Unrecognized carotid artery stenosis discovered by calcifications on a panoramic radiograph

Radiodiagnostics of standard orthodontic radiographs-dental and extradental incidental findings : Do we see everything we should see?

OBJECTIVES

The extent of undetected incidental findings in routine orthodontic radiographs is still unknown. However, incidental findings that are not in the primary focus of orthodontic diagnostics may be of high medical relevance. Therefore, this study aimed to analyse whether incidental findings are reliably detected and which parameters influence the orthodontist's assessment.

METHODS

In a clinical cross-sectional study 134 orthodontists evaluated two orthopantomogram (OPT) and two lateral cephalogram (LC) radiographs each via a standardised online survey. The radiographs were previously examined by three dentists and one radiologist-in a pilot phase-regarding the number of incidental findings and subsequently defining as gold standard in a consensus procedure. The radiographs were presented consecutively, the number of incidental findings detected were noted and the individual findings could be described in free text form.

RESULTS

Overall, 39.1% of the incidental findings were detected. The orthodontists' focus was primarily on the dental region. Here, 57.9% of incidental findings were detected, while 20.3% were detected in extradental regions (p < 0.001). A highly relevant finding of suspected arteriosclerotic plaque was detected in 7.5% of cases (OPT). Significantly more incidental findings were detected on OPTs than on LCs (OPT 42.1%, LC 36.0%, p < 0.001). As participants' length of professional experience increased, significantly more time was spent on the assessment (p < 0.001), correlating positively with the detection of incidental findings.

CONCLUSIONS

Even in daily routine practice, attention must be paid to a thorough assessment of all radiographed regions. The factors time and professional experience can prevent practitioners from overlooking findings outside the orthodontic focus.

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.

Ultrasonographic Evaluation of Soft Tissue Calcifications in the Head and Neck Region Detected on Panoramic Radiographs

OBJECTIVE

The aim of this study is to present a comparison between panoramic radiographs and USG imaging with a focus on revealing the advantages of USG over radiographs, and to show the distribution of calcifications detected in USG by considering the age and gender.

METHODS

A total of 148 patients with soft tissue calcifications as seen on panoramic radiographs were examined with USG imaging. Sialoliths, carotid artery calcifications, tonsilloliths, phleboliths and lymph node calcifications were examined in terms of anatomical localization, distribution and shape.

RESULTS

In the USG evaluation of these 148 patients, soft tissue calcifications were observed in 113 (76.4%) patients. The mean age of the patients with calcification was 55.6 ± 13.1 (min: 22-max: 77). Bilateral calcifications were detected in 25 (22.1%) patients, whereas unilateral calcifications were found in 88 (77.9%) patients. While the rates of tonsilloliths, sialoliths, phleboliths, and lymph node calcifications were statistically similar in male and female patients, the rate of carotid artery calcifications was found to be higher in men than in women (P = 0.017). No statistical significance was found between age groups in terms of the formation of soft tissue calcifications (P = 0.117).

CONCLUSIONS

Panoramic radiographs may mislead clinicians in the diagnosis and differential diagnosis of soft tissue calcifications in the head and neck region due to the presence of distortion, superpositions, metal artefacts, and ghost images. USG is an important diagnostic tool in determining the localization of soft tissue calcifications that can be confused on two-dimensional radiographs, their relationship with neighboring structures, and defining calcification. It can be used safely in the detection of soft tissue calcifications as it provides dynamic imaging without the use of radiation or contrast material compared to other advanced imaging methods.

Carotid Artery Calcifications on Panoramic Radiographs

OBJECTIVE

The objective of this study was to evaluate the prevalence of carotid artery calcifications (CACs) on panoramic radiographs of Polish dental patients.

METHODS

Panoramic radiographs made between 2005 and 2012 in 4000 patients born between 1922 and 1958 were accessed from the server of the Department of Radiology and analyzed for the presence or absence of CACs by a group of trained dentists.

RESULTS

The anatomical area covered by the analysis was visible in 2189 images (54.73%). Calcifications in the carotid arteries were found in 468 (21.68%) patients, including 327 (14.94%) unilaterally and 141 (6.44%) bilaterally. CACs were found in 284 (60.68%) women and 184 (39.32%) men.

CONCLUSIONS

The prevalence rate of CACs detected on panoramic radiographs in patients aged 54 and older was 21.68%, which makes it an important clinical problem.

