|Year : 2022 | Volume
| Issue : 2 | Page : 193-197
Incidental findings of soft tissue radiopacities on digital panoramic radiographs: A cross-sectional study
M Preethy1, Somasundaram Elangovan2, Suman Jhansi Lakshmi2, Senthil Kumar2
1 Department of Oral Medicine and Radiology, Adhiparasakthi Dental College and Hospital, Melmaruvathur, Tamil Nadu, India
2 Department of Oral Medicine and Radiology, KSR Institite of Dental Science and Research (KSR IDSR), Tiruchengode, Tamil Nadu, India
|Date of Submission||08-Feb-2022|
|Date of Decision||04-May-2022|
|Date of Acceptance||07-Jun-2022|
|Date of Web Publication||22-Jun-2022|
10/58, 3rd East Cross Street, Amaravathy Nagar, Arumbakkam, Chennai - 600106, Tamil Nadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: Panoramic radiographs have the unique ability to cover maxilla, mandible, and associated structures in a single image. Hence, the soft tissue calcifications within the region covered can be identified. Aim: To assess the prevalence of incidental findings of soft tissue radiopacities on digital panoramic radiographs. Materials and Method: 2036 digital panoramic radiographs were included in the study. For convenience, each radiograph was divided into 12 segments by 3 vertical lines, and 2 horizontal lines. Calcifications were analyzed based on the anatomical location, number, shape, size, and internal structure. Results: The overall prevalence of soft tissue calcifications was 5.1%. Six types of soft tissue calcifications were identified, which included stylohyoid ligament calcification (53.3%), carotid artery calcification (24.8%), lymph node calcification (5.7%), tonsillolith (3.8%), sialolith (3.8%) and thyroid and triticious cartilage calcification (8.6%). Conclusion: There is no sufficient data in the literature, and hence more studies are needed with a wider sample size to correlate with the available data.
Keywords: Incidental findings, panoramic radiographs, prevalence, soft tissue radiopacities
Key Message: OPGs taken for routine dental care can be used as a key tool by the dentists for timely diagnosis of soft tissue calcifications to reduce potential complications and save lives
|How to cite this article:|
Preethy M, Elangovan S, Lakshmi SJ, Kumar S. Incidental findings of soft tissue radiopacities on digital panoramic radiographs: A cross-sectional study. J Indian Acad Oral Med Radiol 2022;34:193-7
|How to cite this URL:|
Preethy M, Elangovan S, Lakshmi SJ, Kumar S. Incidental findings of soft tissue radiopacities on digital panoramic radiographs: A cross-sectional study. J Indian Acad Oral Med Radiol [serial online] 2022 [cited 2022 Dec 7];34:193-7. Available from: http://www.jiaomr.in/text.asp?2022/34/2/193/347928
| Introduction|| |
In day-to-day practice, the clinicians sometimes fail to observe findings other than those about the patient's chief complaint. If noted at the right time, these unrecognized findings might help the patient tremendously. Since panoramic radiographs can cover maxilla, mandible, and associated structures in a single image, the soft tissue calcifications within the region covered can be identified in them.
A soft tissue radiopacity can be a calcification, ossification, or a foreign body. The deposition of calcium salts in an unorganized fashion in soft tissues is termed heterotopic calcification, classified as dystrophic, metastatic, and idiopathic. The anatomical location, size, shape, distribution, and several calcifications are important for radiographic diagnosis. The accurate diagnosis is of utmost importance as some of these may have serious underlying systemic conditions. Hence, recognizing these entities is important for appropriate referrals and further investigations.
| Subjects and Methods|| |
A descriptive cross-sectional study was conducted using 2036 digital panoramic radiographs collected through the complete enumeration sampling method, taken for patients who visited our department at KSR Institute of Dental Science for different purposes between September 2018 and December 2019. The institutional ethical committee approved the study on 14/12/2018, and the reference ID is 224/KSRIDSR/EC/2018. The radiographs were taken using SIRONA XG3 panoramic machine with specifications of 64 Kvp, 8 mA, and 14.1 seconds. The radiographs taken for patients of both gender and of all age groups were included. The radiographs with preparation and positioning errors and ones with unclear data or inconclusive diagnosis were excluded. Each radiograph was divided into 12 segments by three vertical and 2 horizontal lines for convenience [Figure 1]. [Table 1] shows the criteria used in our study to identify and diagnose soft tissue calcifications.
