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Carotid calcifications in panoramic radiographs in relation to carotid stenosis
Umeå University, Faculty of Medicine, Department of Odontology.ORCID iD: 0000-0003-1320-4400
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Calcifications in carotid atheromas can be detected in a panoramic radiograph (PR) of the jaws. A carotid artery calcification (CAC) can indicate presence of significant (≥ 50%) carotid stenosis (SCS). The aim of this thesis was to (1) determine the prevalence of SCS and burden of atherosclerotic disease among patients revealing CACs in PRs, (2) determine the prevalence of CACs in PRs among patients with SCS, (3) analyze whether the amount of calcium and/or (4) the radiographic appearance of the CACs, can improve the positive predictive value (PPV) for SCS detection among patients with CACs in PRs.

The thesis is based on four cross-sectional studies. Two patient groups were prospectively and consecutively studied. Group A represented a general adult patient population in dentistry examined with PR presenting incidental findings of CACs. These patients were examined with carotid ultrasound for presence or absence of SCS and their medical background regarding atherosclerotic related diseases and risk factors was reviewed. An age and gender matched reference group was included for comparisons. Group B comprised patients with ultrasound verified SCS, examined with PR prior to carotid endarterectomy. The PRs were analysed regarding presence of CACs. The extirpated plaques were collected and examined with cone-beam computed tomography (CBCT) to determine the amount of calcium. The radiographic appearance of CACs in PRs from Group A and B were evaluated for possible association with presence of SCS.

In Group A, 8/117 (7%) of patients with CAC in PRs revealed SCS in the ultrasound examination, all were found in men (8/64 (12%)). Patients with CACs in PRs revealed a higher burden of atherosclerotic disease compared to participants in the reference group (p <0.001). In Group B, where all patients had SCS, 84% revealed CACs in PRs and 99% of the extirpated plaques revealed calcification. CACs with volumes varying between 1 and 509 mm3 were detected in the PRs. The variation in volume did not correlate to degree of carotid stenosis. The radiographic appearance that was most frequently seen in neck sides with SCS (65%) was also frequently found in neck sides without SCS (47%) and therefore the PPV did not improve compared to the PPV solely based on presence of CACs.

CACs in PRs are more associated with SCS in men than in a general population and patients with CACs in PRs have a higher burden of atherosclerotic disease. The majority of patients with SCS show CACs in PRs and the majority of extirpated carotid plaques reveal calcification. The volume of CAC and specified radiographic appearance does not increase the PPV for SCS in patients with CACs in PRs. In conclusion patients with CACs in PRs, and without previous record of cardiovascular disease, should be advised to seek medical attention for screening of cardiovascular risk factors.

Abstract [sv]

Bakgrund Inom ramen för specialist- och allmäntandvård utförs panoramaröntgen-undersökningar dagligen på såväl barn som vuxna. En panoramaröntgenbild (PB) är en översiktsbild som är specifikt anpassad till att återge området för tänder och käkar. Utöver det, avbildas även delar av halsen och som bifynd ibland förkalkningar belägna i området för halspulsådern (karotiskärlet). Dessa förkalkningar kallas för karotisförkalkningar och är ett tecken på åderförkalkning. Åderförkalkning består i huvudsak av en fettrik plackansamling i kärlväggen. Placket kan med tiden förkalkas till varierande grad. Det är dessa förkalkningar vi kan se i PB. När en åderförkalkning ökar i volym kan den utgöra en förträngning i kärlet. Då förträngningen av kärldiametern är ≥ 50% benämns åderförkalkningar belägna i karotiskärlet för ”signifikanta karotisstenoser” (SKS). Graden av förträngning bedöms som regel med ultraljudsundersökning av halskärlen. Bitar av SKS kan lossna varvid det bildas små blodproppar. Eftersom halspulsådern försörjer främre hjärnhalvan med blod så kan dessa bitar täppa till ett av hjärnans blodförsörjande kärl och leda till stroke (slaganfall). För att minska risken att drabbas av stroke kan man ibland operera bort SKS (karotisplacket).

