Identification of stroke prone patients by panoramic radiography

Benefit of Panoramic Radiography in the Detection of Carotid Calcifications: Clinical Case Reports and Review of the Literature

Atherosclerotic lesions in the common carotid artery are one of the most frequent causes of ischemic stroke. They are usually diagnosed by cardiologists and are managed following complementary examinations. In dental practice, panoramic radiograph is a basic examination frequently performed in first line. On this radiography, possible unilateral or bilateral opacities projecting to the latero-cervical regions can be visualized, raising suspicion of carotid calcifications. The aim of this study was to present, through three cases and a review of the literature, the benefit of PR in the diagnosis of carotid calcifications and the approaches to be followed in case of such suspicious images. This would contribute, in some cases, to an early diagnosis and management, thus avoiding the evolution towards cerebral vascular accidents.

Alzheimer's Disease and Oral-Systemic Health: Bidirectional Care Integration Improving Outcomes

Dentistry is an effective healthcare field that can impact Alzheimer's disease through prevention and education. Every day dental providers use an arsenal of assessment protocols directly coinciding with modifiable Alzheimer's risk factors. An innovative way to help in the prevention of Alzheimer's disease is to utilize oral health professionals who reach the public in ways other health care providers may not. Bidirectional care integration is needed to stifle many systemic diseases and Alzheimer's disease is no different. Ultimately with collaborative care the patient reaps the benefits. Alzheimer's is associated with many etiologies and pathophysiological processes. These include cardiovascular health, smoking, sleep, inflammatory pathogens, and diabetes. In the United States, dental providers assess each of these factors daily and can be instrumental in educating patients on the influence of these factors for dementia prevention. Globally, by 2025, the number of people with Alzheimer's disease is expected to rise by at least 14%. Such increases will strain local and national health care systems, but for the US if Medicare were expanded to include dental services, many older adults could be spared needless suffering. The goal of this perspective article is to highlight existing practices being used in the field of dentistry that can easily be adapted to educate patients in preventive care and treat risk factors. It is the duty of healthcare professionals to explore all opportunities to stem the advance of this disease and by integrating oral and systemic health into transdisciplinary science, health care and policy may do just that.

Associations among Periodontitis, Calcified Carotid Artery Atheromas, and Risk of Myocardial Infarction

Cardiovascular disease is a common cause of morbidity and premature mortality. Cardiovascular disease can be prevented when risk factors are identified early. Calcified carotid artery atheromas (CCAAs), detected in panoramic radiographs, and periodontitis have both been associated with increased risk of cardiovascular disease. This case-control study aimed to 1) investigate associations between periodontitis and CCAA detected in panoramic radiographs and 2) determine the risk of future myocardial infarctions due to CCAA combined with periodontitis. We evaluated 1,482 participants (738 cases and 744 controls) with periodontitis and CCAAs recruited from the PAROKRANK study (Periodontitis and Its Relation to Coronary Artery Disease). Participants were examined with panoramic radiographs, including the carotid regions. Associations between myocardial infarction and periodontitis combined with CCAA were evaluated in 696 cases and 696 age-, sex-, and residential area–matched controls. Periodontitis was evaluated radiographically (as degree of bone loss) and with a clinical periodontal disease index score (from clinical and radiographic assessments). We found associations between CCAA and clinical periodontal disease index score among cases (odds ratio [OR], 1.51; 95% CI, 1.09 to 2.10; P = 0.02) and controls (OR, 1.70; 95% CI, 1.22 to 2.38; P < 0.01), although not between CCAA and the degree of bone loss. In a multivariable model, myocardial infarction was associated with CCAA combined with periodontitis, as assessed by degree of bone loss (OR, 1.75; 95% CI, 1.11 to 2.74; P = 0.01). When the cohort was stratified by sex, only men showed a significant association between myocardial infarction and CCAA combined with periodontitis. Participants with clinically diagnosed periodontitis exhibited CCAA in panoramic radiographs more often than those without periodontitis, irrespective of the presence of a recent myocardial infarction. Participants with combined periodontitis and CCAA had a higher risk of having had myocardial infarction as compared with participants with either condition alone. These findings implied that patients in dental care might benefit from dentists assessing panoramic radiographs for CCAA—particularly, patients with periodontitis who have not received any preventive measures for cardiovascular disease.