Calcifications in the neck region of patients with carotid artery stenosis: a computed tomography angiography study of topographic anatomy

OBJECTIVES

The aim of this study was to map the vertical locations of calcified carotid plaques (CCPs), osseous anatomic structures, and calcified soft tissues in the area of the carotid artery, determine to what extent CCPs are superimposed on the cervical spine in coronal images, and analyze the differences between men and women.

STUDY DESIGN

Computed tomography angiography (CTA) scans of 79 patients were studied. CCPs were discovered in 152 of the total 158 neck sides. Evaluations were performed by using sagittal and coronal reformatted CTA images with maximum intensity projection.

RESULTS

Most of the calcified anatomic structures studied, including the carotid bifurcation, were found in close relationship to the level of the third and fourth cervical vertebrae. In the coronal view, all or most of the areas of the CCPs were superimposed on the cervical spine in 22 of 44 (50%) neck sides with CCP in women and in 37 of 108 (34.2%) in men (P = .070).

CONCLUSIONS

The carotid bifurcation is in close proximity to various calcified anatomic structures. This should be taken into account when diagnosing CCPs in panoramic radiographs. In the coronal view, CCPs and the cervical spine are often superimposed; thus, coronal images are not recommended for confirmation of putative carotid calcifications diagnosed on the basis of panoramic radiographs.

Diagnostic accuracy of panoramic radiography in the detection of calcified carotid artery atheroma: a meta-analysis

OBJECTIVE

To determine the diagnostic accuracy of panoramic radiography (PR) in detecting calcified carotid artery atheroma (CCAA) compared with Doppler ultrasonography or angiography (the reference standard).

SOURCES

Cochrane, LILACS, PubMed, Scopus, Web of Science, Google Scholar, Open Grey, and ProQuest were searched. The reference lists of the included studies were also screened.

DATA

Observational studies.

METHODS

Only studies comparing the diagnostic accuracy of PR in detecting CCAA to Doppler ultrasonography or angiography (the reference standard) were included. The primary outcome measures were sensitivity and specificity. The secondary outcomes were negative predictive values, positive predictive values, diagnostic odds ratios, likelihood ratios (positive and negative), receiver operating characteristic curves, accuracy, and Youden's index. Two reviewers independently participated in the study selection, data extraction, and risk of bias assessment without language restriction. Risk of bias was assessed thought QUADAS-2, and the level of evidence was assessed through GRADE.

RESULTS

A total of 773 citations were identified after duplicates were removed, and 12 studies including 1002 patients were included in the final study. The sensitivity and specificity of the different selected studies varied substantially, with sensitivity ranging from 0.31 to 0.95 and specificity from 0.19 to 0.99.

CONCLUSIONS

Most studies reported excellent sensitivity and good specificity. The diagnostic accuracy of PR was good or excellent in 50% of the studies.

CLINICAL SIGNIFICANCE

The identification of CCAA by PR can be a risk predictor for stroke when used as a secondary screening tool.

Unexpected artefacts and occult pathologies under CBCT

Purpose

To present the most frequent occult pathologies unexpectedly encountered via cone-beam computed tomography (CBCT), with particular reference to the diagnostic role of the dentist and that of the radiographer, with a view to clarifying where the diagnostic responsibility lies.

Material and methods

A narrative literature review on the most diffused occult pathologies under CBCT was conducted, with iconographical guide as an example for each category.

Results

The most frequent forms of unexpected pathologies encountered are: the presence of foreign bodies, airway anomaly, and the presence of radio-opacity or -transparency in the maxillofacial district.

Conclusions

The orthodontists must know that they are responsible to recognize these frequent, and potentially serious, pathologies of the head and neck. If the dentist feels unable to take on this responsibility, he or she should, however, be sure to have the scans read by a specialist radiologist.

The frequency and nature of incidental findings in large-field cone beam computed tomography scans of an orthodontic sample

Background

The aim of this study is to evaluate the nature and frequency of incidental findings in large-field maxillofacial cone beam computed tomography (CBCT).

Methods

A total of 427 consecutive CBCT radiologic reports obtained for orthodontic purposes were retrospectively reviewed. Findings were summarized and categorized into six anatomic categories.

