Pathology · patient case question
The bone findings, enlarging hat size and new hearing loss point to which systemic disease?
Patient case: Bulbous root form on a recall radiograph
Patient: Male, 61 years old
Chief complaint: “Nothing hurts — I'm here for my cleaning.”
History: Hearing aid fitted last year. Reports his hat size has increased. Takes no regular medications.
Findings: Periapical radiographs show generalised bulbous, club-shaped root enlargement with the periodontal ligament space and lamina dura following the enlarged outline. The bone shows a patchy, cotton-wool trabecular pattern. Teeth are vital.
Show answer and explanation
Correct answer: B. Paget disease of bone
- A. Osteopetrosis is a failure of osteoclastic resorption producing diffusely dense, brittle bone with obliterated marrow spaces, anaemia and a high risk of osteomyelitis after extraction.
- B. CORRECT. Paget disease is disordered, accelerated bone remodelling in patients over about 40. The classic triad in this vignette — increasing hat size from cranial enlargement, HEARING LOSS from narrowing of the internal acoustic meatus, and a COTTON-WOOL radiographic pattern with hypercementosis — is the exam presentation. SERUM ALKALINE PHOSPHATASE is markedly elevated while calcium and phosphate stay normal.
- C. Fibrous dysplasia presents in children and adolescents as a painless unilateral swelling with a GROUND-GLASS pattern that blends imperceptibly into normal bone. It stabilises after skeletal maturity and does not cause progressive skull enlargement in later life.
- D. Hyperparathyroidism gives generalised demineralisation with LOSS of the lamina dura, a ground-glass or granular trabecular pattern, and brown tumours — plus RAISED SERUM CALCIUM, which Paget disease does not produce.
Note: Dental relevance: enlarging jaws mean dentures stop fitting, extraction sockets heal poorly, and there is a small risk of osteosarcoma in affected bone. Patients are frequently on bisphosphonates, adding MRONJ risk.