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Editor: Panoramic and the Allan G. Farman, BDS, PhD (odont.), DSc (odont.), detection of carotid Diplomate of the American Board of Oral By Dr. Allan G. Farman inferior-posterior to the angle of and Maxillofacial the .6Similar The most common manifestations Radiology, Professor of calcifications are found in the of atherosclerosis are coronary Radiology and Imaging coronary arteries of individuals Sciences, Department of artery disease, peripheral vascular having ischemic heart disease.10 Surgical and Hospital disease and cerebrovascular Atherosclerosis is not the only Dentistry, The University of accidents - .1 In the USA, Louisville School of cause of soft-tissue calcifications 731,000 suffer a stroke each year Dentistry, Louisville, KY. seen anterior to the cervical with 165,000 not surviving.2 There vertebrae in panoramic are approximately 4 million stroke radiographs (Fig. 4). Care needs to Featured Article: survivors. Lifelong disabilities such be applied to differentiate as loss of mobility, aphasia, and carotid calcifications from Detecting Carotid depression often afflict survivors.3 Atherosclerosis calcified triticeous or thyroid Estimated healthcare costs cartilages, calcified lymph nodes related to acute and chronic and non-carotid phleboliths.8 For management of are $40 In the Recent Literature: this reason, it is important to have billion annually. Atheroma-related an Anterior-Posterior (AP) formations of thrombi and emboli Mandibular Trauma radiograph of the neck made in the carotid artery is the most using soft tissue exposure settings. Age Determination frequent cause of stroke.4 Early Calcifications within the carotid detection of carotid Prevalence of Dental arteries will appear lateral to the atherosclerosis has the potential to Anomalies in Down spine, whereas calcifications in save lives and reduce medical Syndrome Patients the thyroid gland, thyroid expenditures. cartilage, triticeous cartilage or Locating Unerupted Teeth Since 1981, Friedlander and his epiglottis will be in the midline, colleagues have actively Stylohyoid Ligament superimposed over the spine. promoted panoramic radiology as Calcification Other calcifications that can be an aid in detecting patients at risk superimposed over the same part of stroke.5 Calcified of the panoramic film include atherosclerotic lesions at the F.A.Q.s phleboliths (sclerosing Film Reimbursement carotid bifurcation can be seen in hemangiomata), and calcified the lower corners of the panoramic acne or lymph nodes. The radiograph adjacent to the stylohyoid and stylomandibular cervical spine and hyoid (Fig. ligaments are situated posterior 1-3). Such atheroma may appear as rather than inferior to the a nodular radiopaque mass or as mandibular ramus – and therefore double radio-opaque vertical lines should be readily differentiated. within the neck. These calcifications are found at the level Associations of the lower margin of the third and Factors predisposing carotid Panoramic Corporation the entirety of the fourth cervical atherosclerosis include advancing [email protected] vertebra, about 1.5 to 2.5 cm age, male gender, systolic “Unfortunately, atherosclerosis is an insidious disease, often providing few signs and symptoms before life threatening catastrophic failure ensues in the form of a stroke or heart attack.” , hypercholester- Friedlander et al. (1999) studied olaemia, cigarette smoking, the prevalence of carotid atheroma mellitus, physical in male patients with obstructive inactivity, , hemostatic sleep apnea.12 Detectable carotid factors, and coronary artery atheroma was found in 22 % of the disease. 1,3 Patients with diabetes study subjects compared to 4% in mellitus, those who have received age and gender matched controls. therapy for head and neck cancer, and patients having Management have a While atherosclerosis-related greater prevalence of calcified maladies are perhaps the most carotid atheromas visible on prevalent cause of life-threatening panoramic radiographs than do human disease, there is still not a healthy, age-matched persons. thorough understanding of its Friedlander and Maeder (2000) causes. Associations are known, and examined the panoramic where these can be changed, the radiographs of men aged 55 to 81 progression of atheroma can be years who were receiving insulin to halted and even reversed. Such treat mellitus, and associations include hypertension, compared these to radiographs excessive dietary intake of from age-matched nondiabetic unsaturated fats, obesity, lack of controls.9 The incidence of physical activity, diabetes mellitus, detected carotid atheroma and