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| Year : 2014 | Volume
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| Issue : 1 | Page : 36-40 |
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| Reliability of digital panoramic radiographs in detecting calcified carotid artery atheromatous plaques: A clinical study |
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Neha Khambete1, Rahul Kumar2, Mukund Risbud3, Anil Joshi4
1 Department of Oral Medicine, Diagnosis and Radiology, CSMSS Dental College and Hospital, Aurangabad, India
2 Department of Conservative Dentistry and Endodontics, MGM Dental College and Hospital, Navi Mumbai, India
3 Department of Oral Medicine, Vasantdada Patil Dental College and Hospital, Sangli, India
4 Department of Radiology, Al Ameen Medical College, Bijapur, India
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| Date of Submission | 12-Oct-2012 |
| Date of Decision | 09-Jul-2013 |
| Date of Acceptance | 19-Jan-2014 |
| Date of Web Publication | 21-Apr-2014 |
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 Abstract | | |
Objectives: The objective of this study was to determine whether digital panoramic radiography is a reliable method to detect calcified carotid artery atheromatous plaques (CCAAP) as compared with ultrasonography.
Study Design: Digital panoramic radiographs were obtained from 50 patients who also underwent carotid ultrasound examination. The images were interpreted by trained maxillofacial radiologist for the presence or absence of calcified atheromatous plaques. The extent of carotid calcification on carotid ultrasonography was determined by a trained Sonologist, which was considered as the gold standard assessment.
Results: Digital panoramic radiographs had a sensitivity of 76% and specificity of 98.66% in determining CCAAP. There was a high level of agreement between diagnoses, with a kappa value of 0.8.
Conclusion: To conclude, digital panoramic radiographs had good sensitivity and high specificity in detecting CCAAP. If properly trained, dentists can detect such plaques and can refer patients to physician for timely medical treatment. Keywords: Calcified carotid artery atheromas, digital imaging, panoramic radiography, ultrasonography
How to cite this article:
Khambete N, Kumar R, Risbud M, Joshi A. Reliability of digital panoramic radiographs in detecting calcified carotid artery atheromatous plaques: A clinical study. Indian J Dent Res 2014;25:36-40 |
How to cite this URL:
Khambete N, Kumar R, Risbud M, Joshi A. Reliability of digital panoramic radiographs in detecting calcified carotid artery atheromatous plaques: A clinical study. Indian J Dent Res [serial online] 2014 [cited 2023 Sep 25];25:36-40. Available from: https://www.ijdr.in/text.asp?2014/25/1/36/131052 |
Cerebrovascular accidents or strokes are the third most common cause of morbidity and mortality in world-wide population. The last few decades have seen a rise in the incidence and prevalence of stroke in India. [1] One-half of all strokes are believed to be the result of atherosclerotic disease at the carotid bifurcation, which is associated with embolization of atherosclerotic debris or a platelet-fibrin clot formed on the plaque surface. [2],[3]
In recent years, many publications have described the detection of calcifications in the region of the carotid bifurcation on panoramic radiographs. [2] Carotid artery calcifications can be detected on the panoramic radiograph below the mandibular angle and adjacent to the cervical vertebrae at the level of the C3-C4 intervertebral junction. Studies have reported a 2-11% prevalence rate of calcified carotid artery atheromatous plaques (CCAAP) on panoramic radiographs in the dental patient population. [4],[5],[6],[7],[8],[9] This gives dentists an additional responsibility to examine this much ignored but vital area on panoramic radiographs. Although calcifications may not imply significant stenosis and not all atherosclerotic lesions are calcified, it is hypothesized that the presence of calcifications seen on dental radiographs may be associated with significant latent carotid disease.
There is limited literature documenting the reliability of conventional panoramic radiographs in detecting CCAAP. [10],[11],[12],[13] Most of these studies concluded that conventional panoramic radiographs are not reliable in detecting calcified atheromatous plaques. [10],[11] None of studies have reported utility of digital panoramic radiographs in detecting CCAAP.
The purpose of this study was to determine if digital panoramic radiography is a reliable method for detecting CCAAP.
| Materials and Methods | |  |
The study plan was formulated, submitted to institutional research board and approval was taken. A total of 50 patients visiting to our dental outpatient department, who were advised panoramic radiographs, were selected for the study with informed consent. Patients were excluded if they were younger than 50 years of age, pregnant or had a history of surgery or radiotherapy to the neck previously.
