Recognition of giant cell arteritis and calcified carotid artery atheromas in dental practice: systematic review and meta-analysis.

Carotid artery calcifications are a risk indicator for both myocardial infarction and stroke

Utility of panoramic radiographs in detecting cervical calcified carotid atheroma by Richard P. Madden et al

Evaluation of calcified carotid artery atheromas detected by panoramic radiograph among 80-year-olds.

CALCIFIED CAROTID ARTERY ATHEROMA ON STANDARD DENTAL RADIOGRAPHS: A PUBLIC HEALTH OPPORTUNITY FOR CARDIOVASCULAR RISK REDUCTION

Simple SummaryThe goal of the present review is to investigate the reliability of panoramic dental images to detect calcified carotid atheroma. The findings of this systematic review exhibit that panoramic radiographs can be used for dental diagnosis and treatment planning, as well as to detect calcified carotid artery atheroma, so it can be a tool to prevent cardiovascular diseases.To investigate the reliability of panoramic dental images to detect calcified carotid atheroma, electronic databases (PubMed, IEEE/Xplore and Embase) were searched. Outcomes included cerebrovascular disease events, cardiovascular disease events, patient previous diseases, and combined endpoints. Risk of bias was evaluated using the Newcastle-Ottawa Scale. Hence, 15 studies were selected from 507 potential manuscripts. Five studies had a low risk of bias, while the remaining nine studies were found to have a moderate risk. Heterogeneous results were obtained but showed that patients with risk factors, such as obesity, diabetes mellitus, hypertension, and smoking, and with calcified carotid atheroma on panoramic images, have a higher prevalence than healthy patients. The evidence in the literature was found to be equivocal. However, the findings of this systematic review exhibit that panoramic radiographs can be used for dental diagnosis and treatment planning, as well as to detect calcified carotid artery atheroma.

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.

To evaluate whether estimates of risk of future cardiovascular events and death and established or unknown diabetes are significantly associated with calcified carotid artery atheromas (CCAAs) on panoramic radiographs (PRs). The main focus was on men and women without previous myocardial infarction (MI). The PAROKRANK (Periodontitis and its Relation to Coronary Artery Disease) study included patients with a first MI and matched control subjects. In this substudy, 738 patients (138 women) and 744 control subjects (144 women) with available PRs were assessed for CCAA. Cardiovascular risk estimates were determined according to the Framingham Risk Score (FRS) and Systematic COronary Risk Evaluation (SCORE). Established and previously unknown diabetes was also determined. CCAA was detected on PRs in 206 control subjects (28%) and 251 patients (34%). FRS was significantly associated with CCAA among control subjects (P=.04) and patients (P=.001). SCORE was associated with CCAA among control subjects (P < .01) but not patients (P=.07). Among men, FRS and SCORE were associated with CCAA in both control subjects and patients. Diabetes was not significantly associated with CCAA after adjustments. Elevated cardiovascular risk scores were associated with CCAA on PRs among control subjects. Diabetes was not independently associated with CCAA, possibly owing to selection bias.

Background and aimsThe purpose of this study was to identify patients at the risk of cerebrovascular attack (CVA) by detecting calcified carotid artery atheroma (CCAA) in panoramic radiography and evaluating their risk factors.Materials and methodsA total of 960 panoramic radiographs of patients above 40 years old were evaluated. Doppler Sonography (DS) was performed for patients who showed calcified carotid artery atheroma (CCAA) in panoramic radiogra-phy in order to determine the presence of CCAA and the degree of stenosis. Cardiovascular risk factors in both groups of patients with CCAA (12 subjects) and without CCAA (3 subjects) were compared using a questionnaire filled out by the patients. Statistical analysis including Fisher and independent t-test applied for data analysis.ResultsFifteen patients (30 sides) showed calcification in their panoramic radiographs, and underwent DS which revealed CCAA in 16 sides (12 patients). Two patients (13.33%) showed stenosis greater than 70%. Among the risk factors, only age showed a significant association with the occurrence of carotid calcified atheroma (P=0.026).Conclusion Considering the results, dentists should refer especially elderly patients with radiographically identified atheromas for further examinations, as asymptomatic CCAA might be associated with high degrees of stenosis.

