Evaluation of calcified carotid atheroma on panoramic radiographs and Doppler ultrasonography in an older population

Orthopantomography Detection of Atheroma Plaques and Its Relationship with Periodontal Disease and Missing Teeth

Background

The aim of this study is to determine the atheromatous plaques' prevalence in orthopantomography and their relationship with periodontal disease and missing teeth. Material and Methods. Orthopantomographs of 1,254 patients over 18 years of age from Clínica Arlanza in Lerma, Burgos, were examined between 2017 and 2021. A Planmeca ProOne® orthopantomograph (68 kV, 7 mA, and 10 sg) was used. Statistical analysis was carried out using SPSS Statistics® version 25. The results of the categorical variables were described as frequencies (%). Contingency tables were made with the qualitative variables, and the chi-square test was applied to study the relationship among them. The measure of statistical power used was the relative risk (RR), which was described with its respective 95% confidence interval (CI). Student's t-test was applied to study the relationship between the qualitative variable "presence or absence of atheroma plaque" and the quantitative variable "number of teeth."

Results

A 6.2% prevalence of atheroma plaques was obtained from 1,079 selected X-rays. The risk in patients with periodontal disease increased as periodontal disease worsened. The risk in patients with periodontal disease increased as periodontal disease worsened as follows: healthy patients vs. periodontal patients with less than 30% bone loss in radiography: RR 0.434, 95% CI 0.181-1.041, p = 0.053 healthy patients vs. patients with between 30%-60% bone loss: RR 0.177, 95% CI 0.075-0.418, p < 0.05 healthy patients vs. patients with more than 60% bone loss: RR 0.121, 95% CI 0.041-0.355, p < 0.05. Patients with calcifications on their orthopantomograms had a lower mean teeth number (20.9 teeth) compared to patients without calcifications (24 teeth), which was statistically significant, t (1077) = -3.125, p < 0.05.

Conclusions

Orthopantomography can be considered a screening method to detect patients at increased cardiovascular risk who are referred for individualized study. It is important to continue research to know the real significance of these findings. Dentists should be aware of the importance of our work in our patients' systemic health.

Overview of Ultrasound in Dentistry for Advancing Research Methodology and Patient Care Quality with Emphasis on Periodontal/Peri-implant Applications

BACKGROUND

Ultrasound is a non-invasive, cross-sectional imaging technique emerging in dentistry. It is an adjunct tool for diagnosing pathologies in the oral cavity that overcomes some limitations of current methodologies, including direct clinical examination, 2D radiographs, and cone beam computerized tomography. Increasing demand for soft tissue imaging has led to continuous improvements on transducer miniaturization and spatial resolution. The aims of this study are (1) to create a comprehensive overview of the current literature of ultrasonic imaging relating to dentistry, and (2) to provide a view onto investigations with immediate, intermediate, and long-term impact in periodontology and implantology.

METHODS

A rapid literature review was performed using two broad searches conducted in the PubMed database, yielding 576 and 757 citations, respectively. A rating was established within a citation software (EndNote) using a 5-star classification. The broad search with 757 citations allowed for high sensitivity whereas the subsequent rating added specificity.

RESULTS

A critical review of the clinical applications of ultrasound in dentistry was provided with a focus on applications in periodontology and implantology. The role of ultrasound as a developing dental diagnostic tool was reviewed. Specific uses such as soft and hard tissue imaging, longitudinal monitoring, as well as anatomic and physiological evaluation were discussed.

CONCLUSIONS

Future efforts should be directed towards the transition of ultrasonography from a research tool to a clinical tool. Moreover, a dedicated effort is needed to introduce ultrasonic imaging to dental education and the dental community to ultimately improve the quality of patient care.

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.

Occult Mönckeberg medial calcinosis of the facial and infraorbital arteries in an elderly edentulous patient

Mönckeberg medial calcinosis (MMC) is a potentially serious vasculopathy involving calcification of the arterial tunica media of the extremities, heart, and other viscera. There are a limited number of cases reported in the dental literature, usually associated with the facial artery. Although MMC is often discerned as an occult radiologic finding in middle-aged adults, its presence may serve as a harbinger for end-stage renal disease, diabetes, other pathologic processes, and possible regional hypoperfusion. The objective of this report is to feature an elderly patient with MMC of the facial and infraorbital arteries. In addition, a brief review of published cases of MMC and its differential diagnosis have been provided. It is recommended that affected patients be referred for a comprehensive medical assessment. Timely discovery of calcified arteries may improve patient outcomes.

Panoramic imaged carotid atheromas are associated with increased neutrophil count: both validated, independent predictors of near-term myocardial infarction

OBJECTIVES

Panoramic images (PXs) demonstrating calcified carotid artery atheromas (CCAAs) are associated with heightened risk of near-term myocardial infarction (MI). Elevated neutrophil counts (NC) within normal range 2,500-6,000 per mm³ are likewise associated with future MI signaling the role neutrophils play in the chronic inflammation process underlying coronary artery atherogenesis. We determined if CCAAs on PXs are associated with increased NC.

METHODS

Investigators implemented a retrospective study of PXs and accompanying medical records of white males ≥ 65 years treated by a VA dental service. Two groups (N = 60 each) were constituted, one with atheromas (CCAA+) and one without (CCAA-). Predictor variable was CCAA + and outcome variable was NC. Bootstrapping analysis determined the difference in mean NCs between two groups, significance set at ≤0.05.