Syfte Syftet med denna avhandling var att ta reda på (1) hur många av de patienter som blir undersökta med PB inom tandvården som uppvisar karotisförkalkningar, hur stor andel som har SKS samt utreda om patienter med förkalkningar i PB i större utsträckning är drabbade av hjärtkärlsjukdomar/risk faktorer, (2) hur ofta utopererade karotisplack innehåller kalk och hur ofta patienter med känd SKS uppvisar karotisförkalkningar i PB, (3) huruvida förkalkningsmängden i utopererade karotisplack är korrelerad till förträngningsgrad, och (4) huruvida det finns något specifikt radiografiskt utseende på karotisförkalkningar i PB som kan användas för att identifiera en större andel patienter med SKS bland patienter som uppvisar karotisförkalkningar i PB, det vill säga minska risken för att skicka patienter utan SKS på ultraljudsundersökning.

Material och metoder Materialet bestod av två huvudgrupper av patienter. Grupp A bestod av patienter undersökta inom tandvården med PB som uppvisat karotisförkalkningar. Alla dessa patienter undersöktes med ultraljud för att bedöma förekomst av SKS. Den medicinska journalen granskades avseende tidigare förekomst av åderförkalkningsrelaterade sjukdomar och risk faktorer. En köns- och åldersmatchad kontrollgrupp utan karotisförkalkningar i PB analyserades på motsvarande sätt för jämförelse. Grupp B bestod av patienter med känd SKS som före operativt avlägsnande av karotisplack undersöktes med PB. PB granskades avseende förekomst av karotisförkalkning och utopererade karotisplack avseende kalkinnehåll. Förkalkningsmängden i de utopererade karotisplacken korrelerades dels till möjlighet att identifiera karotisförkalkning i PB samt till förträngningsgraden i kärlen. Karotisförkalkningarnas utseende delades in i grupper för att utvärdera om vissa utseenden i större utsträckning kunde associeras till förekomst av SKS.

Resultat I Grupp A uppvisade 8/117 (7%) patienter SKS, alla var män, 8/64 (12%). Patienter med karotisförkalkningar i PB hade oftare åderförkalkningsrelaterade sjukdomar och risk faktorer (p < 0,001). I Grupp B hade 84% av patienterna med SKS karotisförkalkning i PB. Bland de utopererade karotisplacken innehöll 99% förkalkningar och förkalkningsvolymen varierade från 1-509 mm3. Möjligheten att upptäcka karotisförkalkning i PB var oberoende av om förkalkningsvolymen var stor eller liten. Förkalkningsvolymen var heller inte korrelerad till hur stor förträngning av kärlet en SKS (≥ 50%) orsakat. Ett radiografiskt utseende på karotisförkalkningar i PB noterades i 65% av de halssidor som hade en SKS. Detta specifika radiografiska utseende återfanns dock även i 47% av halssidor utan SKS. Andelen falskt positiva patienter var således fortsatt hög.

Slutsats Vi fann att 12% män med karotisförkalkningar i PB, undersökta i en generell population inom tandvården, uppvisar SKS. Patienter med karotisförkalkningar i PB uppvisar fler riskfaktorer och är oftare drabbade av hjärt-kärlsjukdomar än patienter utan karotisförkalkningar i PB. Majoriteten av patienter med SKS uppvisar karotisförkalkningar i PB och nära 100% av utopererade karotisplack innehåller kalk. Förkalkningsmängden påverkar inte möjligheten att upptäcka karotisförkalkning i PB. Förkalkningsmängd och specificerade radiografiska utseenden hos karotisförkalkningar i PB förutsäger inte SKS bättre än definitionen ”förkalkning ja eller nej”. Dessa parametrar kan således inte användas till att förfina urvalet bland patienter som uppvisar karotisförkalkning i PB mot högre andel patienter med SKS. Individer med karotisförkalkningar i PB bör uppmanas konsultera vården för undersökning av eventuella risk faktorer för hjärt-kärlsjukdom.

Place, publisher, year, edition, pages
Umeå: Umeå University , 2016. , 54 p.
Series
Umeå University odontological dissertations, ISSN 0345-7532 ; 136
Keyword [en]
carotid stenosis, panoramic radiography, calcification, atherosclerosis
National Category
Dentistry
Research subject
Odontology
Identifiers
URN: urn:nbn:se:umu:diva-119794ISBN: 978-91-7601-447-9 (print)OAI: oai:DiVA.org:umu-119794DiVA: diva2:923886
Public defence
2016-06-03, Sal B, Byggnad 1D, 9 tr, Tandläkarhögskolan, 901 87, Umeå, 09:00 (English)
Opponent
Supervisors
Available from: 2016-05-13 Created: 2016-04-27 Last updated: 2016-06-07Bibliographically approved
List of papers
1. Ultrasound screening for asymptomatic carotid stenosis in subjects with calcifications in the area of the carotid arteries on panoramic radiographs: a cross-sectional study
Open this publication in new window or tab >>Ultrasound screening for asymptomatic carotid stenosis in subjects with calcifications in the area of the carotid arteries on panoramic radiographs: a cross-sectional study
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2011 (English)In: BMC Cardiovascular Disorders, ISSN 1471-2261, E-ISSN 1471-2261, Vol. 11, no 44, 1-9 p.Article in journal (Refereed) Published
Abstract [en]