Results

A total of 842 incidental findings were reported in the 427 CBCT scans (1.97 findings/scan). The most prevalent findings were those located in the airway (42.3%), followed by the paranasal sinuses (30.9%), dentoalveolar (14.7%), surrounding hard/soft tissues (4.0%), temporomandibular joint (TMJ) (6.4%), and cervical vertebrae (1.3%) regions. Non-odontogenic findings, defined as those located outside the dentition and associated alveolus, represented 718 of the 842 (85.3%) findings.

Conclusions

This study confirms the high occurrence of incidental findings in large-field maxillofacial CBCT scans in a sample of orthodontically referred cases. The majority are extragnathic findings, which can be normally considered outside the regions of interest of many dental clinicians. Specifically, incidental findings in the naso-oropharyngeal and paranasal air sinuses are the most frequent. This underscores the need for comprehensive review of the entire data volume and the requisite to properly document all findings, regardless of the region of interest.

Electronic supplementary material

The online version of this article (doi:10.1186/s40510-014-0037-x) contains supplementary material, which is available to authorized users.

The relationship between cephalometric carotid artery calcification and Framingham Risk Score profile in patients with obstructive sleep apnea

PURPOSE

The morbidity rate of arteriosclerosis becomes clinically manifested as acute cardiovascular events. In the progress of atherosclerosis, the carotid artery calcifies and sometimes appears as a calcified mass on a cephalometric radiograph. This study was designed to evaluate cardiovascular risks according to the Framingham Risk Score (FRS) between subjects with and without visible carotid artery calcification on a cephalogram.

METHODS

Subjects diagnosed with obstructive sleep apnea (OSA) were divided into two groups according to whether or not calcification was visible on a cephalometric radiograph in the carotid artery area, and the characteristic differences between the two groups were analyzed. The evaluated variables included age, BMI, apnea-hypopnea index (AHI), SpO2, ESS, blood pressure, medication history, diabetes mellitus (DM), drinking, smoking, and lipid-related measurements. FRSs for stroke, general cardiovascular disease (GCD), and coronary heart disease (CHD) were calculated. Statistical analyses were performed (SPSS 18.0) with significance defined as a two-tailed p value less than 0.05.

RESULTS

A total of 811 subjects completed the data collection (727 males, age 53.0 ± 12.5 years, AHI 31.7 ± 22.6, times/h). From FRSs, probabilities of a GCD, stroke, and CHD within 10 years were 16.0 ± 9.7, 9.8 ± 6.7, and 11.9 ± 8.3 %, respectively. Some 84 subjects exhibited calcification in the carotid arterial area. Calcification subjects were higher GCD risk and older than subjects who had no identified calcification (20.3 ± 10.1 vs 15.6 ± 20.3 %, p = 0.013, 58.8 ± 11.4 vs. 52.3 ± 12.5 years, p < 0.001). Although there is no significant difference in OSA-related variables and FRSs, subjects with visible calcifications have higher prevalence of high blood pressure medication and DM (p < 0.01).

CONCLUSION

While the presence of a calcified mass on a cephalometric radiograph is not diagnostic of atherosclerosis, this information indicates some cardiovascular risk.

Evaluation of carotid artery atheromatous plaques using digital panoramic radiographs with Doppler sonography as the ground truth

OBJECTIVES

The objective of the study was to determine whether digital panoramic radiography is a reliable method to detect calcified carotid artery atheromatous plaques (CCAAP) as compared to ultrasonography.

STUDY DESIGN

Digital panoramic radiographs were obtained from 50 patients who also underwent carotid ultrasound examination. The images were interpreted by trained maxillofacial radiologist for the presence or absence of calcified atheromatous plaques. The extent of carotid calcification on carotid ultrasonography was determined by a trained sonologist which was considered as gold standard assessment.

RESULTS

Digital panoramic radiographs had sensitivity of 76% and specificity of 98.66% in determining calcified carotid artery atheromatous plaques. There was a high level of agreement between diagnoses, with a kappa value of 0.8.

CONCLUSION

To conclude, digital panoramic radiographs had good sensitivity and high specificity in detecting calcified carotid artery atheromatous plaques. If properly trained, dentists can detect such plaques and can refer patients to physician for timely medical treatment.