Prevalence of carotid artery calcifications among 2,500 digital panoramic radiographs of an adult Brazilian population

Background

The aim of the present study was to analyze the epidemiological data of digital panoramic radiographs revealing suggestive images of carotid artery calcifications (CAC) from a Northeast Brazilian population.

Material and Methods

A cross-sectional retrospective study was conducted with 2,500 digital panoramic radiographs obtained from a single imaging reference center in Northeast Brazil. Images from individuals of both sexes and older than 18 years were included and those that did not cover the region of cervical vertebrae or presented low radiographic quality were excluded. Data were analyzed regarding prevalence, location (bilateral, right or left), sex, and age using the Chi-square test at the significance level of 5%.

Results

An amount of 96 (4%) patients presented suggestive images of CAC. The female sex (p=0.003) and individuals aged up to 70 years (p=0.002) were statically significant. 40.4% were found bilaterally, 37.6% on the right side (p<0.001) and 22% on the left side.

Conclusions

In conclusion, this study showed a low prevalence of suggestive images of CAC in digital panoramic radiographs from a Northeast Brazilian population. It was observed a higher prevalence of CAC associated with female sex, older patients, and right side location.

Key words:Atherosclerosis, carotid artery, digital panoramic radiograph, prevalence.

Carotid Artery Calcification: A Digital Panoramic-Based Study

Objective: The aim of this study was to estimate the incidence of carotid artery calcification (CAC) in a sample of Lebanese population using digital panoramic radiographs. Materials and Methods: Panoramic radiographs of 500 patients (281 females and 219 males), aged between 18 and 88 years (mean: 47.9 years), were assessed for CAC. Data collected were analyzed statistically using IBM^® SPSS^® for Windows version 20.0 (SPSS, Chicago, IL, USA). Results: CAC were found in 34 cases (6.8%), among them, 23 females (8.18%) and 11 males (5.02%). Six of all the calcifications were on the right side, against six on the left side, and 22 on both sides. The mean age of patients affected with CAC was 60.9 years (ranging from 18 to 88 years). Chi-square test showed no statistical significance between gender and CAC, while Spearman correlation analysis showed positive low correlation with age (r = 0.179). Conclusion: CAC can be found on routine panoramic radiographs taken in dental clinics; dentists should automatically refer the patients in question for specialized medical evaluation.

Early diagnosis of atherosclerosis with panoramic radiographs: a review

Carotid artery disease has been linked with cerebral vascular accident, also known as stroke, cerebral hemorrhage, or cerebral ischemia. It is caused by narrowing or obstruction of arteries in the neck (the carotid arteries) that are responsible for transporting blood from the aorta to the brain. Panoramic radiographs are used in dentistry to show both dental arches as a supplement to the clinical dental examination. The objective of this study is to highlight the importance of panoramic radiographs for diagnosis of arterial disease, by means of a bibliographic review. The PubMed database was searched using the keywords “atherosclerosis” and “panoramic”, with the filters “last 5 years” and “humans”. Twenty articles were identified, six of which were chosen for this study because they were open access. The review concluded that panoramic radiographs enable early diagnosis of carotid artery calcification, resulting in earlier interventions, and offer an accessible cost.

Prevalence of Pathologic Findings in Panoramic Radiographs: Calcified Carotid Artery Atheroma

OBJECTIVES

To assess the prevalence of images suggestive of calcified carotid artery atheromas (ISCCAA) in panoramic radiographs of patients under dental treatment.

MATERIALS AND METHODS

The sample consisted of 8.338 panoramic radiographs from female (n=5.049) and male (n=3.289) patients under dental treatment between 4 and 94 years of age. The panoramic radiographs were evaluated searching for ISCCAA. The obtained findings were statistically associated with sex and age.

RESULTS

ISCCAA were found in 579 radiographs (6.9%). No statistically significant differences were observed between females and males (p>0.05). ISCCAA were more prevalent in patients having a mean age of 50 (p<0.05).

CONCLUSION

The potential cases of ISCCAA that were assessed on panoramic radiographs are of utmost clinical significance because they can ensure early and correct diagnosis.

Carotid calcification in panoramic radiographs: radiographic appearance and the degree of carotid stenosis

OBJECTIVES:

Approximately 7% of patients examined with panoramic radiographs (PRs) for odontological reasons, and with incidental findings of carotid artery calcification (CAC), have significant (≥50%) carotid stenosis (SCS). The aim of this study was to determine if the radiographic appearance of CACs in PRs could be categorized such that we could improve the positive-predictive value (PPV) for SCS detection.

