|Year : 2022 | Volume
| Issue : 3 | Page : 259-262
Prevalence of calcified carotid artery atheromas on digital panoramic radiographs in type 2 diabetic and non-diabetic patients
K Roja Ramani, K Vinay Kumar Reddy
Department of Oral Medicine and Radiology, Mamata Dental College and Hospital, Khammam, Telangana, India
|Date of Submission||23-Nov-2021|
|Date of Decision||24-May-2022|
|Date of Acceptance||31-Jul-2022|
|Date of Web Publication||26-Sep-2022|
K Roja Ramani
Department of Oral Medicine and Radiology, Mamata Dental College and Hospital, Giriprasad Nagar, Khammam - 507002, Telangana
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: Panoramic radiographs are routinely used in dental clinics and are of great value in the diagnosis of calcified carotid artery atheromas. So the present study is aimed to know the prevalence of calcified carotid artery atheromas on the digital panoramic radiographs of patients with Type 2 diabetes mellitus and non-diabetic. Aim and Objectives: To determine the prevalence of calcified carotid artery atheromas in Type 2 diabetes mellitus and to assess the reliability of digital panoramic radiographs in detection of calcified carotid artery atheromas. Materials and Methods: A total of 100 subjects were included in the present study, 50 Type 2 diabetic patients and 50 age and sex matched healthy individuals were chosen as controls. Blood samples were collected and a digital panoramic radiograph was advised. To confirm those carotid artery calcifications (CACs) which were evident on panoramic radiograph further ultrasound Color Doppler was advised. Results: Among 50 Type 2 diabetic patients 9 (18%) patients showed CACs on digital panoramic radiograph and among 50 controls there were no CACs on digital panoramic radiograph with a statistically significant P value of 0.0022 (P < 0.05). Type 2 diabetes who exhibited CACs on digital panoramic radiograph also showed CACs on ultra sound Color Doppler. Conclusion: Our study concludes that people with Type 2 diabetes mellitus have more prevalence of calcified carotid artery atheromas on digital panoramic radiographs than non-diabetics.
Keywords: Atheromas, carotid artery, hyperglycaemia, panoramic radiographs Key Message: Type 2 diabetic patients have a high risk of carotid artery atheromas due to associated risk factors of hyperglycaemia, hyperlipidaemia. So, the early detection of carotid artery calcifications on digital panoramic radiograph prevents the future risk of cerebrovascular stroke.
|How to cite this article:|
Ramani K R, Reddy K V. Prevalence of calcified carotid artery atheromas on digital panoramic radiographs in type 2 diabetic and non-diabetic patients. J Indian Acad Oral Med Radiol 2022;34:259-62
|How to cite this URL:|
Ramani K R, Reddy K V. Prevalence of calcified carotid artery atheromas on digital panoramic radiographs in type 2 diabetic and non-diabetic patients. J Indian Acad Oral Med Radiol [serial online] 2022 [cited 2022 Dec 10];34:259-62. Available from: http://www.jiaomr.in/text.asp?2022/34/3/259/356962
| Introduction|| |
Diabetes mellitus (DM) is a clinically and genetically heterogeneous metabolic disease which is characterized by hyperglycaemia and dysregulation of carbohydrate, protein, and lipid metabolism.
Approximately 85 to 90% of patients were affected by Type 2 DM and have increased serum glucose, lipid, which leads to great risk for stroke. 80% of strokes are induced by atherosclerotic plaques, mostly detected in the main carotid artery bifurcation region at the level of C3, C4vertebrae.
Panoramic radiographs are most commonly used in dental diagnosis and treatments, and are able to identify carotid artery calcifications (CACs). Early detection of macro vascular complications, atherosclerosis should be thereby prevents the cerebrovascular stroke.
So, the present study is aimed to know the prevalence of calcified carotid artery atheromas on digital panoramic radiographs in Type 2 diabetic patients and non-diabetic.
| Materials and Methods|| |
The data was obtained from the patients who visited the Department of Oral Medicine & Radiology at Mamata Dental College & Hospital by using simple random sampling method. The duration of the present study carried out for one year. A cross-sectional study carried out in a total power of 100 subjects, 50 Type 2 diabetic patients and 50 age and sex matched healthy individuals were chosen as controls. Inclusion criteria for Type 2 diabetic patients: 1) A diagnosis of Type 2 diabetes, that is, in the unmedicated stage having a fasting blood glucose (FBG) level >110 mg/dL; 2) Type 2 diabetics who achieved control either by daily insulin administration or oral hypoglycaemic agents; 3) Age of 50 years or greater, both male and female; 4) Ability to stand proper while taking panoramic radiograph. Exclusion criteria for Type 2 diabetic patients: 1) History of transient ischemic attack; 2) History of cerebrovascular accident.
