Paget Disease: Osteitis Deformans of the Jaw

Paget disease of bone, also called osteitis deformans, is a chronic disorder of bone remodeling that can silently affect the skull and the jaws. In the maxillofacial region it produces progressive bony enlargement, distinctive cotton-wool radiographs and dental complications such as hypercementos...

Paget disease of bone, also called osteitis deformans, is a chronic disorder of bone remodeling that can silently affect the skull and the jaws. In the maxillofacial region it produces progressive bony enlargement, distinctive cotton-wool radiographs and dental complications such as hypercementosis and widening of the alveolar ridges. Understanding its oral signs is essential, because the dentist may be the first clinician to detect the condition and because dental procedures in these patients carry unique risks.

What Is Paget Disease

Paget disease is a metabolic bone disorder in which abnormal osteoclast activity removes bone rapidly, followed by disorganized osteoblastic repair that produces thickened, weakened, mosaic-like bone. The disease usually affects older adults and can involve one bone or multiple bones, with the pelvis, spine, skull and long bones being the most frequent sites. In the craniofacial skeleton, the skull and the maxilla are the most commonly affected bones, and maxillary involvement can give the face a characteristic lion-like or leontiasis appearance as the midface enlarges. The mandible is affected less often but still shows characteristic changes. The jaws may enlarge slowly over years, and the patient may first notice loose dentures, tooth mobility or a change in facial shape.

How It Affects the Jaw

The maxilla and the facial skeleton

The maxilla enlarges progressively, which widens the alveolar ridge, causes the teeth to spread apart, and leads to a prominent midface. The enlarged maxilla can obstruct the nasolacrimal duct or the sinuses.

Dental and periodontal consequences

The teeth are not spared: the root surface may develop hypercementosis, in which excessive cementum thickens the roots, making extraction difficult. The bone surrounding the teeth becomes sclerotic and poorly vascularized, which predisposes to osteomyelitis, especially after extractions. Widened interdental spaces, drifting teeth and persistent pain are common complaints that bring the patient to the dental office.

The systemic picture

Outside the mouth, the disease can cause bone pain, deformity, fractures, bowing of the legs, hearing loss and compression of the skull base structures. Serum alkaline phosphatase is elevated because of the high bone turnover, while the calcium level is usually normal.

Radiographic Features

Cotton-wool appearance

The classic radiographic finding in the jaws is the cotton-wool appearance, in which scattered dense, irregular radiopacities are mixed with areas of radiolucency, giving the bone a patchy, moth-eaten image. In the skull, this produces the characteristic ill-defined radiopaque islands on the vault. The alveolar bone is often more radiodense than normal, and the trabeculae are coarse and irregular.

The maxilla versus the mandible

In the maxilla, the cotton-wool pattern is common and the sinus walls may be thickened. In the mandible, the changes are typically less pronounced, and the mandibular cortex may be thickened with a ground-glass or sclerotic texture.

The dental radiograph changes

Periapical and panoramic radiographs may show hypercementosis of multiple roots, widening of the periodontal ligament space, and a generalized increase in bone density. The lamina dura is often ill-defined and the trabecular pattern is irregular. The diagnosis is suggested when these findings appear in an older patient with enlargement of the maxilla or the skull.

Diagnosis

The diagnosis is based on the history, the clinical findings, the radiographic appearance and the elevation of serum alkaline phosphatase. Bone scintigraphy may show increased uptake in the affected bones, and it is useful to determine the extent of the disease. Rarely, a biopsy is needed when the radiograph is not typical or when a malignant transformation is suspected, although this complication is uncommon.

The osteosarcoma risk

Patients with Paget disease have an increased risk of developing osteosarcoma in the affected bones, and a sudden increase in pain or swelling in a pagetic jaw should raise this concern. The sarcoma has a poor prognosis and requires urgent imaging and biopsy.

Management

Medical treatment

The mainstay of medical treatment is the bisphosphonate therapy, which can normalize bone turnover, reduce pain and control the alkaline phosphatase level. Calcitonin is sometimes used as an alternative, and oral calcium and vitamin D are given to prevent the hypocalcemia that can follow intensive bisphosphonate treatment.

Dental considerations

Dental treatment in a patient with Paget disease requires caution because the pagetic bone heals slowly and is prone to infection and osteomyelitis. Extractions are performed with minimal trauma, and prophylactic antibiotics are often given, especially when the bone is heavily involved. Root canal treatment should be carried out carefully because the roots may be thickened with excessive cementum, and the canals may be obliterated.

Denture care

Because the enlargement of the ridge continues slowly, dentures may require periodic adjustment, and implant placement is generally avoided in severely affected bone. The prosthodontic plan should anticipate future changes in the ridge morphology. Regular recalls with clinical and radiographic monitoring are important to document the progress of the disease and to detect complications early.

Prevention and Daily Care

Oral hygiene in affected patients

Good daily hygiene is especially important for patients with Paget disease because the reduced vascularity of the affected bone increases the risk of periodontitis and osteomyelitis. Brushing with a soft brush and using interdental cleaning reduce the accumulation of plaque, and the patients should be advised to see the dentist at least every six months. A pressure-sensing electric toothbrush such as the BrushO helps protect sensitive and prominent roots and the widened interdental spaces, while its pressure control and two-minute timer offer complete, gentle plaque removal.

Monitoring and communication

The dental team should keep in contact with the physician managing the bone disease, so that changes in medication or new joint symptoms are shared. Any persistent pain, swelling or change in the shape of the jaw should prompt re-evaluation, because these may indicate progression or a rare malignant change. Through coordinated care and meticulous hygiene, most patients can maintain comfort and function for many years.

Conclusion

Paget disease of bone is a chronic metabolic disorder that can enlarge the jaw, produce a cotton-wool radiographic appearance and create real dental challenges such as hypercementosis, osteomyelitis risk and prosthetic problems. Diagnosis rests on clinical findings, radiographs and serum alkaline phosphatase, and management combines bisphosphonates with careful dental care. With a coordinated treatment plan and consistent oral hygiene, the dental team helps these patients preserve their dentition and avoid complications.

（本文由 BrushO 智能牙刷团队撰写，仅供科普参考，不构成医疗建议。）（内容由AI生成，仅供参考）

（内容由AI生成，仅供参考）