|Table 1: Showing The Criteria Used in This Study for Identification and Diagnosis of Soft Tissue Calcifications|
Click here to view
Sample size calculation and power of study
A pilot study using 500 digital panoramic radiographs was conducted. Based on the preliminary results, with an estimated P value of < 0.05, 95% confidence interval (CI), and a power of 80%, the present sample size of 2036 was derived. The formulae that are used for calculating the sample is as follows:
| Results|| |
Out of the total 2036 radiographs examined, 1039 were taken for females and 997 for males. The data analysis was done using Statistical Package for Social Sciences software (SPSS) version 16.0 (Windows version 17.0 SPSS Inc. Chicago, IL, US). The significance level was fixed at 5% (P ≤ 0.05,) and analysis was done using Pearson's Chi-squared test.
A total of 105 radiographs showed soft tissue calcifications, of which 54 were females, and 51 were males. There was no statistically significant difference (p-value 0.139) in the occurrence between females and males [Table 2]. Though all types of calcifications were included in this study, only six could be identified in the sample, namely stylohyoid ligament calcification, carotid artery calcification, lymph node calcification, tonsillolith, and sialolith and thyroid and triticious cartilage calcification [Table 3]. The stylohyoid ligament calcification was the highest among these (53.3%). The comparison of soft tissue calcifications in different age groups and the percentage of the total number of calcifications in all the age groups are shown in [Table 4]. There was a significant difference in occurrence concerning the age groups (p-value 0.013), and a maximum of 27% was observed for the age group between 56 and 65 years in this study. There was no significant difference (p-value 0.065) between unilateral and bilateral occurrence [Table 5].
|Table 2: Comparison of soft tissue calcifications with respect to gender|
Click here to view
| Discussion|| |
The prevalence of soft tissue calcifications in OPG ranged from 1.75% to 19.7% in previous studies, where few studies excluded some of the calcifications.,,,, Our study included all the soft tissue calcifications identified in OPGs [Table 1], and the overall prevalence was 5.1%.
In our study, females had more calcifications (51%) than males (49%), similar to previous literature studies.,,, A maximum of 28 calcifications were identified in the age group between 56 and 65 years. Also, no single calcification was identified in the age group between 76 and 85 years. But this may be due to the limited number of radiographs in this age group included in this study.
In our study, stylohyoid ligament calcification was the most prevalent (53.3%), and the criteria used was given by Eagle, according to which the normal length measures between 25 mm and 30 m; an increase in the measurement would indicate mineralization of stylohyoid ligament [Figure 2]. Other studies that looked at their prevalence showed 3.7%, 27.3%, and 38.57%.,, The number of females showing calcification was slightly more. This study did not include the analysis of patterns of stylohyoid ligament calcification. Eagle's syndrome is the symptomatic manifestation of elongation/ossification of the stylohyoid ligament. The symptoms are due to pressure applied by the elongated along with the adjacent structures.
Our study's prevalence of carotid artery calcification was 24.8% [Figure 3]. Previous studies in the literature showed prevalence rates of 2.3%, 5.1%, 17.39%, and 45.29%.,,, Other studies solely focused on carotid calcifications showed 3.8%, 4%, and 10.8%, respectively.,, Females (17) showed more calcifications than males (9). There was equal prevalence for both unilateral and bilateral occurrence. The two distinct carotid artery calcification patterns are calcified atherosclerotic plaque and monckeberg's medial calcinosis. The literature's risk factors associated with atherosclerosis are old age, previous history of stroke, diabetes mellitus, hypertension, smoking, and hypercholesterolemia.,
Lymph node calcifications accounted for 5.7% [Figure 4]. Only six were identified; four were males and two were females. Five out of six calcifications were unilateral. The possible etiologies couldn't be ascertained because of the non-availability of the patients' medical history. Previous studies in the literature show prevalence rates of 0.6% and 2.1%., These are seen in conditions like tuberculosis, sarcoidosis, systemic sclerosis, rheumatoid arthritis, fungal infections, metastatic thyroid carcinoma, and metastasis from a distant (calcifying) neoplasm.