Studies suggest that radiotherapy to the head and neck may be an important triggering factor for calcified carotid artery atheromas. However, scientific evidences to prove this matter are limited. Therefore, this essay aimed to identify the prevalence of calcified carotid artery atheromas observed by panoramic radiograph in a head and neck cancer population before and after radiotherapy and to correlate them with the sociodemographic features and comorbidities of these patients. For this research, 180 patients submitted to radiotherapy that had panoramic radiographs before and after this treatment, were selected retrospectively. Clinical data from these patients were collected from their medical records. The panoramic radiographs were examined and 35% of the patients demonstrated calcified carotid artery atheromas. There was no significant difference in the prevalence of atheromas before and after radiotherapy. According to clinical data, there was a greater prevalence of strokes in patients with calcified carotid artery atheromas when compared to patients who did not have atheromas (p<0.05). Differences related to age, gender, arterial hypertension, diabetes mellitus, acute myocardial infarctation, tumor location and radiotherapy dose were not observed. Thus, we can conclude that although radiotherapy did not alter the prevalence of calcified carotid artery atheromas in the studied population, this alteration is commonly found in head and neck cancer patients. Therefore, it is important that dentists be aware to the presence of calcified carotid artery atheromas in panoramic radiographs of head and neck cancer patients.

Calcified carotid artery atheromas in panoramic radiographs are associated with a first myocardial infarction: a case-control study

Calcified carotid artery atheroma (CCAA) localization on panoramic radiographs

Objective: Calcified carotid artery atheroma (CCAA) detected by panoramic radiographs has been suggested as an accurate biomarker for cerebrovascular accidents (CVAs). However, there has not been agreement on the relationship between CCAA and risk for stroke or other CVA. Method and materials: The question asked was, "Are patients with CCAA detected on panoramic radiographs more likely to get a stroke or CVA in the future compared to those who do not have CCAA and, further, would Doppler ultrasonography of the neck obtained secondary to panoramic radiography in suspected individuals add value to this association with stroke or CVA?" This meta-analysis was conducted by searching PubMed, Ovid Medline, Dentistry & Oral Sciences Source, CINAHL, Web of Science, Google Scholar, and ClinicalTrials.gov. Six studies that met the inclusion criteria were included in the final analysis; three used panoramic radiography and the rest used panoramic radiography and ultrasonography. Multiple random effect meta-analyses were conducted using RevMan 5.2 software. Conclusion: Evidence from this meta-analysis shows that although detection of CCAA via panoramic radiography to predict risk for stroke may be comparable to Doppler ultrasonography, risk prediction is somewhat more significant when diagnostic confirmation is made using Doppler ultrasonography than panoramic radiography alone. Clinical implications: Because stroke risk assessment is complicated and comprises many additional systemic factors beyond calcification of the carotid artery, CVA prediction is more reliable when Doppler ultrasonography is used after panoramic radiography. Managing hypertension, diabetes, and smoking habit are far more important in risk management of patients with CCAA detection on panoramic radiography.

Objective: The aim of this study was to evaluate the diagnostic capability of dentists in the identification of suggestive images of calcified carotid artery atheroma (CCAA) on panoramic radiographs (PRs) before and after using a problem-based learning method (PBL). Methodology: Five dentists (no specialists in oral and maxillofacial radiology) analyzed 102 digital PRs divided into: PRs with suggestive images of CCAA (n=51) and without suggestive images of CCAA (n=51). After the first analysis, the examiners attended an activity on soft tissue calcifications using the PBL method. Afterwards, they analyzed the 102 PRs again. The results of the analysis were calculated using the Cohen's Kappa Test and the Receptor Operational Characteristic Curves (ROC). Results and Discussion: Regarding examiners’ performance before and after the activity, the intra-examiner test showed reasonable Kappa coefficients (0-0.40). For inter-examiner agreement after the activity, the Kappa coefficient was almost perfect (&gt; 0.80). When comparing examiners’ performance after the activity with a template performed by an experienced radiologist, the Kappa Coefficient was &gt; 0.80 with significant agreement (p&lt;0.05). Conclusion: The precision and the probability of correctly detecting suggestive images of CCAA on PRs increased when the examiners participated in the active pedagogical method. The continuing education of the dentist and how it can make a difference in the systemic health of patients should be considered.