METHODS:

This cross-sectional study included 278 patients with CACs identified by PRs, 127 with SCS and 151 without SCS. CACs were categorized based on the following appearances: (1) single, (2) scattered or (3) vessel-outlining. Correlates were derived for each category according to positivity or not for SCS in the corresponding neck sides. For a representative adult population (in dentistry) presenting with CACs in PRs, PPVs for SCS prediction were then calculated for three subgroups based on different combinations of appearances (2) and/or (3).

RESULTS:

Vessel-outlining CACs corresponded to 65% of neck sides with SCS vs 47% without SCS (p < 0.001). Single CACs corresponded to 15% of neck sides with SCS vs 27% without SCS (p = 0.006). Scattered CACs corresponded to 20% of neck sides with SCS vs 26% without SCS (p = 0.127). In the representative population, the PPVs for SCS detection were comparable (7.2-7.8%) for all three subgroups and when the presence of a CAC is the sole criterion (7.4%).

CONCLUSIONS:

Stratifying the radiographic appearance of CACs in PRs does not improve the PPV for SCS detection. Whether different radiographic appearances are associated with future risk of stroke, or other cardiovascular events, remains unknown.

Prevalence of carotid artery calcification in postmenopausal women and its correlation with atherogenic risk factors

Aim:

The aim of the present study was to determine the prevalence of carotid artery calcification (CAC) in postmenopausal females on panoramic radiographs and to study the correlation of CAC with possible risk factors such as hypertension, osteoporosis, and hypercholesterolemia, among others.

Materials and Methods:

Totally, 1214 panoramic radiographs of postmenopausal females attending the Department of Oral Medicine and Radiology were examined for the presence of CAC. The subjects were also assessed for the presence of various risk factors and the possible correlation to CAC. Statistical analysis was done using Chi-square test, and P < 0.05 was considered to be statistically significant.

Results:

Two hundred and seventy-eight postmenopausal females presented with CAC and a prevalence of 22.9%. These patients presented with a medical history that was laden with risk factors, of which hypertension (71.2%) was the most common risk factor. Hypertension, hypercholesterolemia, osteoporosis, and obesity were significantly (P < 0.05) related to the presence of CAC while age, diabetes, and smoking were not significantly (P > 0.05) related to CAC.

Conclusion:

The incidental finding of CAC on panoramic radiographs during the routine dental examination can provide life-saving information for the identification of postmenopausal females who are at a higher risk for stroke. Oral clinicians should, therefore, record a proper medical history of such patients to identify the atherogenic risk factors and refer such patients to the physician for careful evaluation and conformation of the disease.

Relationship between carotid artery calcification detected in dental panoramic images and hypertension and myocardial infarction

BACKGROUND

Carotid artery calcification may be related to cerebrovascular accident, which may result in death or physical and mental disabilities in survivors.

OBJECTIVES

Our purpose is to study the association of carotid artery calcification (CAC) on dental panoramic radiographs and two risk factors of cerebrovascular accident (CVA) including hypertension and myocardial infarction (MI).

PATIENTS AND METHODS

Panoramic images of 200 patients that were all women above 50 years of age (a population suffering from vascular diseases) were investigated. All panoramic images were provided under similar conditions in terms of the type of panoramic radiograph equipment, type of applied films and the automatic film processor. Then, the patients answered questions about MI history and taking antihypertensive drugs. We also measured the blood pressure of patients in two separate surveys. Data analysis was performed by SPSS statistical program. We used Exact Fisher test and Chi-Square test at a significant level of less than 0.05 to study the effect of these variables on the occurrence of carotid artery calcification.

RESULTS

Among 200 studied samples, 22 of the patients (11%) had carotid artery calcification on the dental panoramic radiograph. In total, 52 patients (26%) had hypertension and four people (2%) had a history of MI. Eleven individuals among patients suffering from hypertension (21.2%) and three individuals among patients with a history of MI (75%) demonstrated CAC on dental panoramic images .

CONCLUSIONS

The relationship between CAC found on dental panoramic radiographs and two CVA risk factors--hypertension and MI-- was significant. Therefore, it seems that detection of CAC on panoramic images of dental patients must be considered by dentists.

