Highly elevated alkaline phosphatase is a good marker of Paget’s disease of bone in the appropriate clinical setting. Bone sequestration is often secondary to chronic osteomyelitis in the jaws. Bisphosphonates are used to treat Paget’s disease and also have been linked to jaw osteonecrosis.

Study the two radiographs which are of the same
patient at (a) 19 years and (b) 34 years of age.

1 . What is the most likely periodontal diagnosis at 34
years of age?

Generalised aggressive periodontitis. The severity
of bone resorption and the radiographic absence of
signs of resorption at 19 years preclude a diagnosis of
chronic periodontitis.

2 . What does the initial phase of treatment involve?

Initially conventional cause-related treatment
is instigated: instruction in toothbrushing and
use of adjunctive aids for interproximal and
subgingival cleaning, RSI, prophylaxis. Ultimately,
treatments such as surgery and the adjunctive use of
antimicrobials might be indicated, but conventional
treatment is first in line.

3 . The patient has a sister who is aged 29 years. What
advice might you offer?

Periodontal screening and radiographic examination.
There is evidence that certain subjects are at high risk
from developing aggressive periodontitis and this
risk may be under genetic control. Siblings should
be screened and affected individuals with children
warned that early signs may develop from around
puberty onwards

A 35-year-old man presents with gross loosening of both his lower left premolar teeth. The gingiva around them looks swollen and is purple–brown in colour. A radiograph shows irregular bone destruction to the apices. Incisional biopsy shows multinucleated osteoclast-like giant cells in a haemorrhagic fibrous stroma.

1. Which investigations should now be performed?
   The serum calcium level should be measured and radiographs reviewed to exclude hyperparathyroidism.
   
2. If these prove negative, what treatment should be undertaken?
   The lesion should be treated by local removal with curettage.
   
3. Which other lesions in the jaws contain multinucleate giant cells of this type?
   Osteoclast-like giant cells are found in
   1. giant-cell granuloma
   2. brown tumour of hyperparathyroidism
   3. Pagetʼs disease of bone
   4. aneurysmal bone cyst
   5. some fibro-osseous lesions, particularly cherubism. 

A 58-year-old woman noticed that her front teeth had become spaced and seeks advice from her dentist. On entering the surgery, the dentist notices that she has difficulty in walking and does not respond to his questions. She has become increasingly deaf and her vision has also deteriorated. On examination, the maxilla and zygoma are enlarged and there is enlargement of the forehead.

1. What diagnosis would you suspect?
Pagetʼs disease of bone results in enlargement of cranial bones and deformation of weight- bearing bones. The cranium is usually expanded in thickness and symptoms may arise from cranial nerve compression.

2. What information might be gained from oral radiographs and blood tests to support this diagnosis?
Radiographs of the jaws may show hypercementosis, cemental masses, abnormal trabeculation and a cotton-wool appearance in the jaws. The alkaline phosphatase level is markedly raised.

3. What are the principal histological features of this disorder?

Disordered bone remodelling is seen; larger osteoclasts are present and the trabeculae show a scalloped outline. Numerous resting and reversal lines, resulting in a mosaic pattern, are seen and the vasculature may be increased. Globular cementum-like masses are seen in the jaws.