The prevalence of tonsilloliths in our study was 3.8% [Figure 5]. The tonsilloliths were found equally (1.9% each) in both genders. Three of the four tonsilloliths identified were found to be unilateral. The OPG studies done to detect soft tissue calcifications showed prevalence rates of 0.9%, 8.69%, 2.5%, and 3.2%, respectively.,,, The panoramic studies done solely to detect tonsilloliths showed prevalence rates of 7.2% and 8.14%., The formation process includes inflammatory debris, epithelial tissue, food, and dead bacteria deposited at the tonsillar crypt, which acts as a nidus for salt deposition.
Sialoliths were identified in our study in a very small number [Figure 6], with a prevalence rate being 3.8%. All of these were identified in males and unilaterally in the submandibular region. The literature shows varying prevalence rates of 1%, 4.3%, 30.43% and 0.5%.,,, Sialoliths are formed due to the slow salivary flow rate and nature of secretions, contributing to the nidus formation and precipitation of calcium salts.
The prevalence of thyroid and triticious cartilage calcification [Figure 7] was 8.6% which was more compared to previous studies. Males showed twice (2.9%) the number as females (5.7%). The two recent studies based solely on cartilage calcification in OPG show 9.3% and 4.5% prevalence rates., These are usually seen as incidental findings without any clinical importance. However, identification is important because these might be confused with carotid artery calcifications which appear in the same region in radiographs.
It is essential to mention here that our study identified no calcification as phlebolith, antrolith, rhinolith, or myositis ossificans. As mentioned earlier, some calcifications may be associated with current or potential morbidities. For example, carotid calcifications may portend serious cardiovascular diseases, and a calcified node may be a manifestation of tuberculosis or metastatic disease. Patients can be referred for further evaluation and management when such calcifications are found.
The main limitation of this study was that the patients' medical history could not be traced because of the retrospective study design. Some radiopacities could not be included in the study because of inadequate evidence for appropriate diagnosis, and no, further radiographic evaluation could be made to confirm it.
The results obtained in this study can be used to compare future studies. More similar studies are needed in different population groups with greater sample sizes to correlate with the available data.
| Conclusion|| |
The stylohyoid ligament calcification was the most commonly identified in the included sample. Also, there is only limited data available in the literature regarding identifying some of the soft tissue calcifications seen in panoramic radiography like phleboliths and myositis ossificans.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Icoz D, Akgunlu F. Prevalence of detected soft tissue calcifications on digital panoramic radiographs. SRM J Res Dent Sci 2019;10:21-5. [Full text]
Nasseh I, Sokhn S, Noujeim M, Aoun G. Considerations in detecting soft tissue calcifications on panoramic radiography. J Int Oral Health 2016;8:742-6. [Full text]
Noffke CE, Raubenheimer EJ, Chabikuli NJ. Radiopacities in soft tissue on dental radiographs: Diagnostic considerations: Clinical review.SADJ 2015;70:53-7.
Ribeiro A, Keat R, Khalid S, Ariyaratnam S, Makwana M, do Pranto M, et al
. Prevalence of calcifications in soft tissues visible on a dental pantomogram: A retrospective analysis. J Stomatol Oral Maxillofac Surg 2018;119:369-74.
White SC, Pharoah MJ. Oral radiology: Principles and interpretation. St. Louis, Mo: Mosby/Elsevier; 2009.
Ramadurai J, Umamaheswari TN. The prevalence of oral and maxillofacial soft tissue calcifications in dental panoramic radiography: A retrospective study. IP Int J Maxillofac Imaging 2018;4:82-6.