RESULTS

The study group of (CCAA+) (mean age 75.9; range 69-91 years) demonstrated a mean NC of 4,843 per mm³ and control group (CCAA-) (mean age 75.3; range; 66-94) a mean NC of 4,108 per mm³. The difference between the groups was significant (p = 0.0008) (95% CI of difference of mean: -432, 431; observed effect size 736).

CONCLUSIONS

CCAAs on PXs of elderly white males are associated with elevated NC; amplifying need for medical consultation prior to invasive dental procedures.

Physiologic and Pathologic Calcifications of Head and Neck Significant to the Dentist

This article aims to help the practitioner identify structures found in routine three-dimensional imaging studies of the head and neck region and understand their significance and possible need for intervention. The prevalence of advanced imaging in dental practice, especially cone beam computed tomography, highlights the need to recognize and identify various high-density structures that are, in fact, soft tissue calcifications or alterations of normal bony anatomy. The wide range of these findings includes both benign and malignant pathologic entities as well as age-related calcifications and remodeling of normal anatomic structures and dystrophic calcifications.

Assessment of carotid artery calcifications on digital panoramic radiographs and their relationship with periodontal condition and cardiovascular risk factors

OBJECTIVE

The main purpose of this study is to determine the presence of carotid artery calcification (CAC) detected on digital panoramic radiographs (DPRs) retrospectively and correlate the findings with cardiovascular risk factors including gender, age, smoking status, hypertension, diabetes, and hyperlipidemia, along with atherosclerotic cardiovascular disease and periodontal status.

METHODS

This clinical study is registered at ClinicalTrials.gov as NCT04017078. DPRs, periodontal status and cardiovascular risk factors of 1,101 patients (576 males, 525 females) were evaluated. The patients were grouped based on whether CAC was detected in dental DPRs [CAC (+)] or not [CAC (-)]. Periodontal status was categorised as gingivitis, periodontitis, and gingivitis with reduced periodontium (periodontally stable patient).

RESULTS

Out of 1,101 patients, whose mean age was 42.1 ± 15.5 years and 525 (47.7%) were female, 34 (3.1%) were diagnosed with CAC on DPRs. No significant difference was observed between groups considering gender, hypertension, diabetes, hyperlipidemia, smoking, and periodontal status. Patients aged 40-55 years (n = 398, 36.15%) and patients older than 55 years (n = 222, 20.16%) were associated with CAC (odds ratio = 4.49, 95% confidence interval = 1.65-12.17, P = 0.003; odds ratio = 4.41, 95% confidence interval = 1.33-14.61, P = 0.015, respectively).

CONCLUSION

Among all parameters, only age exhibited significant correlation with an increased risk of carotid calcification. Further studies with prospective designs and larger study populations are needed.

A 5 years follow-up for ischemic cardiac outcomes in patients with carotid artery calcification on panoramic radiographs confirmed by doppler ultrasonography in Turkish population

OBJECTIVE

To evaluate the diagnostic accuracy of digital panoramic radiograph (DPR) for detection of carotid artery calcification (CAC) confirmed by Doppler Ultrasonography (DUSG) and to clarify the relationship between between CAC identified by DPR and cardiovascular events through a 5 year follow-up period.

METHODS

Of 3600 consecutive patients examined, 158 patients presented with CAC as detected by DPR. The final study group was composed of 96 patients who had CAC confirmed by DUSG or CT angiogram. The control group was composed of 62 patients who has normal DUSG. The end point of the study was the occurrence of any cardiovascular event.

RESULTS

72 (75%) of the 96 patients with CAC confirmed by DUSG (16 patients had significant stenosis) had bilateral and 24 (25%) had unilateral CAS as detected by DUSG. There was a low agreement between the examination results with a κ value of 0.488 (p < 0.005) for calcification. Study data revealed that smoking, chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM) and diastolic hypertension were significantly more common in patients with CAC than the control group (p < 0.05). During the follow-up period, 13 subjects had myocardial infarction and 1 subject died; in the control group, 1 patient died after MI and 1 patient died of a non-cardiac event.

CONCLUSION

Patients with CAC detectable by DPR concomitant with COPD, DM, smoking or diastolic hypertension are more likely to suffer from vascular events. Therefore, patients with detectable carotid plaque in DPR require referral to a cardiovascular surgery clinic for further investigations.

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.

Assessment of carotid calcifications on digital panoramic radiographs: Retrospective analysis and review of the literature

OBJECTIVES

To assess the validity of digital panoramic radiographs as an effective means of diagnosis for atherosclerosis and as a potential aid in the early detection of the disease.

STUDY DESIGN

We reviewed 2014 digital panoramic radiographs taken throughout 2012 and 2013 to identify the presence of calcified atherosclerotic plaques of both female and male patients all aged over 18 years. In addition the medical records of these patients were reviewed in order to establish if there were any predisposing risk factors for atherosclerosis. Statistical analysis was performed to identify any possible link between radiographic atherosclerotic plaques and predisposing risk factors for atherosclerosis using univariate and multivariate models. Statistical significance criteria was defined as P<0.05.

RESULTS

Out of 2014 patients (1149 female and 865 male), 191 (9.5%) were determined to have calcified atherosclerotic plaques on panoramic radiography. There was a statistically significant relationship between the presence of calcified atherosclerotic plaques and the established risk factors of atherosclerosis such as gender (OR=2.39, P<0.001), age (OR=1.5, P<0.001), stroke (OR=5.38, P<0.001) and hypertension (OR=2.11, P<0.001).

CONCLUSION

To our knowledge this is the largest study investigating atherosclerotic plaques on digital panoramic radiographs ever carried out in Portugal. Dental practitioners need to be aware of these incidental findings and to consider referring these patients for further investigations to confirm diagnosis.