Panoramic radiographic examination
Each patient was subjected to digital panoramic radiographic examination by orthopantomogram machine, panorex dental X-ray system (Meditronics (ASIA) Pvt. Ltd., Mumbai, India) at 70-74 kVp, 10 mA, for 10 s using phosphor plates of size 6" × 12". Panoramic radiography was performed with the mandible placed on the chin rest of the machine and the patient in a standing position. Although positioning the patient for radiographic examination and a larger phosphor plate was used. Care was taken to include a relatively wide area distal and inferior to angle of mandible in order not to miss CCAAP. The plates were processed in computed radiography (CR) system regius nano CR reader (Konica Minolta Medical Imaging Inc. NJ, USA) with a high resolution 87.5 µm mode. The images were recorded in digital imaging and communications in medicine format. The images were enhanced for obtaining optimum density, contrast and brightness.
The processed digital images were then carefully scrutinized by experienced oral radiologist for the presence of nodular, punctate and linear radiopacities in the soft-tissues of the neck posteroinferior to angle of mandible at the lower margin of third and fourth cervical vertebra i.e., the area of bifurcation of the common carotid artery. The differential diagnosis of calcified atheromatous plaques given by Almog et al., was used to differentiate these plaques from other anatomic and pathologic radiopacities. [14]
Ultrasonographic examination
Carotid ultrasound was performed for each patient by a high resolution B-mode ultrasound system GE Logiq 5 Pro with the frequency 8-12 MHz using linear probe. Both right and left carotids were assessed by the Sonologist. The carotid artery scanning protocol consisted of imaging the carotid arteries in the longitudinal and transverse planes. The initial exploratory examination consisted of a gray-scale examination in transverse and longitudinal scan of the carotid system followed by a detailed longitudinal examination of the specific arterial segments. Scans were obtained along the entire course of the carotid artery from the supraclavicular notch to the angle of mandible.
The ultrasonographic examination of the patients was carried out to confirm whether the radiopaque bodies seen on the panoramic radiograph were indeed vessel wall calcifications or not and to attempt to determine the exact location and nature of the calcified body if not intravascular.
The panoramic radiographic findings and ultrasonographic findings in each case were carefully recorded in the proforma and were subjected to further analysis. Statistical analysis was performed using SPSS version 16 (IBM Corp,Chicago, USA) statistical program (IBM Corp, Chicago, US) and relevant results were obtained. The patients who had atheromatous plaques on panoramic radiographs and ultrasound examination were referred to physicians for further management.
| Results | | |
Fifty patients with the age range of 50-84 years with a mean age of 64.45 years were included in this study. Out of these 50 patients 17 patients showed presence of radiopaque bodies posteroinferior to angle of mandible at the lower margin of third and fourth cervical vertebra. Thus, the prevalence of calcified atheromatous plaques was established to be 34%. Out of these, three patients showed the presence of radiopaque bodies bilaterally. [Table 1] shows the distribution of radiopaque bodies according to sides. Thus in total, we had 20 radiopaque bodies suggestive of atheromatous plaques. Further, the patients underwent ultrasonographic examination to confirm if the atheromatous plaques were indeed vascular calcifications or not [Figure 1] and [Figure 2]. | Figure 1: Cropped digital panoramic radiograph showing radiopaque body at left C3-C4 junction suggestive of calcifi ed atheromatous plaque
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 | Figure 2: Ultrasound showing hyperechoic area confi rming presence of calcifi ed atheromatous plaque
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 | Table 1: Distribution of atheromatous plaques on panoramic radiographs according to side
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In this study, we screened total 50 patients by using ultrasonographic examination. Both sides of each patient were observed on the images with a total of 100 analyzed cervical regions. In 100 regions, we had total 25 ultrasonographic images showing calcified plaques out of which 19 calcified plaques were detected on panoramic radiographs. In six cases, the plaques were not detected on panoramic radiographs [Figure 3] and [Figure 4]. However in one case, the radiopaque body detected on panoramic radiograph was not an atheromatous plaque, but was greater cornua of hyoid bone [Figure 5]. [Table 2] and [Figure 6] depict the correlation between panoramic radiographic and ultrasonographic findings. | Figure 3: Cropped digital panoramic radiograph showing absence of any radiopaque body
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 | Figure 4: Ultrasound showing hyperechoic area confi rming presence of calcifi ed atheromatous plaque suggestive of false negative result
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 | Figure 5: Cropped digital panoramic radiograph showing radiopaque body which was greater cornua of hyoid bone suggestive of false positive result
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 | Figure 6: Graph showing correlation of panoramic radiographic and ultrasonographic fi ndings
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 | Table 2: Utility of panoramic radiography to detect any calcifi ed carotid artery atheromatous plaques
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Thus it was established that digital panoramic radiography had 76% sensitivity and 98.66% specificity in detecting calcified atheromatous plaques. The positive predictive value was 95% and negative predictive value was 92.5%. The level of agreement between panoramic radiography and ultrasonography was determined by calculating kappa (K) value. The kappa value calculated in our study was, K = 0.8, which indicates a high level of agreement between digital panoramic radiography and ultrasonography.