Prevalence of findings compatible with carotid artery calcifications on dental panoramic radiographs

Cerebrovascular accidents are responsible for killing or disabling more than half a million Americans every year. They are the third leading cause of death in this country. In Germany, the annual stroke incidence reaches 182 cases per 100,000 inhabitants. Stroke there is the fourth leading cause of death. There is a need of finding cost-effective means of decreasing stroke mortality and morbidity. Instruments for early diagnosis are of great humanitarian and economic importance. All possible clinical findings should be taken into account. It is not the demand of this study to present the panoramic radiograph as a screening test method for early diagnosis of atherosclerosis. The aim is to show the potential of this radiograph used in everyday clinical dental practice by the prevalence of radiopaque findings in the carotid region. This study included panoramic dental radiographs of 2,557 patients older than 30 years of age. Fifty-nine percent of the patients were women and 41% were men. The radiographs were adjudged for signs compatible with carotid arterial calcifications appearing as a radiopaque nodular mass adjacent to the cervical vertebrae at or below the intervertebral space C3-4. Of all these radiographs, 4.8% showed radiopaque findings compatible with atherosclerotic lesions. The proportion of women reached 64.8% and that of men reached 35.2%. In accordance to recent literature, the results of this study show that about 5% of the patients show radiological findings compatible with carotid arterial calcifications. Some of these patients at risk for a cerebrovascular accident may be identified in the dentist's office by appropriate review of the panoramic dental radiograph. The suspicion of carotid artery calcifications demands an impetuous referral to an appropriate practitioner who can assist in the control of risk factors and if necessary arrange surgical removal of the carotid arterial plaque. So, the dentist should be aware of this problem and able to make a contribution to stroke prevention.

Prevalence of calcified carotid artery on panoramic radiographs in postmenopausal women

BACKGROUND AND AIMS

This study was designed to evaluate the prevalence of calcified carotid artery in 50 year-old and older postmenopausal dental outpatients for early diagnosis of individuals at risk of stroke.

MATERIALS AND METHODS

This is a descriptive study of 200 panoramic radiographs. These radiographs included post-menopausal women referring to the Department of Oral Medicine at Shahid Beheshti Faculty of Dentistry during 2006-2007. The x-ray machine, developer and film type were the same for all the radiographs. Statistical analysis included chi-square test and Fisher's exact test.

RESULTS

We found 22 calcified carotid arteries. The left and right carotid arteries were involved in 7 and 9 cases, respec-tively. In 6 cases both carotid arteries were calcified. Four individuals had no vascular risk factor excluding age and others had at least one risk factor. We found significant statistical correlation between hypertension, past history of myocardial infarction, and hypercholesterolemia with calcified carotid artery on panoramic radiographs.

CONCLUSION

Under the limitations of the present study, prevalence of calcified carotid arteries is 11.0 % in 50 year-old and older postmenopausal dental outpatients.

Prevalence in digital panoramic radiographs of carotid area calcification among Iraqi individuals with stroke-related disease

OBJECTIVE

The purpose of this study was to determine the prevalence of carotid calcification on digital dental panoramic tomography in a group of the Iraqi population who have some stroke-related vascular and or metabolic disease.

STUDY DESIGN

Digital dental panoramic tomographic images of 157 adult patients of age range 40-80 years having chronic illnesses such as coronary heart diseases, hypertension, type 2 diabetes, and hyperlipidemia and of 43 control subjects (age range 40-71 years, free of systemic diseases) were made and examined for the presence of carotid artery calcification adjacent or just below the intervertebral space between C3, C4, and C5 on both sides of patient's neck. The study group was subclassified into vascular, metabolic, and vascular-metabolic groups. Determinations were made of the prevalence, number, and distribution of carotid area calcifications. Forward stepwise logistic regression analysis was used to determine which risk factor is more liable to develop carotid artery area calcification.

RESULTS

The statistical difference between patients with stroke-related diseases (vascular, metabolic, and vascular-metabolic groups) versus patients in the control group was highly significant concerning the prevalence of carotid area calcifications (P < .01). Carotid area calcification was identified in 38.8% of the study group. Bilateral calcifications were observed more than unilateral calcification for both genders (26.6% vs. 13.9% for men; 24.4% vs. 12.8% for women).

CONCLUSION

People with stroke-related vascular and/or metabolic diseases have greater prevalence of calcified area calcifications seen on panoramic radiographs than people who are otherwise healthy.

Calcified carotid artery atheroma and stroke: a systematic review

BACKGROUND

Calcified carotid artery atheroma (CCAA) and its identification on panoramic radiographs have been advocated as a predictor of a cerebrovascular accident (CVA).