Bilateral tonsilloliths and calcified carotid atheromas: case report and literature review

Tonsilloliths and calcified carotid atheromas are dystrophic calcifications that can be identified in routine oral radiographs. This case report is the first description in the English literature of the simultaneous occurrence of bilateral tonsilloliths and calcified carotid atheromas. Panoramic oral radiographs from a 62-year-old woman presented bilateral radiopaque images of the left and right ramus of the mandible; multiple and well-defined radiopacities below the left angle of the mandible, next to the C3-C4 cervical vertebrae; and a single radiopacity on the right side between the hyoid bone and the mandible base. Computed tomography confirmed the exact location of the calcifications in the oropharyngeal and carotid spaces. A diagnosis of bilateral tonsilloliths and calcified carotid atheromas was reached. Doppler ultrasound indicated a degree of stenosis of ± 20% within the right and left carotids. The patient was referred to a vascular surgeon to evaluate the calcified carotid atheromas. Follow-up of the tonsilloliths was also performed.

Cephalometric calcified carotid artery atheromas in patients with obstructive sleep apnea

BACKGROUND

In the progress of atherosclerosis, the carotid artery calcifies and sometimes appears as a calcified mass on a cephalometric radiograph.

PURPOSE

This study was designed to evaluate the prevalence of calcification in cephalometric radiographs of OSA patients and to identify the differences between subjects with and without carotid artery calcification.

METHODS

A total of 1,520 X-rays were evaluated. Data for group A, 508 traditional X-rays, were collected from the UBC Sleep Apnea Dental Clinic and data for group B, 1,012 digital X-rays, were obtained from the Tsuda Hospital in Japan. Subjects were divided into two groups according to whether or not calcification was present in the carotid artery area and the characteristic differences between these two groups were analyzed.

DISCUSSION

Group A had 34 (6.7%) subjects who exhibited calcification in the carotid arterial area, while group B had 96 (9.5%) subjects who revealed calcification. Group A calcification subjects had a significantly lower body mass index (BMI) than subjects who had no calcification (26.9 ± 3.2 vs. 29.7 ± 5.6, p<0.01). Group B calcification subjects were older than subjects who had no calcification (57.6 ± 12.6 vs. 49.8 ± 14.5, p<0.000). Previous reports have found the prevalence of calcification on X-rays of OSA patients to be higher than the prevalence of calcification found in the general population.

CONCLUSION

While the presence of a calcified mass on a cephalometric radiograph is not diagnostic of atherosclerosis, this information might help to aid in screening for the condition.

Mandibular cortical index evaluation in masked and unmasked panoramic radiographs

OBJECTIVES

The first aim of this study was to evaluate intra- and interobserver agreement in evaluating the mandibular cortical index (MCI) in masked and unmasked panoramic radiographs. The second aim was to evaluate the effect of previous experience of MCI classification on the observers' performance.

METHODS

Three observers separately evaluated MCI, twice in masked and twice in unmasked panoramic radiographs, with 2 week intervals. The observations were repeated more than 9 months later. The second and third observers were inexperienced in evaluating MCI. Weighted kappa statistics were used to evaluate the inter- and intraobserver agreement.

RESULTS

In the first session of the study, the kappa values for intraobserver agreements in masked panoramic radiographs were between 0.565 and 0.789; in unmasked panoramic radiographs, they were between 0.420 and 0.732. The kappa values for interobserver agreement were between 0.131 and 0.392 in masked radiographs and between 0.043 and 0.225 in unmasked radiographs. In the second session of the study, the kappa values for intraobserver agreements in masked panoramic radiographs were between 0.586 and 0.786. The kappa values for intraobserver agreements in unmasked panoramic radiographs were between 0.558 and 0.781. The kappa values for interobserver agreement were between 0.146 and 0.510 in masked radiographs and between 0.174 and 0.568 in unmasked radiographs.

CONCLUSIONS

Masking has no effect on the evaluation of panoramic radiographs for MCI. Previous experience causes higher intraobserver agreement. Intra- and interobserver agreement increases along with the increased experience in MCI evaluations.

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 of carotid and pulp calcifications: a correlation using digital panoramic radiographs

OBJECTIVE

To compare the prevalence of pulp calcification with that of carotid calcification using digital panoramic dental radiographs.

STUDY DESIGN

Digital panoramic radiographs of patients at a dental oncology clinic were included if (1) the carotid artery bifurcation region was visible bilaterally and (2) the patient had non-restored or minimally restored molars and/or canines. An endodontist evaluated the images for pulpal calcifications in the selected teeth. An oral and maxillofacial radiologist independently evaluated the same images for calcifications in the carotid bifurcation region. Odds-ratio and Pearson chi(2) were used for data analysis. Presence of pulpal calcification was also evaluated as a screening test for the presence of carotid calcification.