Background: Directed ultrasonic screening for carotid stenosis is cost-effective in populations with > 5% prevalence of the diagnosis. Occasionally, calcifications in the area of the carotid arteries are incidentally detected on odontological panoramic radiographs. We aimed to determine if directed screening for carotid stenosis with ultrasound is indicated in individuals with such calcifications. Methods: This was a cross-sectional study. Carotid ultrasound examinations were performed on consecutive persons, with findings of calcifications in the area of the carotid arteries on panoramic radiography that were otherwise eligible for asymptomatic carotid endarterectomy. Results: Calcification in the area of the carotid arteries was seen in 176 of 1182 persons undergoing panoramic radiography. Of these, 117 fulfilled the inclusion criterion and were examined with carotid ultrasound. Eight persons (6.8%; 95% CI 2.2-11.5%) had a carotid stenosis - not significant over the 5% pre-specified threshold (p = 0.232, Binomial test). However, there was a significant sex difference (p = 0.008), as all stenoses were found in men. Among men, 12.5% (95% CI 4.2-20.8%) had carotid stenosis - significantly over the 5% pre-specified threshold (p = 0.014, Binomial test). Conclusions: The incidental finding of calcification in the area of the carotid arteries on panoramic radiographs should be followed up with carotid screening in men that are otherwise eligible for asymptomatic carotid endarterectomy.

Place, publisher, year, edition, pages
BioMed Central, 2011
Keyword
endarterectomy, stroke, emboli, trial, risk
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:umu:diva-45670 (URN)10.1186/1471-2261-11-44 (DOI)000294287500001 ()21752238 (PubMedID)
Available from: 2011-08-09 Created: 2011-08-09 Last updated: 2017-12-08Bibliographically approved
2. Detection of calcifications in panoramic radiographs in patients with carotid stenoses ≥50%
Open this publication in new window or tab >>Detection of calcifications in panoramic radiographs in patients with carotid stenoses ≥50%
Show others...
2014 (English)In: Oral surgery, oral medicine, oral pathology, oral radiology, and endodontics, ISSN 1079-2104, E-ISSN 1528-395X, Vol. 117, no 3, 385-391 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: Carotid stenoses ≥50% are associated with increased risk for stroke that can be reduced by prophylactic carotid endarterectomy (CEA). Calcifications in arteries can be detected in panoramic radiographs (PRs). In a cross-sectional study, we analyzed (1) extirpated plaques for calcification, (2) how often PRs disclosed calcified plaques, (3) how often patients with stenoses ≥50% presented calcifications in PRs, and (4) the additional value of frontal radiographs (FRs).

STUDY DESIGN: Patients (n = 100) with carotid stenosis ≥50% were examined with PRs and FRs before CEA. Extirpated carotid plaques were radiographically examined (n = 101).

RESULTS: It was found that 100 of 101 (99%) extirpated plaques were calcified, of which 75 of 100 (75%) were detected in PRs; 84 of 100 (84%) patients presented carotid calcifications in the PRs, in 9.5% contralateral to the stenosis ≥50%.

CONCLUSIONS: Carotid calcifications are seen in PRs in 84% of patients with carotid stenosis ≥50%, independent of gender. FRs do not contribute significantly to this identification.

