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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 33  |  Issue : 3  |  Page : 271-275

Diagnostic reporting of calcified carotid atheroma in digital panoramic radiograph – A retrospective study


Department of Oral Medicine and Radiology, Tamil Nadu Government Dental College and Hospital, Chennai, Tamil Nadu, India

Date of Submission19-Oct-2020
Date of Decision23-Mar-2021
Date of Acceptance01-May-2021
Date of Web Publication28-Sep-2021

Correspondence Address:
Dr. Iswarya Kathiresan
Post Graduate Student, Department of Oral Medicine and Radiology, Tamilnadu Government Dental College and Hospital, Chennai - 600 003, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_215_20

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   Abstract 


Context: Cerebrovascular disease remains one of the leading causes of death in many countries. Aim: To evaluate the presence of calcified carotid atheroma in digital panoramic radiographs, thereby referring the patients to cardiology for early management and prevention of stroke. Settings and Design: Hospital- based, cross- sectional retrospective study. Materials and Methods: The study design included 1000 digital panoramic radiographs taken for the needful patients in the Department of Oral Medicine and Radiology for a period of one year from November 2018 to October 2019. Two examiners (experienced maxillofacial radiologists) evaluated the presence of calcified carotid atheroma in panoramic radiographs. Results: Out of 1000 digital panoramic radiographs, 39 panoramic radiographs were found to have the presence of calcified carotid atheroma, of which 9 were male and 30 were female panoramic radiographs. The prevalence was found to be higher in the age group between 45 to 54 years. Conclusion: Panoramic radiographs help to assess the presence of calcified carotid atheromas. Careful evaluation of panoramic radiographs by maxillofacial radiologists for carotid atheromas could be life-saving in the prevention of stroke.

Keywords: Cardiology, carotid atheroma, panoramic radiographs, radiology, stroke


How to cite this article:
Sadaksharam J, Kathiresan I. Diagnostic reporting of calcified carotid atheroma in digital panoramic radiograph – A retrospective study. J Indian Acad Oral Med Radiol 2021;33:271-5

How to cite this URL:
Sadaksharam J, Kathiresan I. Diagnostic reporting of calcified carotid atheroma in digital panoramic radiograph – A retrospective study. J Indian Acad Oral Med Radiol [serial online] 2021 [cited 2021 Nov 29];33:271-5. Available from: https://www.jiaomr.in/text.asp?2021/33/3/271/326896




   Introduction Top


Cerebrovascular accident (stroke) is defined as a sudden loss of brain function due to ischemia or hemorrhaging in the central nervous system.[1] The major risk factors for stroke include hypertension, diabetes, and other risk factors include age, smoking history, total cholesterol level, stress, sedentary lifestyle, obesity.[2],[3]

Detached embolus from the atheroma is the major cause of the stroke. Calcification usually occurs in more mature and deeper parts of the atheromatous plaque.[4]

The atheroma plaques may accumulate in the carotid artery which subsequently produces narrowing of the artery and further, it may lead to a decrease in the cerebral blood flow. When these carotid artery atheromas become calcified, they can be seen on a panoramic radiograph.


   Materials and Method Top


The cross-sectional retrospective study was conducted in the Department of Oral Medicine and Radiology. After obtaining approval from the Institutional Ethical Review Board (IRB Reference No: 4/IERB/2020 dated 5.1.2020) digital panoramic radiographs were taken for a period of one year from November 2018 to October 2019. The principles of Helsinki declaration have been followed in the study (Given in the year 1964 and recent modification in 2013). Properly taken digital panoramic radiographs with proper visualization of radiographic structures and age group between 45 to 80 years were included in the study. Panoramic radiographs that had distortion particularly in the region of the cervical spine or those radiographs without cervical spines were excluded from the study. The variables age, gender and location of the carotid atheroma were considered for statistical analysis. Statistical analysis is done using SPSS software version 20.0. Chi square test was performed and the values were evaluated.

