.1034/j.1600-0714.2001.300101.x
  19. Lighterman, L. Renal osteodystrophy with oral manifestations. J Oral Surg 1952;10:233.
  20. Alvin Sellers, Alan C. Winfield, Shaul G. Massry. Resorption of condyloid process of mandible. An unusual manifestation of renal osteodystrophy. Arch Intern Med 1973;131:727-728. https://doi.org/10.1001/archinte.1973.00320110111017
  21. Dick R., Jones D. N. Temporomandibular joint changes in patients undergoingchronic haemodialysis. Clin Radiol 1973;24:72-76. https://doi.org/10.1016/S0009-9260(73)80120-5
  22. Hartmut H. Malluche, Hanna Mawad, Marie-Claude Monier-Faugere. Effects of treatment of renal oseodystrophy on bone histology. Clin J Am Soc Nephrol 2008;3:S157-S163. https://doi.org/10.2215/CJN.02500607