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Zaghden O, Jaziri R, Kammoun R, Chaabani I, Alaya TB. Benefit of Panoramic Radiography in the Detection of Carotid Calcifications: Clinical Case Reports and Review of the Literature. Case Rep Dent 2023; 2023:3989502. [PMID: 37305808 PMCID: PMC10257549 DOI: 10.1155/2023/3989502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/04/2023] [Accepted: 05/06/2023] [Indexed: 06/13/2023] Open
Abstract
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.
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Affiliation(s)
- Olfa Zaghden
- Department of Radiology, University Dental Clinic, University of Monastir, Monastir, Tunisia
| | - Rawia Jaziri
- Department of Radiology, University Dental Clinic, University of Monastir, Monastir, Tunisia
| | - Rym Kammoun
- Department of Radiology, University Dental Clinic, University of Monastir, Monastir, Tunisia
- Laboratory of Histology and Embryology, Faculty of Dental Medicine of Monastir, University of Monastir, Monastir, Tunisia
- ABCDF Laboratory for Biological Clinical and Dento-Facial Approach, University of Monastir, Monastir, Tunisia
| | - Imen Chaabani
- Department of Radiology, University Dental Clinic, University of Monastir, Monastir, Tunisia
- Unity of Bioactive Natural Substances and Biotechnology, Faculty of Dental Medicine, University of Monastir, Monastir, Tunisia
| | - Touhami Ben Alaya
- Department of Radiology, University Dental Clinic, University of Monastir, Monastir, Tunisia
- Unity of Bioactive Natural Substances and Biotechnology, Faculty of Dental Medicine, University of Monastir, Monastir, Tunisia
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Janiszewska-Olszowska J, Jakubowska A, Gieruszczak E, Jakubowski K, Wawrzyniak P, Grocholewicz K. Carotid Artery Calcifications on Panoramic Radiographs. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:14056. [PMID: 36360932 PMCID: PMC9654866 DOI: 10.3390/ijerph192114056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 10/23/2022] [Accepted: 10/26/2022] [Indexed: 06/16/2023]
Abstract
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.
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Affiliation(s)
| | | | | | | | | | - Katarzyna Grocholewicz
- Department of Interdisciplinary Dentistry, Pomeranian Medical University in Szczecin, 70-111 Szczecin, Poland
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Cetin MB, Sezgin Y, Yılmaz MNN, Seçgin CK. Letter to the Editor: Authors' Response. Int Dent J 2022; 72:258-259. [PMID: 35131087 PMCID: PMC9275351 DOI: 10.1016/j.identj.2021.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Mehtap Bilgin Cetin
- Baskent University, Department of Periodontology, Faculty of Dentistry, Ankara, Turkey.
| | - Yasemin Sezgin
- Baskent University, Department of Periodontology, Faculty of Dentistry, Ankara, Turkey
| | | | - Cansu Köseoǧlu Seçgin
- Baskent University, Department Of Oral And Maxillofacial Radiology, Faculty of Dentistry, Ankara, Turkey
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Yeşilova E, Bayrakdar İŞ. Radiological evaluation of maxillofacial soft tissue calcifications with cone beam computed tomography and panoramic radiography. Int J Clin Pract 2021; 75:e14086. [PMID: 33576139 DOI: 10.1111/ijcp.14086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 02/09/2021] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE We aimed to present the radiologic characteristics of maxillofacial soft tissue calcifications with a comparison of cone beam computed tomography (CBCT) and panoramic radiography (PR) findings. MATERIALS AND METHODS The study was based on CBCT images obtained for different purposes between October 2017 and September 2018. The absence, location and radiological characteristics of some calcifications were evaluated in 252 patients. Statistical analysis was performed with SPSS version 21.0; P < .05 was considered to indicate statistical significance. RESULTS Palatine tonsilloliths were the most common calcifications in our study. Calcifications were most frequent in the sixth decade of life. Women had larger calcifications than men. There was a relationship between the sizes measured by CBCT and PR for tonsilloliths. In PR, Region 2 had significantly more calcifications compared with the other regions. The C2 vertebral level was the most common region for tonsilloliths based on CBCT. CONCLUSIONS Tonsilloliths have a high prevalence. The regular peripheral type had a higher risk of being a tonsillolith in PR. The peripheral/internal characteristics and the dimensions of calcifications between the two imaging modalities were in harmony. The location of calcification in PR and CBCT was important to distinguish the type of calcification.
