Routine Panoramic Radiographs Research Articles

Non-syndromic supernumerary fourth molar: A report of two cases and review of literature

Background: Supernumerary teeth are excess teeth found in a normal dentition, with a prevalence of 0.1‒3.8% in the permanent dentition and 0.3‒0.6% in the primary dentition. This case series presents two non-syndromic supernumerary fourth molar cases in two male and female patients. Case Report: This study describes two rare supernumerary fourth molar cases. Both cases were asymptomatic and impacted in the maxillary arch. A routine panoramic radiograph revealed the presence of them for the first time. The medical and familial records of the patients were non-contributory, with no abnormalities in the extraoral examination. Conclusion: Well-developed, impacted supernumerary teeth are rare occurrences in individuals with no concurrent diseases or syndromes. Dental practitioners should know the different types of supernumerary teeth and manage them according to their type and possible complications.

Fractal dimension analysis of different mandibular regions in familial Mediterranean fever patients: A cross-sectional retrospective study.

Familial Mediterranean fever (FMF) is a genetic condition that may cause loss of bone mineral density (BMD) due to chronic inflammation. Previously, fractal dimension (FD) analysis values of mandibular cortical bone were shown to be lower in osteoporosis. Therefore, FD might be considered as an auxiliary tool to refer patients for dual-energy x-ray absorptiometry (DXA), which is the gold standard for BMD measurement. The purpose of this cross-sectional retrospective study was to evaluate trabecular and cortical microarchitecture of the mandible with FD analysis on panoramic radiographs in a subpopulation of FMF. Also, the effect of colchicine use was investigated. Forty-three FMF patients, aged between 10.8 and 71.2 years, and age- and gender-matched control group consisting of patients, who had no systemic diseases, were included. Demographic information such as age and gender, and colchicine use were recorded. In terms of age, the patients were classified as <30 and 30< years. On each panoramic radiographs five regions of interest were selected on the mandible as: 1- premolar, 2- molar, 3- angular, 4- condylar, and 5- basal cortical bone regions on right (R) and left (L) sides. Statistical significance was accepted at p<0.05 level. Intra- and inter-observer agreements demonstrated good to excellent consistency. In FMF patients, L3 and L4 values were higher, whereas L5 values were lower (p<0.05) than the control group. In terms of age, the difference between groups was insignificant in FMF patients (p>0.05), whereas in control group R3 and L4 values were higher in the 30< age group (p<0.05). Regarding gender and colchicine use, the difference between groups was insignificant (p>0.05). FMF disease might be a candidate for referral to DXA examination based on decreased bone density in the mandibular cortex detected by FD measurements on routine panoramic radiographs. Further studies are warranted to ascertain this relationship.

Deep convolution neural network for screening carotid calcification in dental panoramic radiographs.

Ischemic stroke, a leading global cause of death and disability, is commonly caused by carotid arteries atherosclerosis. Carotid artery calcification (CAC) is a well-known marker of atherosclerosis. Such calcifications are classically detected by ultrasound screening. In recent years it was shown that these calcifications can also be inferred from routine panoramic dental radiographs. In this work, we focused on panoramic dental radiographs taken from 500 patients, manually labelling each of the patients' sides (each radiograph was treated as two sides), which were used to develop an artificial intelligence (AI)-based algorithm to automatically detect carotid calcifications. The algorithm uses deep learning convolutional neural networks (CNN), with transfer learning (TL) approach that achieved true labels for each corner, and reached a sensitivity (recall) of 0.82 and a specificity of 0.97 for individual arteries, and a recall of 0.87 and specificity of 0.97 for individual patients. Applying and integrating the algorithm in healthcare units and dental clinics has the potential of reducing stroke events and their mortality and morbidity consequences.