| Method|| |
After obtaining the ethical clearance from the institutional ethical committee, Mamata Dental College, (MDC-T-D128804002) and consent of the patient according to Helsinki Declaration, detailed history and oral examination of the patients was carried out, blood samples were collected and a digital panoramic radiograph was performed. Blood samples were collected to estimate FBG levels, postprandial blood glucose (PPBG) levels and lipid profile including total serum cholesterol, triglycerides (TGLs), high-density lipoproteins (HDLs), low-density lipoproteins (LDLs), very low-density lipoproteins (VLDLs), HbA1c in 50 diagnosed Type 2 diabetic patients and FBG, PPBG, and lipid profile, in all 50 controls. To confirm those CACs which were evident on panoramic radiograph, further ultrasound Color Doppler was advised.
A digital panoramic radiograph was taken for all the Type 2 diabetic patients and non-diabetic (controls) using ORTHOPHOS XG 5 Sirona digital panoramic X-ray system. The unit was operated at 8 mA, the peak kilo voltage at 66 Kvp and exposure time of 14 seconds. The radiographs obtained from both the groups were examined by an observer with experience of 20 years under ambient light through the use of transmitted light from a standard viewing box for detecting the presence of CACs. Any calcifications seen on the radiographs were noted and marked. Radiographically, the calcified atheromatous plaques appear as single or multiple discrete radiopaque nodular masses within the soft tissues of the neck, 1.5 cm inferior and 2.5 cm posterior to the cortical rim of the midpoint of angle of mandible [Figure 1]
|Figure 1: Digital panoramic radiograph showing right and left carotid artery calcifications|
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The patients whose digital panoramic radiographs showed CACs were subjected to ultrasonography along with 2D Color Doppler and spectral Doppler using ultrasonography unit HDI 1500 Phillips Color Doppler with facilities of 2D and duplex Doppler studies, for further confirmation. Calcifications appear as hyper echoic areas along the lumen of the artery [Figure 2].
|Figure 2: Ultrasound Color Doppler confirming carotid artery calcifications|
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Statistical comparison of risk factors and atheroma prevalence rates were done by t-test with IBM SPSS 20 version Karnataka, India. Other statistical test included was Chi-square test. Results of our study were statistically significant with a P value of 0.0022 (<0.05).
| Results|| |
Out of 50 Type 2 diabetic patients, 33 (66%) were male patients and 17 (34%) were female patients with mean age of 55.54 years. Among controls 26 (52%) were male patients and 24 (48%) were female patients with mean age of 52.28 years. Statistical comparison of risk factors in Type 2 diabetic patients, and healthy controls was done by t-test [Table 1].
In the present study on comparison of FBG, PPBG, total serum cholesterol, TGL, LDL, VLDL levels between Type 2 diabetic patients and controls, all the values except HDL increased from controls to Type 2 diabetic patients with statistically significant values (P < 0.05).
It was observed that among 50 Type 2 diabetic patients 9 (18%) patients showed CACs on digital panoramic radiograph and among 50 controls there were no CACs on digital panoramic radiograph with a statistically significant P value of 0.0022 (P < 0.05) [Table 2].
|Table 2: Comparison of Type 2 diabetes and controls with respect to carotid artery calcifications on digital panoramic radiograph|
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9 patients (18%) in Type 2 diabetes who exhibited CACs on digital panoramic radiograph also showed CACs on ultra sound Color Doppler [Table 3].
|Table 3: Carotid artery calcifications on ultrasound Color Doppler in Type 2 diabetes group|
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| Discussion|| |
Cerebrovascular accidents are the third most common cause of morbidity and mortality in worldwide population and are believed to be the result of atherosclerotic plaque at the carotid bifurcation.
CACs are more prevalent in certain patients such as hypertension, old age, Type 2 diabetes, heart disease, metabolic syndrome, and obesity.
Panoramic radiography is one of the most common diagnostic tool used in routine dental practice which provides information regarding oral and facial structures and allows to observe the area of the first, second, third cervical vertebrae, which helps in the early diagnosis of calcified atheroma in common carotid artery.,
Digital radiography in dentistry has been around for more than a decade. Digital radiography offers the ability of image enhancement by altering the contrast and density which helps in better detection of calcified atheromatous plaques.
So the present study is done to evaluate the relation of CACs on digital panoramic radiograph in Type 2 diabetic and non-diabetic patients.