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Affiliation(s)
- Esra Yeşilova
- Oral and Maxillofacial Radiology Department, Faculty of Dentistry, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - İbrahim Şevki Bayrakdar
- Oral and Maxillofacial Radiology Department, Faculty of Dentistry, Eskişehir Osmangazi University, Eskişehir, Turkey
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5
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Can carotid artery calcifications on dental radiographs predict adverse vascular events? A systematic review. Clin Oral Investig 2020; 25:37-53. [PMID: 33245449 DOI: 10.1007/s00784-020-03696-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 11/10/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To investigate the predictive value of carotid artery calcifications (CACs) seen on dental imaging for future adverse events related to cerebrovascular and cardiovascular diseases. METHODS Electronic databases (PubMed, Embase, SCOPUS and Cochrane) and selected grey literature were searched. Outcomes included stroke, transient ischaemic attack (TIA), myocardial infarction (MI), angina, heart failure, future interventional revascularization procedures and death. Risk of bias was assessed using the Newcastle-Ottawa Scale. RESULTS 5 studies were selected from 1011 records. All were of moderate to low risk of bias. Results were heterogeneous but showed that patients with CACs on panoramic radiographs (PANs) were more likely to experience strokes, TIA, MI and future revascularization procedures compared to control groups. The differences between groups were not all found to be statistically significant. Bilateral vessel-outlining CACs were an independent risk marker for future vascular events. Patients who are not currently being managed for cardiovascular risk factors should be referred for further evaluation. Those already being treated for atherosclerosis may not benefit from additional investigations. CONCLUSION The evidence for the predictive value of CACs on PANs for adverse future vascular events is equivocal but can help to identify at-risk patients who require further evaluation. CLINICAL RELEVANCE Dentists must be able to recognize CACs on PANs and make appropriate referrals for patients to be evaluated for cardiovascular risk factors, especially those who have not previously been assessed.
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Çetin MB, Sezgin Y, Yilmaz MNN, Seçgin CK. Assessment of carotid artery calcifications on digital panoramic radiographs and their relationship with periodontal condition and cardiovascular risk factors. Int Dent J 2020; 71:160-166. [PMID: 32996164 PMCID: PMC9275109 DOI: 10.1111/idj.12618] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
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.
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Affiliation(s)
- Mehtap Bilgin Çetin
- Department of Periodontology, Faculty of Dentistry, Baskent University, Ankara, Turkey
| | - Yasemin Sezgin
- Department of Periodontology, Faculty of Dentistry, Baskent University, Ankara, Turkey
| | | | - Cansu Köseoğlu Seçgin
- Department of Dentomaxillofacial Radiology, Faculty of Dentistry, Baskent University, Ankara, Turkey
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7
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Paju S, Pietiäinen M, Liljestrand JM, Lahdentausta L, Salminen A, Kopra E, Mäntylä P, Buhlin K, Hörkkö S, Sinisalo J, Pussinen PJ. Carotid artery calcification in panoramic radiographs associates with oral infections and mortality. Int Endod J 2020; 54:15-25. [PMID: 32865251 DOI: 10.1111/iej.13394] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 08/24/2020] [Indexed: 12/23/2022]
Abstract
AIM To study the prevalence of carotid artery calcification (CAC) in relation to apical and marginal periodontitis, subgingival dysbiotic bacterial species and serum and saliva immune responses against them. In addition, the aim was to analyse the association of CAC with angiographically verified coronary artery disease (CAD) and mortality. METHODOLOGY In the present random Parogene cohort, the patients had an indication for coronary angiography. Apical and marginal periodontitis were diagnosed during clinical and radiographic oral examinations, and CAC on panoramic radiographs (n = 492). Presence and severity of CAD were registered from angiography. Subgingival dysbiotic bacterial species were quantitated using checkerboard DNA-DNA-hybridization, and serum and saliva antibody levels were determined by immunoassays. The cohort