RESULTS

A total of 247 panoramic radiographs were evaluated. 32% (n = 80) had pulpal calcifications and 25% (n = 61) had carotid calcifications with 12% (n = 29) having both carotid and pulp calcifications. A significantly higher prevalence of both pulp and carotid calcification was found in subjects older than age 60 years compared to younger age groups. Accuracy of pulpal calcification in screening for carotid calcification was 66.4%.

CONCLUSIONS

Both pulp and carotid calcifications were more prevalent in older individuals. The presence of pulp calcification was not a strong predictor for the presence of carotid calcification.

Reliability of panoramic radiograph for carotid atheroma detection: a study in patients who fulfill the criteria for carotid endarterectomy

OBJECTIVES

To evaluate the reliability of panoramic radiograph (PR) for carotid artery atheroma detection, by comparing its results with the carotid-vertebral digital subtraction angiography (DSA) findings, as well as with the detected calcium deposition in the carotid plaques, which were surgically resected, using direct radiographs.

STUDY DESIGN

Forty consecutive patients suffering from carotid artery atherosclerotic occlusive disease confirmed by preoperative DSA, fulfilling the criteria for carotid endarterectomy, were operated on. Preoperatively, all of the patients had undergone PR, while postoperatively all of the surgically resected carotid plaques were radiographed using radiographic films and submitted to histologic examination. Compared with the DSA and the radiographic film findings, the PR results were classified as: 1) true-positive; 2) true-negative; 3) false-positive; or 4) false-negative.

RESULTS

Panoramic radiograph has low sensitivity and specificity compared with the DSA findings and the direct radiographs results. However, a positive predictive value (PPV) of 100% per patient as well as for luminal stenosis >80% was documented.

CONCLUSION

Even in the subgroup of patients who fulfill the criteria for carotid endarterectomy, PR has a low sensitivity and specificity; therefore, it cannot be considered to be a useful screening tool for atheroma detection in the general dental population. However, the 100% PPV per patient and for luminal stenosis >80%, indicates that positive calcification PR findings at the C(3)-C(4) region are highly suggestive for carotid artery atherosclerotic occlusive disease. Therefore, especially asymptomatic patients should be referred for further examination.

Utility of panoramic radiographs in detecting cervical calcified carotid atheroma

OBJECTIVE

The objective of this study was to determine the utility of panoramic radiographs for detecting extracranial calcified carotid atheroma and carotid luminal stenosis.

STUDY DESIGN

Panoramic radiographs were obtained on 52 adult participants who had carotid ultrasound examination. Extent of carotid calcification and stenosis was determined by a cardiologist from ultrasound reports, which were considered gold standard assessments. A trained and calibrated oral and maxillofacial radiologist interpreted the radiographs for presence or absence of carotid calcifications. We examined the utility of panoramic radiographs to diagnose any carotid artery changes (diagnostic scheme 1) or only moderate to severe changes (scheme 2). Generalized estimating equations were used to account for clustering of observations within subjects.

RESULTS

Under diagnostic schemes 1 and 2, radiographs had low sensitivity to detect carotid calcifications (31.1% and 25.0%, respectively) and stenoses (22.7% and 21.4%, respectively).

CONCLUSIONS

When compared to ultrasonography, panoramic radiography is not a reliable means to detect carotid artery calcifications or stenoses.

Digital panoramic radiography: a reliable method to diagnose carotid artery atheromas?

OBJECTIVES

The aim of the present study is to evaluate the panoramic radiographs of 4106 patients for carotid artery atheromas (CAAs) and to correlate our findings with the literature.

MATERIALS AND METHODS

The digital panoramic radiographs of 4106 dental patients (2428 female, 1678 male) were evaluated. Radiographs of patients 40 years of age or older were randomly chosen from a computer database. CAA findings were defined as radiopaque masses adjacent to the cervical vertebrae at or below the intervertebral space between C3 and C4 on the panoramic radiograph. The patients who had CAA findings were contacted by telephone, and some of them agreed to further evaluation. Evaluation included carotid ultrasound, ECG, echocardiography and treadmill exercise testing at the Department of Cardiology.