Treatment Strategy of Mandibular Second Molar Impaction: A Literature Review

Purpose: This literature review aimed to investigate the treatment consideration and strategy of mandibular second molar (MM2) comprehensively, which can be of great assistance on managing and solving such a rare disturbance. Methods: Previous studies were identified in PubMed or Embase database using the keywords “orthodontic,” “molar impaction,” and “uprighting molar.” To enrich the contents of every aspect of the topic, other several related articles were also reviewed and included. Results: Forty-six articles were included and systematically discussed in this review, which were arranged according to prevalence, etiology, diagnosis, treatment strategy, and clinical methods. The incidence of MM2 impaction is 0.06%–0.3% worldwide, and it is related to genetics, craniofacial morphology, space problem, obstacles during eruption, abnormal eruption mechanism, or systemic diseases. Impacted MM2 can be diagnosed by a routine panoramic radiograph according to the definition and criteria. Decision-making depends on patient age, root stage and condition of the impacted tooth, with optimal age of 14 and incompletion root formation. Every treatment option has its indication, benefit/shortcoming, and success rate. Among the four treatment options discussed in this review article, surgical exposure and orthodontic uprighting of the impacted MM2 shows better predictability and success rate, with relatively less side effects. The key biomechanism is to provide the distalizing and uprighting force to rotate the MM2 around the center of resistance, presenting a tipback moment. With various uprighting approaches, either conventional methods or skeletal anchorage devices, to provide pushing/pulling force, tipped molars can be easily corrected. Conclusions: Mandibular second molar impaction is a challenging disturbance that requires proper clinical, radiological, biomechanical evaluation, and suitable treatment option and appliance selection for successful treatment result.

A retrospective diagnostic study of prevalence of orofacial calcifications using panoramic radiograph: To insinuate the unseen.

The prevalence of calcifications in the head and neck region has long been observed and has a strong value of presaging systemic illness. The observations of such calcifications in routine panoramic radiographs (PR) demands keen follow-up and health check-up of patients. In developing countries, the use of routine panoramic radiographs is a common one owing to its cost effectiveness and feasibility. Thus, knowledge of prevalent calcifications and the ability to diagnose it while correlating with possible systemic condition is mandatory. This article is primarily about the prevalence of soft tissue calcifications in head and neck region while emphasising the clinical importance. A total of 22,000 panoramic radiographs were included after adapting the inclusion and exclusion criteria. All the included radiographs were examined using Dentsply Sirona Sidexis 4 Dental imaging software in full screens. A total of 22,000 PRs were analyzed, of which 7,832 were male and 14,168 were female. The age range of patients included were from 6 to 88 years with a mean of 41 years ± 11.4 years standard deviation. Of the analyzed PR's, a total of 1228 calcifications were found in 1041 (4.731%) patients which comprised of 497(6.34%%) calcifications in male and 731 calcifications in female (5.159%). From which, 16 different soft tissue calcifications were reported while stylomandibular ligament calcification being the most reported one. Panoramic radiographs is yet an essential diagnostic tool, as a dentist our role in diagnosing systemic conditions is inevitable. A high prevalence of calcifications demands thorough examination of radiographs on routine. Early detection od calcifications ensures prevention of further progression of disease. Key words:Orofacial calcification, panoramic radiography, atherosclerosis, dystrophic calcification.

Maxillary radiolucency in a 39-year-old man

A 39-year-old man came to an oral and maxillofacial surgery office for evaluation of a lesion in the left maxilla. The patient’s general dentist referred him after a radiolucency within the posterior maxillary left quadrant was noted on a routine panoramic radiograph. He had no symptoms and denied pain or swelling in the area of the lesion. The patient reported a history of tooth extraction in the area many years ago. Medical, family, and social histories were noncontributory. Extraoral head and neck examination was unremarkable, with no evidence of adenopathy, palpable masses, or facial asymmetry, and cranial nerves were grossly intact. Dr. Alamri is a senior resident, Advanced Oral and Maxillofacial Pathology Program, Department of Oral Diagnostic Sciences, School of Dental Medicine, University at Buffalo, The State University of New York, Buffalo, NY. Dr. Violante is a periodontist in private practice, Buffalo, NY. Dr. Schellati is an oral and maxillofacial surgeon in private practice, Victor, NY. Dr. Hinchy is an assistant professor, Department of Oral Diagnostic Sciences, School of Dental Medicine, University at Buffalo, The State University of New York, Buffalo, NY. Dr. Aguirre is the program director, Advanced Oral and Maxillofacial Pathology Program and a professor, Department of Oral Diagnostic Sciences, School of Dental Medicine, University at Buffalo, The State University of New York, Buffalo, NY.

Methods of Definitive Correction of Mandibular Deformity in Hemimandibular Hyperplasia Based on Radiological, Anatomical, and Topographical Measurements-Proposition of Author's Own Protocol.