was followed-up for 10 years or until death (median 9.9, range 0.21-10.4) via linkage to the national death register. The statistical models were adjusted for age, gender, smoking, hypertension, diabetes and dyslipidemia. RESULTS A total of 102 (20.7%) patients had detectable CAC, which was moderate in 81 (16.4%) and severe in 21 (4.3%). CAC was associated (OR, 95% CI) with severe apical periodontitis (2.25, 1.15-4.41), root canal fillings (1.15, 1.04-1.26), alveolar bone loss (2.66, 1.21-5.84), severe periodontal inflammation (2.23, 1.11-4.47), high level of gram-negative subgingival species (2.73, 1.34-5.50), saliva IgG against dysbiotic species (1.05, 1.01-1.10/unit) and severe (2.58, 1.36-4.90) and chronic (2.13, 1.15-3.93) CAD. A total of 105 (20.7%) patients died during the follow-up and 53 (10.4%) deaths were because of cardiovascular diseases (CVD). Severe CAC predicted worse survival with HRs (95% CI) of 3.08 (1.58-6.06) for all-cause and 3.43 (1.42-8.25) for CVD death. CONCLUSIONS CAC on panoramic tomography was associated with (i) apical and marginal periodontitis and dysbiotic bacterial species giving rise to an immunological response, and with (ii) severe, chronic CAD and increased mortality. The results further emphasize the role of oral infections in CAD and the importance of referring a patient with CAC for a cardiovascular evaluation.
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Affiliation(s)
- S Paju
- Department of Oral and Maxillofacial Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - M Pietiäinen
- Department of Oral and Maxillofacial Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - J M Liljestrand
- Department of Oral and Maxillofacial Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - L Lahdentausta
- Department of Oral and Maxillofacial Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - A Salminen
- Department of Oral and Maxillofacial Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - E Kopra
- Department of Oral and Maxillofacial Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - P Mäntylä
- Oral and Maxillofacial Diseases, Institute of Dentistry, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland
| | - K Buhlin
- Department of Oral and Maxillofacial Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Division of Periodontology, Division of Oral Diseases, Department of Dental Medicine, Karolinska Institutet, Huddinge, Sweden
| | - S Hörkkö
- Research Unit of Biomedicine, Medical Microbiology and Immunology, Faculty of Medicine, University of Oulu, Oulu, Finland.,Medical Research Center and Nordlab Oulu, University Hospital and University of Oulu, Oulu, Finland
| | - J Sinisalo
- Heart and Lung Center, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - P J Pussinen
- Department of Oral and Maxillofacial Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Gustafsson N, Ahlqvist J, Näslund U, Buhlin K, Gustafsson A, Kjellström B, Klinge B, Rydén L, Levring Jäghagen E. Associations among Periodontitis, Calcified Carotid Artery Atheromas, and Risk of Myocardial Infarction. J Dent Res 2019; 99:60-68. [DOI: 10.1177/0022034519885362] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
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.
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Affiliation(s)
- N. Gustafsson
- Oral and Maxillofacial Radiology, Department of Odontology, Umeå University, Umeå, Sweden
| | - J. Ahlqvist
- Oral and Maxillofacial Radiology, Department of Odontology, Umeå University, Umeå, Sweden
| | - U. Näslund
- Heart Centre, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - K. Buhlin
- Periodontology, Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - A. Gustafsson
- Periodontology, Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - B. Kjellström
- Cardiology Unit, Department of Medicine K2, Karolinska Institutet, Stockholm, Sweden
| | - B. Klinge
- Periodontology, Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Periodontology, Faculty of Odontology, Malmö University, Malmö, Sweden
| | - L. Rydén
- Cardiology Unit, Department of Medicine K2, Karolinska Institutet, Stockholm, Sweden
| | - E. Levring Jäghagen
- Oral and Maxillofacial Radiology, Department of Odontology, Umeå University, Umeå, Sweden
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9
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Constantine S, Roach D, Liberali S, Kiermeier A, Sarkar P, Jannes J, Sambrook P, Anderson P, Beltrame J. Carotid Artery Calcification on Orthopantomograms (CACO Study) - is it indicative of carotid stenosis? Aust Dent J 2018; 64:4-10. [DOI: 10.1111/adj.12651] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2018] [Indexed: 12/14/2022]