Place, publisher, year, edition, pages
Elsevier, 2014
National Category
Clinical Medicine Dentistry
Research subject
Odontology
Identifiers
urn:nbn:se:umu:diva-86143 (URN)10.1016/j.oooo.2014.01.010 (DOI)000331062700029 ()24528796 (PubMedID)
Available from: 2014-02-18 Created: 2014-02-18 Last updated: 2017-12-06Bibliographically approved
3. Calcium quantity in carotid plaques: detection in panoramic radiographs and association with degree of stenosis
Open this publication in new window or tab >>Calcium quantity in carotid plaques: detection in panoramic radiographs and association with degree of stenosis
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2015 (English)In: Oral surgery, oral medicine, oral pathology and oral radiology, ISSN 2212-4403, E-ISSN 2212-4411, Vol. 120, no 2, 269-274 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: To determine calcium volume in extirpated carotid plaques, analyze correlations between calcium volume and degree of stenosis, and analyze whether calcium volume influences the possibility of detecting stenosis in panoramic radiographs.

STUDY DESIGN: Ninety-seven consecutive patients with ultrasonography-verified carotid stenosis were examined with panoramic radiography before surgery. Extirpated carotid plaques (n = 103) were analyzed for calcium volume by cone beam computed tomography (CBCT). Panoramic radiographs were analyzed for carotid calcifications.

RESULTS: The median calcium volume was 45 mm(3) (first quartile subtracted from the third quartile [IQR], 14-98 mm(3)). We observed no correlation between calcium volume and degree of stenosis. Seventy-eight stenoses were situated within the region included in the panoramic radiographs, and their volumes ranged from 0 to 509 mm(3). Of these, 99% revealed carotid calcifications on panoramic radiographs.

CONCLUSIONS: We found no association between calcium volume and degree of carotid stenosis. Calcium volume did not influence the possibility of detecting carotid calcifications in panoramic radiographs.

National Category
Dentistry Radiology, Nuclear Medicine and Medical Imaging
Research subject
Odontology; Radiology; Medicine, cardiovascular disease
Identifiers
urn:nbn:se:umu:diva-107590 (URN)10.1016/j.oooo.2015.04.010 (DOI)000360302600022 ()26166031 (PubMedID)
Available from: 2015-08-25 Created: 2015-08-24 Last updated: 2017-05-10Bibliographically approved
4. Carotid calcification in panoramic radiographs: radiographic appearance and the degree of carotid stenosis
Open this publication in new window or tab >>Carotid calcification in panoramic radiographs: radiographic appearance and the degree of carotid stenosis
Show others...
2016 (English)In: Dento-Maxillo-Facial Radiology, ISSN 0250-832X, E-ISSN 1476-542X, Vol. 45, no 6, 20160147Article in journal (Refereed) Published
Abstract [en]

Objectives: Approximately 7% of patients examined with panoramic radiographs (PRs) for odontological reasons, and with incidental findings of carotid artery calcification (CAC), have significant (≥50%) carotid stenosis (SCS). The aim of this study was to determine if the radiographic appearance of CACs in PRs could be categorized such that we could improve the positive-predictive value (PPV) for SCS detection.

Methods: This cross-sectional study included 278 patients with CACs identified by PRs, 127 with SCS and 151 without SCS. CACs were categorized based on the following appearances: (1) single, (2) scattered or (3) vessel-outlining. Correlates were derived for each category according to positivity or not for SCS in the corresponding neck sides. For a representative adult population (in dentistry) presenting with CACs in PRs, PPVs for SCS prediction were then calculated for three subgroups based on different combinations of appearances (2) and/or (3).

Results: Vessel-outlining CACs corresponded to 65% of neck sides with SCS vs 47% without SCS (p < 0.001). Single CACs corresponded to 15% of neck sides with SCS vs 27% without SCS (p = 0.006). Scattered CACs corresponded to 20% of neck sides with SCS vs 26% without SCS (p  = 0.127). In the representative population, the PPVs for SCS detection were comparable (7.2–7.8%) for all three subgroups and when the presence of a CAC is the sole criterion (7.4%).

Conclusions: Stratifying the radiographic appearance of CACs in PRs does not improve the PPV for SCS detection. Whether different radiographic appearances are associated with future risk of stroke, or other cardiovascular events, remains unknown.

Place, publisher, year, edition, pages
British Institute of Radiology, 2016
Keyword
carotid stenosis, panoramic radiography, calcification
National Category
Dentistry Radiology, Nuclear Medicine and Medical Imaging
Research subject
Odontology
Identifiers
urn:nbn:se:umu:diva-119791 (URN)10.1259/dmfr.20160147 (DOI)000381711400003 ()
Note

First published in theses in manuscript form.

Available from: 2016-04-27 Created: 2016-04-27 Last updated: 2017-11-30Bibliographically approved

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