In order to fully evaluate and establish the degree of bone overgrowth, various radiological studies are essential in the careful planning of the amount of surgical excision. In the presented paper, the authors use self-designed anatomo-topographical reference points for planning the surgeries. Routine panoramic radiographs and low-dose computed tomography based on anatomical landmarks help in measuring the proportions of mandibular bone overgrowth with the following preoperative anatomical landmarks: (Go-Go), (Go(Right)-Gn), (Go(Left)-Gn), and (Me–Gn). Measurements taken at selected points and landmarks (gonion-gnathion/gnathion-menton) are easy to conduct. In the authors’ proposal, the main key factor is total chin correction, which is necessary in cases of severe overgrowth; when F0 > C and Go-Gn>, there is >7 mm of vertical bone overgrowth, and the mandibular canal is positioned <5 mm from the inferior mandibular border—MIB. Larger overgrowths (>7 mm) have a greater outcome on the final symmetry than smaller overgrowths. As no guidelines are known, the authors present their own proposal.

What Features on Routine Panoramic Radiographs Could Help Orthodontists to Estimate the Occurrence of Condylar Hyperplasia from Other Mandibular Asymmetries—Retrospective Analysis Study

Hemimandibular hyperplasia (HH) and elongation (HE) are the most common pathologies present in the mandible. Presented condylar hyperplasias have their own radiological and clinical features. In most cases, patients suffer from various forms of malocclusion. From a total of 150 asymmetrical jaw radiographs evaluated, 46 were evaluated and included in this study. A retrospective study on the data of 46 selected patients treated, diagnosed, and consulted from various forms of mandibular and skeletal asymmetry based on routine diagnostic panoramic radiographs evaluated typical and atypical radiological and anatomical symptoms of condylar hyperplasia. The presented evaluation focused on mandibular, maxillary, and other bones, in order to distinguish condylar hyperplasia from other forms of mandibular asymmetry. The degree of maxillary downward growth followed by the occurrence of an open bite on the affected side estimate the degree/presence or cessation of growth in the affected condyle. Mandibular asymmetry with incisor teeth inclination remains the most typical characteristic of condylar hyperplasia. Increased height of mandibular ramus differentiates between condylar hyperplasia and elongation, which also influences the position of the inferior alveolar nerve. Mentioned symptoms, described as the acronym “Go Moira!”, are useful in a quick and simple “glimpse of an eye” differential diagnostic approach. It is possible to quickly and accurately establish the first diagnosis simply by a careful evaluation of patients’ panoramic radiographs.

CORRELATION OF PANORAMIC RADIOGRAPHIC FINDINGS AND CLINICAL FINDINGS OF DENTAL PATIENTS AT MOI TEACHING AND REFERRAL HOSPITAL, KENYA

Purpose: The purpose of this study was to determine the correlation of panoramic radiographic findings and clinical findings among dental patients at Moi Teaching and Referral Hospital (MTRH), Kenya.&#x0D; Materials and Methods: This was a hospital based cross sectional study conducted at the Radiology and Imaging department and dental department at Moi Teaching and Referral Hospital from September, 2019 to June, 2020. A total of 93 consenting patients were enrolled using systematic random sampling. Standard chart review forms were administered, and clinical examination findings documented. Panoramic radiograph findings were then discussed with a consultant radiologists and findings recorded. Descriptive statistics were carried out. Categorical variables were summarized as frequencies and proportions, and reported in tables. Numerical variables were summarized as median and interquartile ranges. Cross tabulation was done to compare clinical examination and panoramic radiograph findings where total raw agreement was reported as proportions.&#x0D; Results: 93 patients whose ages ranged from 5-73 years with a mean of 29 years were included into the study. Radiographic features of dental caries were present in 54% of panoramic radiographs compared to clinical examination (50.5%) while 23.7% of radiographs revealed impacted teeth compared to clinical examination (19.4%). Radiographic features of periodontitis were observed in 14% compared to clinical examination (16.1%). Fractures (12.9%) were observed radiographically compared to (10.7%) clinically. Periapical lesions (8.6%) were observed radiographically compared to clinical examination (6.4%). Temporo-mandibular disorder (6.5%) were observed both on radiographs and clinical examination. Radiographic features of missing teeth (3.2%) were observed compared to clinical examination (1.1%) while only 1.1% of malpositioned teeth were observed radiographically compared to clinical examination (2.2%). Notably, mandibular lesions (3.2%) and nasal congestion (14%) were only discovered radiographically. The overall raw agreement between panoramic radiograph and clinical examination was 75.3% (70/93) with a p value of less than 0.001.&#x0D; Unique contribution to theory, practice and policy: The study recommends that all patients presenting with dental conditions should be done panoramic radiograph to improve diagnosis. Moi Teaching and Referral Hospital and the Ministry of Health to consider routine panoramic radiographs in the guidelines for the assessment of dental patients in all the hospitals offering, dental health services