Inclusion criteria

Panoramic radiograph with proper visualization of structures, both male and female panoramic radiographs of patients aged between 45 – 80 years from the archives of the radiology department from November 2018 to October 2019.

Exclusion criteria

Panoramic radiographs of patients aged below 45 years, faulty radiographs without proper visualization of structures.

All digital panoramic radiographs were taken in ORTHOPHOS XG, SIRONA with exposure factors of 14.1 s, 64 kVp, and 8 mA. A total of 6527 digital panoramic radiographs were taken from November 2018 to October 2019. 1486 panoramic radiographs fall into the inclusion criteria of which 486 panoramic radiographs were excluded due to distortion of the radiographic image [Figure 1].
Figure 1: Selection criteria for panoramic radiographs

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Sample size estimation

A sample size of 457 was required to achieve power (1 - β) of 80% with α error of 0.5%. Since our hospital is a tertiary care center, we doubled the sample size, and hence, we included 1000 digital panoramic radiographs which were available in our radiology department for our study. All the panoramic radiographs were examined and evaluated for the presence of calcified carotid atheroma by two experienced maxillofacial radiologists.

Identification of carotid atheromas on radiographs

Radiopacities of nodular masses or vertical co- linear lines that are located approximately at a distance of 2.5 cm posterior to the angle of the mandible and adjacent to the third and fourth cervical vertebrae were interpreted as calcified carotid atheroma.[5]


   Results Top


Digital panoramic radiographs were evaluated by two experienced maxillofacial radiologists for the presence of calcified carotid atheroma [Figure 2] either unilaterally or bilaterally depending upon their presence after ruling out the other calcification in carotid artery areas such as thyroid cartilage, triticeous cartilage, calcified lymph nodes, salivary gland calculus, etc., Of 1000 panoramic radiographs which were included in the study, 531 panoramic radiographs were of males and 469 panoramic radiographs were of females. A total of 39 digital panoramic radiographs showed the presence of calcified carotid atheroma [Figure 3].
Figure 2: Represents a digital panoramic image showing the presence of unilateral carotid atheroma on right side (marked by arrow)

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Figure 3: Representing cropped image of panoramic radiograph showing the presence of calcified carotid atheroma near C4 and C5 vertebrae (marked by arrow on right side, note the curvilinear appearance of atheroma)

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The mean age of higher prevalence of calcified carotid atheroma was found to be 45-54 years which accounts for about 1.9% [Figure 4]. Significantly it was interesting to see the higher prevalence in females (30 panoramic radiographs) than males (9 panoramic radiographs) [Figure 5]. When comparing the presence of carotid atheroma either unilaterally or bilaterally, unilateral (28 panoramic radiographs) presence of carotid atheroma was more prevalent than bilateral carotid atheromas (11 panoramic radiographs) [Figure 6].
Figure 4: Representing the distribution of calcified carotid atheroma among different age groups Total number of calcified carotid atheroma – 39

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Figure 5: Representing the prevalance of carotid atheroma among males and females

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Figure 6: Representing unilateral and bilateral prevalance of calcified carotid atheroma

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The variables: age, gender, and location of carotid atheroma were considered for statistical analysis. The Chi-square test was performed and the values were evaluated. The p- value was <0.001 for all three variables which were highly statistically significant [Table 1].
Table 1: Statistical analysis using chi-square test

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   Discussion Top


Friedlander and Lande were the first people to report the radiographic identification of calcified carotid atheroma by panoramic radiographs which has increased the attention of calcifications in maxillofacial radiographs.[6] Till then many studies have been done to associate the presence of calcified carotid atheroma and the occurrence of stroke.[7]

Coronary calcifications are similar to carotid calcifications and the carotid calcifications can be seen in radiographic views such as posteroanterior view of skull, panoramic radiographs, lateral cephalogram, c- spine neck view.[4],[7]

Multiple correlations of the presence of calcified carotid atheroma with systemic conditions like dilated cardiomyopathy, type 2 diabetes, obstructive sleep apnea, renal disease have been reported in various studies.[7],[8]

In a study conducted by Neha et al.,[9] the prevalence of calcified carotid atheroma was found to be higher in diabetes mellitus patients than non-diabetic patients.

