If you conducted a routine head and neck evaluation and noticed swelling around the parathyroid glands of a patient, what may you suspect is going on? If this same patient presented with osteoporosis on their medical history, would you make a correlation? The parathyroid glands are typically two small pea sized glands that rest behind the thyroid gland and are responsible for producing parathyroid hormone (PTH).1 The role of this hormone is to keep blood calcium levels from going too low by releasing calcium from the bones. In instances where PTH overreacts, too much calcium is released from the bones, causing a spike in blood calcium.1 Various symptoms and comorbidities may result from a primary hyperparathyroidism diagnosis, however as oral health care providers, we can become vigilant in bringing awareness to warning signs. This article is going to review the current literature on primary hyperparathyroidism (PHPT), along with signs, symptoms, and the role of the oral health care provider in advising patients to seek care.
Overview of Primary Hyperparathyroidism (PHPT)
PHPT is the third most common endocrine disorder after diabetes mellitus and hypothyroidism and is most prevalent in post-menopausal women.2 In 80% of cases, PHPT is attributed to benign parathyroid adenoma, which is what may be detected on a head and neck evaluation. In 15-20% of cases, it could be a multi gland disorder, meaning multiple adenomas or multi gland hyperplasia. In rare cases, PHPT could be a result of parathyroid carcinoma.2 Routine bloodwork may also indicate elevated levels of blood calcium, however patients with mild cases are typically asymptomatic prior to their diagnosis. For patients in later stage PHPT that are symptomatic, signs can include constipation, frequent urination, increased thirst, joint pain, kidney pain, lethargy, fatigue, loss of appetite, and muscle weakness.1,3 As mentioned earlier, when PTH overreacts, calcium is pulled from the bones into the blood. When too much calcium is available in the blood, it goes into the kidneys and filters through the urine, resulting in kidney stones.4 Research states that 10-20% of patients with PHPT present with kidney stone disease, also known as urolithiasis.1 The symptoms of PHPT are somewhat vague and may not lead a provider to suspect a PHPT diagnosis, however leaving this condition undiagnosed can lead to long term health complications and risks for early mortality.
PHPT and Quality of Life
In cases of PHPT, PTH is being produced at an elevated rate, which results in more calcium being pulled from the bones than is needed by the body. When bones release calcium, they go through a process called bone turnover. This is essentially how the bones maintain homeostasis of calcium when it is lost- the bones resorb and then become replaced. In patients with PHPT, this high rate of bone turnover leads to a higher rate of bone loss over time, specifically cortical bone.1,2 The gradual loss of cortical bone results in osteopenia or osteoporosis, placing patients at much higher risk for bone fractures, even with minimal trauma. Bone fractures are a common comorbidity with PHPT and are taken into serious consideration when evaluating someone for surgery.4 A recent meta-analysis was conducted to measure the risk of fracture in patients with PHPT in comparison to a healthy control population. Statistically significant results indicated the risk of total fracture, which included vertebral and non-vertebral fractures, was higher among patients with PHPT compared to the control population.3 This same study also compared bone mineral density (BMD) of patients with PHPT to healthy controls. Statistically significant results concluded that the risk of vertebral fracture was higher among symptomatic patients with PHPT in comparison to the healthy control population.3 These risk factors can alter quality of life and are correlated with excess morbidity and higher rates of premature mortality.2
The only true treatment option for this condition is surgery through parathyroidectomy, however many instances involve simple non-operative observation. The rationale behind parathyroidectomy is to increase BMD and while several studies have shown positive results after treatment completion, further longitudinal studies must be completed to make a definitive correlation between surgery and long-term results.5 A 10-year randomized controlled trial compared PHPT patients that underwent parathyroidectomy and those with PHPT who were observed without any surgical intervention. Parathyroidectomy treatment yielded statistically significant results over non-observation regarding BMD.5 The results of this study are leading to believe that positive outcomes from parathyroidectomy compared to observation improved bone mineral density over time.
Role of the Oral Health Practitioner PHPT is more prevalent in developing countries where routine biochemical screening is not practiced and vitamin D deficiency is a frequent occurrence.3 Although PHPT affects a very small portion of patients in western cultures, it is imperative to be aware of warning signs that may present on a patient’s medical history or head and neck evaluation. For patients over the age of 50 who already have an osteoporosis diagnosis, the oral health care practitioner should inquire if the patient is having yearly evaluations to check their blood calcium and parathyroid hormone levels, as it is well understood that osteoporosis can be a result of PHPT. Routine bloodwork suggested by the oral health care provider-whom the patient may be seeing more frequently than their primary care provider or endocrinologist- could be life altering for a patient that may have underlying PHPT. A comprehensive head and neck evaluation at every appointment will also allow the oral health practitioner to screen for any potential swelling or tumors around the thyroid and parathyroid glands. Should any areas be identified, it is the responsibility of the provider to make the appropriate referral for further screening and assessment.
Conclusion
PHPT is a condition not frequently diagnosed and if left untreated, could result in numerous risk factors leading to a higher mortality rate. Bringing the “why” back into head and neck evaluations can assist with connecting the dots for patients in their medical histories. Drawing correlations between osteoporosis, osteopenia, and PHPT could be a new concept to many patients and providers. As oral health care providers, it is our obligation to take a detailed look into patient’s medical histories, beyond updating medications and allergies routinely. Bringing these conversations into the operatory will assist patients in achieving true oral systemic health.
References
1. Primary Hyperparathyroidism [Internet]. Johns Hopkins Medicine; 2024 [cited 10 May 2024]. Available from https://www.hopkinsmedicine.org/health/conditions-and-diseases/primary-hyperparathyroidism#:~:text=Primary%20hyperparathyroidism%20is%20a%20condition,by%20releasing%20calcium%20from%20bones
2. Pappachan JM, Lahart IM, Viswanath AK, et al. Parathyroidectomy for adults with primary hyperparathyroidism. Cochrane Database Syst Rev. 2023;3(3): 1-77.
3. Narayana N, Palui R, Merugu C, et al. The risk of fractures in primary hyperparathyroidism: A meta-analysis. J Bone Miner Res. 2021;5(4): 1-9.
4. Primary Hyperparathyroidism [Internet]. National Institute of Diabetes and Digestive and Kidney Diseases; 2024 [cited 10 May 2024]. Available from https://www.niddk.nih.gov/health-information/endocrine-diseases/primary-hyperparathyroidism
5. Lundstam K, Pretorius M, Bollersley J, et al. Positive effect of parathyroidectomy compared to observation on BMD in a randomized controlled trial of mild primary hyperparathyroidism. J Bone Miner Res. 2023;38(3): 372-380.