| Discussion | | |
Traditionally, screening for cervical carotid artery atheromatous plaques was solely within the purview of physicians and was based on auscultation of the neck for a bruit. At best, this was a crude screening method because the examination had only 50% specificity and 50% sensitivity. As this method was based on the physician's skill, it was subjective. [13] Ever since then, efforts have been made to detect these lesions as early as possible and search for a reliable screening method continues. So far ultrasonography has been the most reliable screening method. Approximately 25 years ago, Arthur Friedlander in 1981 first unveiled the presence of soft tissue calcifications in this unvisited territory of panoramic radiographs. The reported prevalence of calcified atheromatous plaques ranges from 2% to 11%. However in our study, the prevalence was much higher (34%). This may be attributed to use of digital radiography. Digital radiography in dentistry has been around for more than a decade and it has improved significantly during that time. Digital radiography offers the ability of image enhancement by altering the contrast and density, which helps in better detection of atheromatous plaques. [15],[16]
There has been a great deal of controversy regarding reliability of panoramic radiographs in detection of CCAAP. Madden et al., reported that conventional panoramic radiography had a low reliability in detection of CCAAP. [10] Friedlander et al., in their study reported 4.2% prevalence of CCAAP on panoramic radiographs out of which 23% of population had significant internal carotid artery stenosis. [13] Khosropanah et al. in their study concluded that panoramic radiographs were not good screening tool for detection of carotid stenosis. [17] However Ravon et al., reported that subjects with positive Doppler ultrasound readings of carotid arteries due to calcified arterial plaques were accurately detected by means of conventional panoramic radiography. They had a moderate level of agreement with K value of 0.61. [18] In a study conducted by Romano-Sousa et al., showed that there was a high level of agreement between diagnosis of calcified carotid atheromas seen on panoramic radiographs and color Doppler images with a K = 0.78. [12] According to these studies panoramic radiographs had low to moderate specificity and low positive predictive value. In our study, however panoramic radiography has 76% sensitivity at detecting CCAAP. When calcifications were detected radiographically, this diagnosis was correct 95% of the time with a high positive predictive value compared with ultrasonography as the gold standard. The specificity of panoramic radiography to rule out calcification was very good at 98.66%. The negative predictive value was 92.5%, reflecting few false negatives. We report very high level of agreement between panoramic radiographic and ultrasonographic findings with a K value of 0.8. So far this is the highest level of agreement reported in the literature. The high level of agreements may be related to use of digital imaging instead of conventional film based imaging.
In the present study, it was not our intention to indicate panoramic radiography as the method of choice for detecting calcified plaques in the carotid artery. Instead, we intended to demonstrate that digital panoramic radiography is an important adjuvant for general evaluation by the dentist, who can adequately refer patients to physicians if a suspicion of atheromatous plaque or other pathology arises.
| Conclusion | | |
Digital panoramic radiographs were found to be very effective in detecting calcified atheromatous plaques with high sensitivity and specificity. Panoramic radiography cannot be used as a routine screening tool for detecting calcified carotid atheromatous plaques. Although calcified atheromatous plaques found on panoramic radiographs indicated for routine dental treatment are useful for detecting asymptomatic patients at risk of stroke and referring such patients to physicians for further diagnosis and treatment so that to increase the length and quality-of-life for people with carotid artery atheromatous plaques.
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Correspondence Address:
Neha Khambete
Department of Oral Medicine, Diagnosis and Radiology, CSMSS Dental College and Hospital, Aurangabad
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0970-9290.131052
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2] |
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