Prevalence of calcified carotid atheroma in patients undergoing radiotherapy to neck and in post-menopausal women have also been studied by Markman et al.,[10] and Friedlander et al.,[11] respectively.

In a study conducted by Nona et al.,[12] the prevalence of calcified carotid artery atheromas on digital panoramic images among perimenopausal and postmenopausal African American women was studied. The study included 171 African American women and it evidenced a 24% of prevalence of calcified carotid atheroma. And also, among those who were calcified carotid atheroma positive, there was a significantly increased prevalence of dyslipidemia with age.

Studies that have been done in past regarding the age and prevalence of carotid atheroma show that age 55 and above are at the highest risk.[13] It is contradictory to our study in which the results have shown that the prevalence is common in the age group of 45 to 54 years.

It is evident from our study that the prevalence of calcified carotid atheroma is more common in women than in men which are following the studies conducted by Ohba et al.,[14] and Imanimoghaddam et al.[15] These studies have also shown the increased prevalence of calcified carotid atheroma among women.

Tamura et al.,[16] in their study had found that systemic conditions like hypertension, hyperlipidemia, and cardiovascular disease are common in patients with calcified carotid atheroma.

Care should be taken in the proper evaluation of calcified carotid atheroma which should not be confused with the triticeous cartilage which is the radiopacity seen in the carotid region. Ahmad et al.,[17] reported that most triticeous cartilages are round whereas most calcified carotid atheromas appear as curvilinear radiopacities.

Alternatively, modified posteroanterior radiographs of the neck made using soft tissue exposure can help differentiate calcified carotid atheroma from other calcifications. On the posteroanterior view radiographs, calcified carotid calcifications appear lateral to the spine and other calcifications like triticeous cartilage, calcifications in the thyroid gland, epiglottis will be in the center which will be superimposed over the spine.[4]

Panoramic radiographs have an accuracy of about 80-82% for identifying the presence of calcified carotid atheromas when compared to colour doppler ultrasonography.[18] Calcification can be observed on ultrasound imaging by a hyperechogenic interface and a posterior acoustic shadowing.[4]

Asymptomatic patients with the incidental finding of calcified carotid atheroma on panoramic radiographs should be appropriately referred to the cardiology department along with the images of panoramic radiographs indicating the presence of atheroma without delay. Thereafter patients should also be subjected to ultrasound imaging of neck or colour doppler imaging to confirm the presence of calcified carotid atheroma

Risk factors such as diabetes, hypertension, serum cholesterol level should be correlated and monitored at regular intervals and the levels are to be maintained within normal limits to prevent the progression of carotid atheroma to stroke. The treatment of calcified carotid atheroma varies depending upon the percentage of stenosis of the carotid artery due to atheroma.

Simple measures taken during the routine dental procedures such as measurement of arterial blood pressure and analysis of blood or urine sugar level before extraction of the tooth helps in the identification of new cases of hypertension and diabetes and thereby treating it in an earlier stage.

In the same way, panoramic radiographs which are taken in day-to-day dental practice for needful dental procedures should be carefully evaluated by the maxillofacial radiologists for the presence of calcified carotid atheroma which could be lifesaving in the prevention of stroke. Steps should also be taken to spread the knowledge about calcified carotid atheroma in panoramic radiographs among general dental surgeons.

Limitations and Future prospects

The limitations of our study are since it is a purely retrospective study, ultrasound imaging of the neck was not done.

A prospective study should be done in the future including patients with comorbidities such as hypertension, diabetes mellitus, hyperlipidemia, etc., Along with colour doppler ultrasound imaging and proper follow- up of the patients for a longer period. The identification of calcified carotid atheroma in these patients will be useful in the prevention of cerebrovascular diseases.