Prevalence of Incidental Radiopacities in Panoramic Radiographs

Routine panoramic radiographs often reveal hidden lesions other than those related to the patient's chief complaint [1]. The study aims to determine the prevalence of incidental radiopacities in panoramic views. There are several conditions where calcifications can occur in soft tissue, including major and minor salivary glands, lymph nodes, and blood vessels, such as sialolith, phlebolith, exostosis, dystrophic calcifications, etc. [2]. Interpretation of panoramic radiograph should consider the possibilities of soft tissue calcification super-imposed in bone. Three hundred and sixty (360) panoramic radiographs are included in the study. The prevalence and distribution of radiopacities were documented along with the probable diagnosis. In addition, statistical analysis was done by SPSS software to evaluate the age and gender-related distribution of radiopacities in panoramic radiographs.

Odontoma in a young and anxious patient associated with unerupted permanent mandibular cuspid: A case report

Odontomas are among the most frequent odontogenic tumors of the jaws that generally appear as single or multiple teeth-like radiopaque lesions. As reported in the literature, they often interfere with tooth eruption and are usually discovered by routine panoramic radiographs. This case report shows a compound odontoma and the associated impaction of the underlying mandibular permanent right cuspid in an ASA II 10-year-old male Caucasian patient. Treatment plan involved surgical excision with histopathological analysis. No signs and symptoms were observed over 6 months of follow-up.

SQUAMOUS ODONTOGENIC TUMOR: REPORT OF A RARE CASE

A 51-year-old black woman sought care in a hospital because of an asymptomatic lesion involving the left anteroposterior region of the mandible identified in a routine panoramic radiograph. Intraoral physical examination revealed a small expansion of the region. Radiographic examination showed a multilocular radiolucent lesion with well-defined borders in the left side of the mandible, involving elements 31 to 35 and measuring approximately 5 cm in diameter. The treatment consisted of an excisional biopsy complemented with curettage. Histopathologic examination showed fragments of a benign odontogenic neoplasia presenting proliferation of polyhedral and cuboidal epithelial cells with eosinophilic cytoplasm, organized in nests, and intermingled by dense connective tissue. Cystic degeneration and individual keratinization of neoplastic cells were also observed. Neoplastic cells were positive in immunohistochemical reactions for cytokeratins 14 (CK14) and 19 (CK19). A diagnosis of squamous odontogenic tumor was established, and the patient remains without signs of recurrence after 18 months. A 51-year-old black woman sought care in a hospital because of an asymptomatic lesion involving the left anteroposterior region of the mandible identified in a routine panoramic radiograph. Intraoral physical examination revealed a small expansion of the region. Radiographic examination showed a multilocular radiolucent lesion with well-defined borders in the left side of the mandible, involving elements 31 to 35 and measuring approximately 5 cm in diameter. The treatment consisted of an excisional biopsy complemented with curettage. Histopathologic examination showed fragments of a benign odontogenic neoplasia presenting proliferation of polyhedral and cuboidal epithelial cells with eosinophilic cytoplasm, organized in nests, and intermingled by dense connective tissue. Cystic degeneration and individual keratinization of neoplastic cells were also observed. Neoplastic cells were positive in immunohistochemical reactions for cytokeratins 14 (CK14) and 19 (CK19). A diagnosis of squamous odontogenic tumor was established, and the patient remains without signs of recurrence after 18 months.