TYPES OF STUDIES REVIEWED

The authors conducted an electronic search using 11 databases to evaluate the evidence from the literature that links CCAA detection on panoramic radiographs and the precipitation of CVAs among those people. They used the Reporting Recommendations for Tumor Marker Prognostic Studies (REMARK) checklist to perform this systematic review.

RESULTS

One study of the 54 studies the authors identified satisfied the REMARK criteria in which CCAA was associated with a negligible increased risk of stroke (95 percent confidence interval, 0 to 0.04 percent) in the population studied.

CLINICAL IMPLICATIONS

This systematic review suggests the data supporting the hypothesis that radiographically detectable CCAA is associated with an increased risk of stroke are incomplete and inconclusive. Further research is needed, as clinical guidelines for risk prediction using panoramic radiographs cannot be established on the basis of the current evidence.

Long-Term Cigarette Smoking Increases the Prevalence of Carotid Artery Calcification Seen on Panoramic Dental Radiographs in Male Patients

Panoramic dental radiographs are commonly used in general dentistry and oral and maxillofacial surgery to examine upper and lower teeth, maxilla, mandible and the surroundings simultaneously. Carotid artery calcification, a specific indicator of atherosclerotic change of the carotid arteries, can be seen on the radiographs. Many studies have suggested that cigarette smoking is a risk factor of atherosclerotic change as well as cerebral infarction. We hypothesized that smoking could increase the prevalence of carotid artery calcification, and compared the radiographs of smokers and non-smokers aged 50 years and over: 146 male smokers, 165 male non-smokers, 42 female smokers and 422 female non-smokers. This is the first study to focus on carotid artery calcification seen on panoramic dental radiographs to show the connection between smoking and atherosclerotic change. In male patients, carotid artery calcification was seen in 18 (14.1%) of the smokers, and in 8 (4.8%) of the non-smokers, which clearly shows that male patients aged 50 years old or over are more likely to develop carotid artery calcification if they smoke. However, there is no significant difference between female smokers and female non-smokers in the same age group. Dentists are in a good position to find carotid artery calcification on radiographs. When this is found on a radiograph, the patient should be advised to stop smoking and be referred to a physician for further tests. Clinicians should be aware that this radiographic finding indicates the presence of atherosclerotic change of the carotid arteries.

Stroke: epidemiology, classification, risk factors, complications, diagnosis, prevention, and medical and dental management

Cerebrovascular accident, or stroke, refers to an acute onset of neurologic deficits lasting more than 24 hours or culminating in death caused by a sudden impairment of cerebral circulation. Stroke is the third leading cause of death and a major cause of long-term disability in the United States. This article provides the dental community with an up-to-date understanding of the epidemiology, classification, risk factors, complications, diagnosis, prevention, and medical and dental management issues pertaining to stroke.

Carotid artery calcification detected on panoramic radiographs in a group of Thai population

OBJECTIVE

To determine the prevalence of carotid artery calcification (CAC) detected on panoramic radiographs in a Thai population.

STUDY DESIGN

The panoramic radiographs of the patients 50 and older (N = 1,370) visiting Mahidol University from January 1998 through September 2004 were retrospectively reviewed for CAC. The medical records of the positive subjects were then reviewed.

RESULTS

Thirty-four (2.5%) of the 1,370 patients, 16 men and 18 women, with a mean age of 69 and a range of 50 to 87 years, had 1 or more CACs. These calcifications were unilateral in 25 (73.5%) and bilateral in 9 (26.5%) subjects. Of those positive subjects, 18 reported hypertension, 10 reported diabetes mellitus, and 5 reported hyperlipidemia.

CONCLUSIONS

Although it is uncommon to find CAC in the Thai population, dentists should be aware of this calcification on the routine panoramic radiographs and promptly refer for cerebrovascular and cardiovascular evaluation.

A readability analysis of Australian stroke information

The aims of this study were to document the readability of a stroke education brochure and to illustrate how the readability of this document might be improved. Readability analyses using three different formulas were conducted on a stroke education brochure from the Australian National Stroke Foundation. Consistent with previous studies of the readability of written health information, results indicated that the overall level of difficulty of the material was too complex for the average member of the public to read and understand. Revision of a randomly selected section of text using established guidelines for writing patient information, and subsequent reanalysis of this section, showed that simple revisions of health literature can dramatically improve readability. Given the importance of effective communication of preventative information about stroke, we present these results as a model of how future revisions of difficult to read stroke-related literature might be conducted to improve public education.