Radiographically, the calcified atheromatous plaques are presented as irregular, circular linear or heterogeneous radiopaque masses with unilateral or bilateral distribution. These calcified plaques tend to be circular when small and linear or thin rectangular when enlarged. They are located 1.5 cm inferior and 2.5 cm posterior to the cortical rim at midpoint of angle of mandible approximately at the inferior margin of third cervical vertebra (between C3 and C4) near the hyoid bone. They have to be differentiated from other radiopacities such as hyoid bone, epiglottis, calcified triticeal cartilage, thyroid cartilage, stylohyoid ligament, stylomandibular ligament, sialoliths, phleboliths, tonsilloliths, and calcified lymph nodes.,
Carotid artery atheromas appear as circular when small and linear or thin rectangular when enlarged, whereas calcified triticeal cartilage is mostly oval with smooth margins, thyroid cartilage is located medial to image of C4 which can sometimes lead to confusion.
Diabetic patients with hyperglycaemia and high lipid profile are more prone to develop micro-vascular and macro-vascular complications, as well as recurrent infections and impaired wound healing.,
Macro-vascular disease characterized by atherosclerotic changes in large blood vessels, and its major clinical effects are seen in the coronary arteries (angina, myocardial infarction), lower extremities (gangrene), and carotid artery (stroke).
The degree of modification of lipoproteins (e.g., Oxidation, glycation, size, and composition) is associated with risk of coronary heart disease and stroke. LDL was positively associated and HDL was inversely associated with carotid atherosclerosis. People with diabetes have LDL particles that are smaller and are depleted of core lipids.
The small, dense lipoprotein particles enter the arterial wall and are oxidized and engulfed by the vascular wall macrophages and esterify the LDL, transforming it into a foam cell and accumulation of foam cells constitutes the major component of the atheromatous plaque. Calcium salts taken up by atheromatous plaque cause radiopaque appearance on radiographs.,,
To confirm radiopaque CACs which were seen on the panoramic radiograph, Doppler ultrasonography examination of the patients was carried out. In ultrasonography, calcified carotid atheroma was seen as an area of dense hyper-echoic region with acoustic shadowing placed 2.5 cm below and 1.5 cm above the carotid artery bifurcation.
To determine the degree of color saturation Color Doppler used which shows normal laminar flow appears as a region of homogeneous color and Stenosis (results in the production of a high velocity jet) appears as abrupt change in the color flow pattern. Color Doppler provides additional information used to detect a significant stenosis. Color aliasing, persistence, and bruit all indicate flow disturbance.
As Type 2 diabetic patients with high risk of calcified carotid artery atheromas due to associated risk factors of hyperglycaemia, hyperlipidaemia, screening of patients in dental clinic with digital panoramic radiography may help in early diagnosis of carotid artery atheromas.
On evaluation of the results, in the present study it was evident that among 50 Type 2 diabetic patients 9 (18%) patients showed CAC on digital panoramic radiographs and ultra sound Color Doppler. Among 50 controls there were no CACs on digital panoramic radiograph with a statistically significant P value of 0.0022 (P < 0.05).
The results in the present study were consistent with the studies conducted by Friedlander and Maeder (2000), Ardakani FE (2007), Tofangchiha (2011), Khambete (2012), Dharma RaoV (2014), as in these studies there was evidence of calcified carotid artery atheromas on panoramic radiographs of Type 2 diabetic patients.
In their studies, there was also evidence of calcified carotid artery atheromas on panoramic radiographs in controls, but in our study there was no evidence of CACs on digital OPG in controls.
Thus, the results of our study suggests a positive correlation of Type 2 DM with calcified carotid artery atheromas on digital panoramic radiograph and with serological evidence of associated risk factors of increased FBS, PPBS, serum total cholesterol, TGL, LDL, VLDL, and decreased HDL values. CACs on digital panoramic radiograph were confirmed by ultrasonography with Color, Spectral Doppler. There was no evidence of calcified carotid artery atheromas on digital panoramic radiographs of controls. So early diagnosis, education and awareness of these patients may decrease risk of cerebrovascular stroke.
| Conclusion|| |
Our study concludes that digital panoramic radiograph is a reliable aid in detecting the CACs. Therefore early detection of the patients who are under future risk for stroke is possible and necessary treatment, management, and preventive measures can be taken there by saving lives of the patients.
The limitations of the present study are not being specific in terms of the artery whether the calcifications are present in the internal or external carotid artery. Male and female predominance also not specified.
Further studies with large sample size with inclusion of other risk factors like hypertension, obesity, metabolic syndrome, and smoking are recommended.
So the dentists caring for subjects with dental problems should carefully evaluate their panoramic radiographs for the evidence of CACs, and refer them for medical evaluation as indicated.
I would like to thank you Dr Kotya Naik Maloth and Dr Sunitha Kesidi for immense support throughout the project.
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
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]