RESULTS

Of 4106 patients, 88 patients (2.1%; 70 female, 18 male) had one or more radiopaque mass detected on digital images. All 88 patients with CAA findings were contacted by telephone and 23 agreed to further evaluation at the university hospital. Of these 23 patients, 8 (34.7%) had CAAs on carotid ultrasound and 15 (65.3%) had normal carotid arteries. From these eight patients with CAAs on Doppler ultrasound, 7 (30.4%) had plaques that were not haemodynamically significant and only one (4.3%) had significant plaque. The patient with severe carotid artery stenosis consequently underwent endarterectomy operation. There were no statistically significant differences between male and female in CAAs (P>0.05).

CONCLUSION

Digital panoramic images may have some diagnostic value for detecting CAAs and this early diagnosis could potentially increase the length and quality of life for people with CAAs.

Correlating carotid artery stenosis detected by panoramic radiography with clinically relevant carotid artery stenosis determined by duplex ultrasound

OBJECTIVE

We sought to assess the utility of panoramic radiography as an adjunct screening tool for detecting significant asymptomatic carotid artery stenosis. The specific aim was to correlate calcifications seen in the region of the carotid bifurcation with clinically relevant carotid artery stenosis as determined by duplex ultrasound (DUS).

STUDY DESIGN

Routine dental panoramic films of patients 55 and older (n = 778) at the University of Rochester Eastman Dental Center were retrospectively reviewed for calcifications around the carotid bifurcation. Patients with such calcifications were referred for DUS, and raw data were interpreted by a vascular surgeon blinded to the radiographic findings. Groups were compared by using the chi(2) test.

RESULTS

Twenty-seven patients (3.5%) had suggestive radiographic calcifications on one or both sides, 20 of whom consented to DUS. Clinically significant carotid stenoses (>50% lumenal narrowing) were present in 50% of the sides with calcification compared with 21% of the sides without (P =.08, chi(2)). Three patients (15% of those screened with DUS) had stenoses greater than 80% and underwent 4 carotid endarterectomies as a direct result of screening.

CONCLUSIONS

Data suggest that clinically significant stenosis may exist if calcifications are observed on panoramic radiographs. Incidental examination of this area carries a minimal cost and appears beneficial as a screening tool for carotid disease, although definitive testing must follow.

Calcification of the branches of the external carotid artery detected by panoramic radiography: a case report

Atherosclerosis, a progressive inflammatory disease, may lead to stroke, coronary artery disease, or peripheral artery disease. The prevalence of atherosclerosis associated with morbidity and mortality is very high in industrialized countries. This report describes the case of a 49-year-old male patient whose panoramic radiograph taken as part of a dental examination showed calcification in the branches of the external carotid artery. The right facial artery and left maxillary, facial, and lingual arteries were also calcified. The patient had a history of thrombosis in the right axillary and brachial veins with extension to half of the brachiocephalic trunk. In addition, selective lesions were found in the aorta and mitral valve. The patient's medical history also included hypertriglyceridemia, essential arterial hypertonia, terminal renal insufficiency, renal anemia, neurogen disturbance micturition, secondary hyperparathyroidism, hyperuricemia, lymphatic edema, polyneuropathy, tachyarrhythmia absoluta, and erysipelas. The case presented reports on the possibility of detecting signs of atherosclerosis in arteries of the maxillofacial region by use of panoramic radiography.

Carotid calcification on panoramic radiographs: an important marker for vascular risk

OBJECTIVE

The objective of this study was to determine whether carotid calcifications are harbingers of future vascular events.

STUDY DESIGN

Between 1986 and 2000, 71 patients were found to have carotid artery calcifications on routine panoramic films. Medical records were reviewed for vascular risk factors existing before and vascular end points subsequent to the radiographs.

RESULTS

The mean age of our patients was 68 years. Sixty-one (86%) had preexisting vascular risk factors, 73% with multiple risk factors. Forty-one end points occurred in 29 patients. The average time to an end point was 2.7 years. The end points included myocardial infarction (8, 11%), stroke (5, 7%), death (11, 15%), revascularization procedures (8, 11%), transient ischemic attack (2, 3%), and angina (7, 10%). Twenty-three patients (34%) had major end points of myocardial infarction, stroke, or death.

CONCLUSIONS

Carotid calcifications identified on panoramic radiographs are powerful markers for subsequent vascular events. Patients found to have carotid calcification on panoramic radiographs should be referred for cerebrovascular and cardiovascular evaluation and aggressive management of vascular risk factors.