Affiliation(s)
- S Constantine
- South Australian Dental Service; The Queen Elizabeth Hospital; Women's and Children's Hospital; Adelaide South Australia Australia
- The University of Adelaide; Adelaide South Australia Australia
| | - D Roach
- The University of Adelaide; Adelaide South Australia Australia
- The Queen Elizabeth Hospital; Adelaide South Australia Australia
| | - S Liberali
- Special Needs Unit; Adelaide Dental Hospital; SA Dental Service; Adelaide South Australia Australia
| | - A Kiermeier
- Statistical Process Improvement Consulting and Training Pty Ltd; Gumeracha South Australia Australia
| | - P Sarkar
- The Queen Elizabeth Hospital; Adelaide South Australia Australia
| | - J Jannes
- Central Adelaide Local Health Network; Adelaide South Australia Australia
- University of Adelaide; Adelaide South Australia Australia
| | - P Sambrook
- SA Dental Service; Head of Unit OMS; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - P Anderson
- Australian Craniofacial Unit; Women's and Children's Hospital; Adelaide South Australia Australia
| | - J Beltrame
- Michell Professor of Medicine; The Queen Elizabeth Hospital; University of Adelaide; Cardiology Academic Lead; Central Adelaide Local Health Network; Adelaide South Australia Australia
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Thanakun S, Pornprasertsuk-Damrongsri S, Izumi Y. C-reactive protein levels and the association of carotid artery calcification with tooth loss. Oral Dis 2016; 23:69-77. [DOI: 10.1111/odi.12575] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 08/20/2016] [Accepted: 08/22/2016] [Indexed: 12/13/2022]
Affiliation(s)
- S Thanakun
- Department of Oral Medicine and Periodontology; Faculty of Dentistry; Mahidol University; Bangkok Thailand
| | | | - Y Izumi
- Department of Periodontology; Graduate School of Medical and Dental Sciences; Tokyo Medical and Dental University; Tokyo Japan
- Global Center of Excellence Program for Tooth and Bone Research; Tokyo Medical and Dental University; Tokyo Japan
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11
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Bengtsson VW, Persson GR, Berglund J, Renvert S. A cross-sectional study of the associations between periodontitis and carotid arterial calcifications in an elderly population. Acta Odontol Scand 2015; 74:115-20. [PMID: 26066062 DOI: 10.3109/00016357.2015.1050603] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To evaluate if the presence of periodontitis is associated with carotid arterial calcifications diagnosed on panoramic radiographs in an elderly population. MATERIALS AND METHODS Study individuals were randomly selected from the Swedish civil registration database representing the aging population (60-96 years) in Karlskrona, Sweden. Bleeding on probing (BOP) and the deepest probing measurement at each tooth were registered. The proportions of teeth with a probing depth ≥ 5 mm and the proportion of teeth with bleeding on probing were calculated. Analog panoramic radiographs were taken and the proportion of sites with a distance ≥ 5 mm between the alveolar bone level and the cement-enamel junction (CEJ) were assessed. A diagnosis of periodontitis was declared if a distance between the alveolar bone level and the CEJ ≥ 5 mm could be identified from the panoramic radiographs at > 10% of sites, probing depth of ≥ 5 mm at one tooth or more and with BOP at > 20% of teeth. RESULTS Readable radiographs were obtained from 499 individuals. Carotid calcification was identified in 39.1%. Individuals were diagnosed with periodontitis in 18.4%. Data analysis demonstrated that individuals with periodontitis had a higher prevalence of carotid calcifications (Pearson χ(2) = 4.05 p < 0.05) and with a likelihood of 1.5 (95% CI = 1.0, 2.3, p < 0.05). CONCLUSIONS Data analysis demonstrated a significant association between periodontitis and carotid calcification.
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Affiliation(s)
| | - G Rutger Persson
- a 1 University of Kristianstad , Kristianstad, Sweden
- b 2 Department of Periodontics, University of Washington , Seattle, WA, USA
- c 3 Department of Oral Medicine, University of Washington , Seattle, WA, USA
| | | | - Stefan Renvert
- a 1 University of Kristianstad , Kristianstad, Sweden
- d 4 Institute of Technology , Karlskrona, Sweden
- e 5 Dublin Dental Hospital Trinity College , Dublin, Ireland
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