Ultrasonographic confirmation of carotid artery atheromas diagnosed via panoramic radiography

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ABSTRACT

Background

Studies have shown that panoramic radiographs can capture images of calcified atheromas in the internal carotid artery (ICA) in some neurologically asymptomatic patients receiving routine dental care. However, the prevalence of these hemodynamically significant lesions—that is, those causing greater than 50 percent vessel lumen occlusion with the consequent heightened risk of stroke—has been evaluated rarely. The purpose of this study was to use Doppler ultrasonography (DUS) to determine the prevalence of large occlusive lesions detected initially via panoramic radiography. Aggressive medical and surgical interventions directed toward these large lesions have been shown to moderate the risk of stroke.

Study Design

The authors analyzed the panoramic radiographs of 1,548 consecutively treated, neurologically asymptomatic dental patients who were 50 years or older. Those with presumptive atheromas underwent DUS for confirmation of the diagnosis and for determination of the degree of stenosis.

Results

The radiographs of 65 patients (4.2 percent) showed at least one ICA atheroma. Thirty-eight patients had bilateral opacities and 27 had unilateral opacities. DUS evaluation of the 103 sides of the neck with a radiographically identified atheroma revealed that none of the ICAs were normal, 81 (79 percent) had less than 50 percent stenosis, 18 (17 percent) had 50 to 69 percent stenosis and four (4 percent) had 70 percent or greater stenosis. Four of the ICAs on the 27 sides without calcifications were deemed normal and 23 had less than 50 percent stenosis.

Conclusions

These results demonstrate that a subset of patients (15 [23 percent] of 65) with an occult atheroma discovered on panoramic radiography had significant (≥ 50 percent) levels of ICA stenosis.

Clinical Implications

Dentists should refer all patients with radiographically identified atheromas to a physician for confirmation of the diagnosis and a determination of the magnitude of disease, because antiatherogenic interventions have been shown to prevent a stroke.

Section snippets

BACKGROUND

Traditionally, screening for cervical carotid artery atheromas 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 a 50 percent specificity and a 50 percent sensitivity. Collateral confirmation was difficult, but occasionally the lesion could be visualized on a plain radiograph of the cervical spine or on the superior aspect of a standard chest radiograph.

Approximately 25

Subjects

The survey population consisted of 1,614 consecutively treated (between Nov. 1, 2002, and March 31, 2004) outpatients attending the oral surgery section of the dental service at the Veterans Affairs Outpatient Clinic, Sepulveda, Calif. Inclusion criteria for patients were as follows:

  • age 50 years or older;

  • the ability to undergo panoramic radiography, and if it showed a possible atheroma, the ability to undergo a DUS study.

Exclusion criteria included poor-quality radiographs (that is, overexposed

Sample characteristics and radiographic findings

Of the 1,614 subjects initially evaluated, 66 had radiographs of poor image quality and were excluded. The final sample population of 1,548 consisted of 1,487 men ranging in age from 50 to 83 years (mean age, 61.2 years) and 61 women ranging in age from 50 to 79 years (mean age, 64.3 years).

Of the final sample population of 1,548 patients, 65 (61 men and four women) (4.2 percent) had observable opacities consistent with carotid artery calcification on their panoramic radiographs (Figure 1,

DISCUSSION

The results of this study demonstrated that 4.2 percent of neurologically asymptomatic patients 50 years or older had calcified atheromas in one or both ICAs, as shown on panoramic radiographs. Furthermore, DUS studies demonstrated that 15 patients (23 percent) with radiographically identified atheromas had hemodynamically significant stenotic disease (≥ 50 percent) that placed them at a heightened risk of developing stroke.

CONCLUSION

The results of this study demonstrate that when dentists evaluate carefully the panoramic radiographs of neurologically asymptomatic patients for the presence of calcified carotid artery atheromas, they can, on occasion, identify patients with advanced disease. Clinicians should refer all patients with atheromalike lesions on their radiographs to a physician, because aggressive medical treatment of early and advanced atherosclerotic disease has been shown to decrease the likelihood of fatal and

References (23)

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    Furthermore, 80% of patients with CCAAs on PRs have low-grade stenosis (<50% blockage), when assessed with Doppler ultrasonography.8 Furthermore, no arteries with normal arterial structure have been seen presenting CCAA.25 Previous reports have supported the recommendation that men below age 75 years without a history of cerebrovascular disease, but with CCAAs on PRs, should have a cardiovascular risk profile assessment.2

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1

Dr. Friedlander is associate chief of staff and director of Graduate Medical Education, VA Greater Los Angeles Healthcare System; director of Quality Assurance, Hospital Dental Service, University of California, Los Angeles Medical Center; and a professor, Oral and Maxillofacial Surgery, School of Dentistry, University of California, Los Angeles.

2

Dr. Garrett is an associate professor, Advanced Prosthodontics, Biomaterials and Hospital Dentistry, University of California, Los Angeles; director, Weintraub Center for Reconstructive Biotechnology, School of Dentistry, University of California, Los Angeles; and director, Oral Biology Research Laboratory, VA Greater Los Angeles Healthcare System.

3

Dr. Chin is a staff radiologist, Imaging Service, VA Greater Los Angeles Healthcare System, and an assistant clinical professor of radiology, David Geffen School of Medicine, University of California, Los Angeles.

4

Dr. Baker is chief, Vascular Surgery Section, VA Greater Los Angeles Healthcare System, and a professor of surgery, David Geffen School of Medicine, University of California, Los Angeles.

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