MULTIPLE ORTHOKERATINIZED ODONTOGENIC CYSTS IN A 17-YEAR-OLD PATIENT

A 17-year-old white male patient sought dental treatment because of asymptomatic lesions identified in a routine panoramic radiograph. Intraoral and extraoral physical examinations revealed a small expansion of the left body of the mandible and teeth mobility involving elements 35 to 37. A large unilocular radiolucent lesion with well-demarked borders involving teeth 31 to 38 was noticed. On the right side, a unilocular radiolucent lesion with well-demarked borders was identified adjacent to the distal root of tooth 47. The diagnostic hypotheses included keratocysts related to Gorlin syndrome. Excisional and incisional biopsies were performed on the right and left sides of the mandible, respectively. Histopathologic analysis showed cystic capsules lined by orthokeratinized stratified epithelium presenting a flat surface with the connective tissue capsule and no palisading of the basal cells. The left side lesion has been decompressed, and there were no signs of recurrence after a 4-month follow-up period.

Carotid Artery Calcification: A Digital Panoramic-Based Study.

Objective: The aim of this study was to estimate the incidence of carotid artery calcification (CAC) in a sample of Lebanese population using digital panoramic radiographs. Materials and Methods: Panoramic radiographs of 500 patients (281 females and 219 males), aged between 18 and 88 years (mean: 47.9 years), were assessed for CAC. Data collected were analyzed statistically using IBM® SPSS® for Windows version 20.0 (SPSS, Chicago, IL, USA). Results: CAC were found in 34 cases (6.8%), among them, 23 females (8.18%) and 11 males (5.02%). Six of all the calcifications were on the right side, against six on the left side, and 22 on both sides. The mean age of patients affected with CAC was 60.9 years (ranging from 18 to 88 years). Chi-square test showed no statistical significance between gender and CAC, while Spearman correlation analysis showed positive low correlation with age (r = 0.179). Conclusion: CAC can be found on routine panoramic radiographs taken in dental clinics; dentists should automatically refer the patients in question for specialized medical evaluation.

Ossifying fibroma – diagnosis, treatment, and follow-up: case report and literature review

OBJECTIVE: This article presents a case of ossifying fibroma (OF), including its diagnosis, treatment, and 15-month clinical and radiographic follow-up as well as a review of the literature about this pathology.CASE REPORT: A routine panoramic radiograph of a 27-year-old, systemically healthy, white woman revealed a radiolucent lesion with well-defined sclerotic margins of approximately 3 × 2 cm in the mandible. The histopathological diagnosis revealed it was an OF. Lower Right Canine and Lower Right First Premolar teeth were endodontically treated for later surgical removal of the tumor. There was no history of trauma in the region.CONCLUSION: OF is a benign fibro-osseous tumor of the craniofacial bones commonly involving the jaws, especially the mandible. The diagnosis is based on a combination of clinical, radiographic and histologic criteria. Conservative treatment is an effective option that reduces morbidity and simplifies postoperative rehabilitation. We emphasize the importance of properly documenting individual cases and interpreting postoperative radiographic images along with the patients in order to avoid possible confusion between areas of bone repair and of potentially suspicious lesions in the future.

Prevalence of C-shaped mandibular molars in the Portuguese population evaluated by cone-beam computed tomography.

Objective:The purpose of this study was to evaluate the prevalence of first and second C-shaped mandibular molars in a Western European population of Portuguese Caucasians.Materials and Methods:Patients having both routine panoramic radiograph and presurgical cone-beam computed tomography (CBCT) exams were selected. The CBCT examination was performed at five different axial levels and the mandibular molars were classified as C-shape according to the Fan criteria. Differences between genders, age groups, left and right side, type of tooth, and root concavity side were determined. The molars were classified as nonfused roots (NFRI–II), FRI–III, or single root with single canal (SS) groups, using the panoramic radiograph. The prevalence of C-shaped anatomy was calculated to each group.Results:A total of 1783 teeth (695 first molars and 1088 second molars) from 792 patients were included in the study. The prevalence of C-shaped configurations was 0.6% and 8.5% to mandibular first and second molars, respectively. The differences between gender, teeth, and root concavity direction were considered statistically significant (P < 0.05). The FR had a significantly higher rate of C-shapes when compared to NFR (P < 0.05). Intrarater reliability was 93.6%.Conclusions:The FR radiographic appearance may be considered a predictor of this anatomy. Second mandibular molars and females had a higher incidence ratio. Apparently, the mandibular C-shaped anatomy is more common in the population of this study than that has been previously reported for the European population.