Vengalath J, Puttabuddi JH, Rajkumar B, Shivakumar GC. Prevalence of soft tissue calcifications on digital panoramic radiographs: A retrospective study. J Indian Acad Oral Med Radiol 2014;26:385-9. [Full text]
Alves N, Deana NF, Garay I. Detection of common carotid artery calcifications on panoramic radiographs: Prevalence and reliability. Int J Clin Exp Med 2014;7:1931-9.
Monsour PA, Romaniuk K, Hutchings RD. Soft tissue calcifications in the differential diagnosis of opacities superimposed over the mandible by dental panoramic radiography. Aust Dent J 1991;36:94-101
Reddy RS, Kiran CS, Madhavi NS, Raghavendra MN, Satish A. Prevalence of elongation and calcification patterns of elongated styloid process in south India. J Clin Exp Dent 2013;5:e30–5.
Rai S, Misra D, Singh N, Khatri M, Tyagi K, Mallick P. Prevalence and calcification of stylohyoid complex in North West part of India and its correlation with a general and dental health condition. J Indian Acad Oral Med Radiol 2017;29:174-9. [Full text]
Lins CC, Tavares RM, Silva CC. Use of digital panoramic radiographs in the study of styloid process elongation. Anat Res Int 2015;2015:474615.
Andrade KM, Rodrigues CA, Watanabe PC, Mazzetto MO. Styloid process elongation and calcification in subjects with tmd: Clinical and radiographic aspects. Braz Dent J 2012;23:443-50.
Salman B, Nash P, Niall C. An unusual cause of recurrent throat pain-calcified stylohyoid ligament. J Coll Physicians Surg Pak 2012;22:258-60.
Santos JM, Soares GC, Negreiros Nunes Alves AP, Kurita LM, Silva PG, Costa FW. Prevalence of carotid artery calcifications among 2,500 digital panoramic radiographs of an adult Brazilian population. Med Oral Patol Oral Cir Bucal 2018;23:e256–61.
Constantine S, Roach D, Liberali S, Kiermeier A, Sarkar P, Jannes J, et al
. Carotid Artery Calcification on Orthopantomograms (CACO Study)–Is it indicative of carotid stenosis?. Aust Dent J 2019;64:4-10.
Barona-Dorado C, Gutierrez-Bonet C, Leco-Berrocal I, Fernández-Cáliz F, Martínez-González JM. Relation between diagnosis of atheromatous plaque from orthopantomographs and cardiovascular risk factors. A study of cases and control subjects. Med Oral Patol Oral Cir Bucal 2016;21:e66–71.
Ertas ET, Sisman Y. Detection of incidental carotid artery calcifications during dental examinations: Panoramic radiography as an important aid in dentistry. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112:e11-7.
Gunduz K, Canitezer G, Avsever H. Tuberculous lymph node calcification detected on routine panoramic radiography: An unusual case. J Oral Maxillofac Radiol 2014;2:61-3. [Full text]
Ghabanchi J, Haghnegahdar A, Khojastehpour L, Ebrahimi A. Frequency of tonsilloliths in panoramic views of a selected population in southern Iran. J Dent (Shiraz) 2015;16:75–80.
Aoun G, Nasseh I, Diab HA, Bacho R. Palatine tonsilloliths: A retrospective study on 500 digital panoramic radiographs. J Contemp Dent Pract 2018;19:1284-7.
Mandel L. Multiple bilateral tonsilloliths: Case report. J Oral Maxillofac Surg 2008;66:148-50.
Aoun G, Nasseh I. Calcified triticeous cartilage detected on digital panoramic radiographs in a sample of Lebanese population. J Clin Imaging Sci 2018;8:16.
] [Full text]
Soares GC, Kurita LM, Alves AP, de Barros Silva PG, Santos JM, Costa FW. Prevalence of calcified triticeous cartilage-compatible images on 2500 digital panoramic radiographs of a Brazilian population sample. J. Health Biol Sci 2020;8:1-6.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]