BackgroundThe aims of this study were to verify if head and neck radiotherapy (RT) is able to induce calcified carotid artery atheroma (CCAA) in a large head and neck cancer (HNC) population and also to compare the socio-demographic and clinical findings of patients with and without CCAA detected on panoramic radiographs.Material and MethodsPanoramic radiographs taken before and after head and neck radiotherapy (RT) of 180 HNC patients were selected and analyzed in order to identify the presence of CCAA. In addition, CCAA presence or absence on panoramic radiographs were compared and correlated with clinicopathological findings.ResultsA high overall prevalence of CCAA was found on panoramic radiographs (63 out of 180 = 35%) of HNC patients. No significant difference of CCAA before and after RT was observed. There were also no differences between groups (with and without CCAA) regarding age, gender, tobacco and alcohol use, arterial hypertension, diabetes mellitus, acute myocardial infarction, hypercholesterolemia, tumor location, clinical stage of disease and RT dose. However, there was a greater prevalence of strokes in patients with CCAA (p<0.05).ConclusionsAlthough CCAA were frequently found in panoramic radiographs of patients with HNC, RT seems not to alter the prevalence of these calcifications.Key words:Head and neck cancer, radiotherapy, carotid artery diseases, panoramic radiography.

We have previously shown that panoramic X-rays (PXs) demonstrating calcified carotid artery atheromas (CCAA) are associated with increased systemic inflammation demonstrating increased neutrophil lymphocyte ratios (NLRs), a validated risk indicator of fatal myocardial infarctions arising from coronary artery atherosclerosis. Using this same cohort of patients (with minor adjustments because of missing data), we sought to determine if a like association existed between PXs evidencing CCAA and elevated red blood cell distribution width (RDW) given conflicting data as its reliability relative to NLR as a biologic marker of system inflammation. We hypothesized that CCAAs on PXs would simultaneously be associated with both increased NLR and RDW. Investigators implemented a cross-sectional study design. Study sample consisted of patient medical records and PXs of white men ≥ 55 years. Two groups (N = 50 each) were constituted, one with atheromas (CCAA+) and without atheromas (CCAA-). The predictor variable was CCAA+and outcome variables were NLR and RDW. Bootstrapping analysis was employed to analyze the differences in mean NLRs and RDWs between groups since the data was not normally distributed. Statistical significance determined to be ≤ 0.05 for all tests. The Medical Center's Institutional Review Board approved the research protocol. A study group of 50 CCAA+men (mean age 71; range 58-89 years) demonstrated a mean NLR of 2.98 ± 1.38 and an RDW of 13.21 ± 0.85. A control group of 50 CCAA- males (mean age 70 range; 55-91 years) evidenced a mean NLR of 2.38 ± 0.77 and an RDW of 13.16 ± 0.77. Bootstrapping comparison of NLR values evidenced significant (P = 0.008) difference (95% confidence interval of difference of mean: - 0.4272, 0.4384; observed effect size: 0.579) between groups; however, there was no significant difference in RDW values between the groups. Furthermore, logistic regression modeling demonstrated that for a one unit increase in NLR the odds of being CCAA+ (vs. CCAA-) increases by a factor of 1.659. The existence of CCAA seen on PXs of elderly white men is associated with significantly (P = 0.008) elevated NLR values but is not associated with increases in RDW.