Asymptomatic calcifying cystic odontogenic tumor presenting as a random radiographic finding

Calcifying cystic odontogenic tumor (CCOT), a rare odontogenic lesion, usually appears as radiolucency with radiopacities. This characteristic finding may not always be evident depending on the lesion stage, growth, and histopathological features. An asymptomatic case of CCOT alongside an unerupted third molar that was discovered randomly after a routine panoramic radiograph is presented in a 28-year-old male patient. The imaging examination by cone beam computed tomography revealed a unilocular corticated radiolucency in close association with the buccal aspect of a fully impacted mandibular third molar that extended to the apical third of the tooth. The roots appeared outside the lesion and there was no evidence of resorption or jaw bone erosion. Based on the imaging findings, the provisional clinical diagnosis was dentigerous cyst. After the surgical removal of the cystic lesion, which had adhered in the cemento-enamel junction of the third molar, the histopathological examination showed a CCOT. Unerupted third molars should be investigated radiographically even in the absence of clinical signs for the early diagnosis and management of the various odontogenic cysts and tumors.

Maxillary odontogenic keratocyst: a clinical case report

Odontogenic keratocysts are benign lesions of the maxillomandibular region with high growth potential resulting in huge bone destruction. The presence of multiple Odontogenic keratocysts can be associated with the Gorlin-Goltz syndrome. There are two accepted theories of their origin: remnants of dental lamina and proliferation of cells from the basal layer of oral epithelium into the mandible or maxilla. Odontogenic keratocysts are usually asymptomatic and are diagnosed incidentally on routine periapical or panoramic radiographs. The type of treatment is related to their high recurrence rate. The objective of the present study is to report a clinical case of a surgical treatment of a parakeratinized odontogenic keratocyst by enucleation in a fourteen-year old girl. This technique was used since the complete removal of the cyst posed no risks of complications from a dental and/or anatomical point of view. Furthermore, it facilitated the comprehensive anatomohistopathological analysis of the lesion including its clinical, histopathological, and radiological aspects.

Gubernacular Cord and Canal

The gubernacular cord, located within the gubernacular canal, links the tooth follicle to the overlying gingiva and can be identified in the alveolar region of the lingual/palatal surface of deciduous teeth. Some authors believe that the gubernacular canal and cord play a role in the guiding the course of tooth eruption, whereas others claim that these structures can influence the development of an adenomatoid odontogenic tumor (AOT). Here, we present the case of an 11-year-old female who, on a routine panoramic radiograph, presented a well-defined radiolucency around the crown of an impacted tooth associated with a canal in the apical direction, which was diagnosed as hyperplastic dental follicle associated with gubernacular cord. It is likely that most cases presenting gubernaculum dentis are undiagnosed or misdiagnosed. Current data show that there is a histogenetic relationship between the gubernaculum dentis and AOT; hence its importance.

Evaluation of calcified carotid atheroma on panoramic radiographs and Doppler ultrasonography in an older population.

AimThe aim of this study is to determine the reliability of panoramic radiograph (PR) as a screening tool for the detection of calcified carotid atheroma (CCA) by comparing it with Doppler ultrasonography (DU) examination. A second aim was to evaluate the relationship among CCA, systemic diseases, smoking, and body mass index in an older population.Materials and methodsA total of 1,650 PRs of patients aged over 45 years (736 males and 914 females) were randomly selected. All the patients had been referred to the Faculty of Dentistry, Afyon Kocatepe University, Afyonkarahisar, Turkey, during 2013–2014 for routine PR screening. Medical data were collected from the archival records of the dental school. The patients were divided into two groups: Group A (study group), CCA findings were confirmed by DU (n=59); and Group B (control group), CCA findings were not confirmed by DU (n=34).ResultsOf the 1,650 individuals, 93 (5.63%) were detected to have CCA on PR. The population consisted of 43 males and 50 females with mean age of 59.84±10.92 years. No difference was determined in respect of CCA between the sexes (P=0.745). There was a significant difference between Group A and Group B in respect of hypertension (P=0.004). But there was no difference between Group A and Group B in respect of age (P=0.495), BMI (P=0.756), diabetes (P=0.168), and smoking (P=0.482) distribution.ConclusionAlthough PR cannot be used as an initial diagnostic method when searching for CCA, dentists should be aware of CCA on a routine PR, particularly in older patients who may also have the risk factors of obesity, diabetes mellitus, hypertension, and smoking. Recognizing of CCA especially in hypertensive patients could potentially increase the length and quality of life for individuals.