   Conclusion Top


Atherosclerosis is not only a disease of old age, nowadays it has become a disease of young adults mostly around the second and third decade of life. In our present study, out of 1000 digital panoramic radiographs, 39 panoramic radiographs were found to have the presence of calcified carotid atheroma which accounts for about 3.9%. Once the presence of calcified carotid atheroma is evaluated in the panoramic radiographs by maxillofacial radiologists, the patient should be informed about it and the possible outcomes of atheroma mainly the stroke. The patient should also be informed that although the identification of calcified carotid atheroma on panoramic radiography provides reasonable accuracy of up to 80%, the false positive rate could be also there up to 20%.[4]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Gandluru VR, Kiran AR, Samatha Y. Identification of carotid artery calcifications on digital panoramic radiograph in a group of South Indian population: A retrospective study. J Dent Oral Sci 2020;2:1-16.  Back to cited text no. 3
    
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Mupparapu M, Kim IH. Calcified carotid artery atheroma and stroke: A systematic review. J Am DentAssoc 2007;138:483-92.  Back to cited text no. 7
    
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Friedlander AH, Friedlander IK, Yueh R, Littner MR. The prevalence of carotid catheromas seen on panoramic radiographs of patients with obstructive sleep apnea and their relation to risk factors for atherosclerosis. J Oral Maxillofac Surg 1999;57:516-21; discussion 521-2.  Back to cited text no. 8
    
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Khambete N, Kumar R. Calcified carotid atherosclerotic plaques on digital panoramic radiographs in patients with Type II diabetes mellitus: A case control study. J Indian Acad Oral Med Radiol 2015;27:42-7.  Back to cited text no. 9
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Markman RL, Conceição-Vasconcelos KG, Brandão TB, Prado-Ribeiro AC, Santos-Silva AR, Lopes MA. Calcified carotid artery atheromas on panoramic radiographs of head and neck cancer patients before and after radiotherapy. Med Oral Patol Oral Cirugia Bucal 2017;22:e153-8.  Back to cited text no. 10
    
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Friedlander AH, Altman L. Carotid artery atheromas in postmenopausal women. Their prevalence on panoramic radiographs and their relationship to atherogenic risk factors. J Am Dent Assoc2001;132:1130-6.  Back to cited text no. 11
    
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Aghazadehsanai N, Chang TI, Garrett NR, Friedlander AH. Prevalence of calcified carotid artery atheromas on digital panoramic images among perimenopausal and postmenopausal African American women. Oral Surg Oral Med Oral Pathol Oral Radiol 2017;123:621-5.  Back to cited text no. 12
    
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Guimarães Henriques JC, Kreich EM, Helena Baldani M, Luciano M, Cezar de Melo Castilho J, Cesar de Moraes L. Panoramic r in the diagnosis of carotid artery atheromas and the associated risk factors. Open Dent J 2011;5:79-83.  Back to cited text no. 13
    
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Imanimoghaddam M, Rah Rooh M, Mahmoudi Hashemi E, Javadzade Blouri A. Doppler sonography confirmation in patients showing calcified carotid artery atheroma in panoramic radiography and evaluation of related risk factors. J Dent Res Dent Clin Dent Prospects 2012;6:6-11.  Back to cited text no. 15
    
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Ahmad M, Madden R, Perez L. Triticeous cartilage: Prevalence on panoramic radiographs and diagnostic criteria. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;99:225-30.  Back to cited text no. 17
    
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Gustafsson N, Ahlqvist JB, Näslund U, Wester P, Buhlin K, Gustafsson A, et al. Calcified carotid artery atheromas in panoramic radiographs are associated with a first myocardial infarction: A case-control study. Oral Surg Oral Med Oral Pathol Oral Radiol 2018;125:199-204.e1.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1]



 

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