tobacco habits. approximated 20% among the Unfortunately, atherosclerosis is diabetics compared to 4% for an insidious disease, often providing controls. few signs and symptoms before life Friedlander et al. (1998) studied threatening catastrophic failure the detection by panoramic ensues in the form of a stroke or of radiation-induced heart attack. It is for this reason that accelerated atherosclerosis in the dentist’s careful evaluation of 10 patients with osteoradio-necrosis. the panoramic dental radiograph Fig. 1. Case #1: Carotid atherosclerosis The prevalence for carotid might be instrumental in saving a occur most frequently at the bifurcation calcifications in patients who had patient’s life. Individuals with of the common carotid. Initially there is received on averaged a dose of 60 panoramic radiographs intimal thickening. This is followed by varying degrees of obstruction. The Gy to the carotid demonstrating possible carotid atherosclerotic plaque often calcifies, artery disease should be followed bifurcation was 28%. The prevalence and it is the calcific deposits that can was 5% in a matched sample of up using an Anterior-Posterior (AP) be seen on panoramic radiography. non-irradiated patients. The head film with exposure settings difference was statistically highly sufficiently low to show the soft significant (p = 0.001). Chen et al. tissues (fig. 5). If calcification is (2001) found the prevalence of confirmed to be in the region of the calcified carotid atheroma in carotid arteries on the AP view, the panoramic radiographs for head patient should be referred to a and neck cancer patients prior to physician for confirmation of irradiation to be 7% giving further carotid atherosclerosis. Doppler support to irradiation promoting duplex sonogaphy is a noninvasive carotid artery atherosclerosis.11 method of choice for reevaluation “ It is for this reason that the dentist’s careful evaluation of the panoramic dental radiograph might be instrumental in saving a patient’s life.”

of such individuals. images. Unless one can see the Patients with more than 60% anterior outline of the third and blockage of the carotid artery can fourth cervical vertebrae to the have the likelihood of stroke side of the panoramic image, one reduced by more than half if is probably missing details of the endarterectomy is performed to relevant region. Taking a radiograph surgically remove the plaque.13,14 with the patient one centimeter Those with less extensive lesions can anterior and one centimeter be treated using a drug regimen superior to the instructions of the such as aspirin (which is an manufacturer of the panoramic antiplatelet agent) or triflusal to system would optimize the image stem atherosclerosis progression for carotid calcification detection and reduce embolus formation.15,16 – as would underexposure; however, Modification in life-style is usually this is not recommended as it is necessary to increase daily suboptimal for evaluation of the exercise, avoid foods high in teeth and . The panoramic Fig. 2. Case #2: Calcified atheroma of the carotid artery saturated fats and, where technique modification described bifurcation. There are extensions applicable, to be treated for would be best left to follow-up to a into both the internal and the hypertension and/or to cease regularly performed panoramic external carotid arteries in this smoking.2,17,18 radiograph. case. (Detail from panoramic (3) Viewing conditions are radiograph.) Cautions critical to detecting carotid (1) It is possible for a carotid artery atheroma using panoramic images. to be occluded by atheromatous The radiograph should be viewed plaque in the absence of on a view box with a variable noticeable calcification. While one rheostat to adjust the intensity of can question the possibility of the transmitted light. The ambient carotid disease when finding lighting should be subdued. A hot suspicious calcifications, one light is also helpful when looking for should never use the panoramic carotid calcifications. radiograph as a test for carotid atherosclerosis; you should not give the patient the “all clear” based References upon a panoramic radiograph 1. Tegos TJ, Kaldodiki E, Sabetai MM, Nicolaides AN. The genesis of alone. It is the patient’s physician, atherosclerosis and risk factors: a not his or her dentist that should be review. Angiology 2001;52:89-98. the final diagnostician. 2. Gorelick PB, Sacco RL, Smith DB, Fig. 3. Case #3: Calcified atheroma of (2) Different panoramic systems the carotid artery bifurcation. (Detail Alberts M, Mustone-Alexander L, from panoramic radiograph.) result in nonidentical radiographic Rader D, Ross JL, Raps E, Ozer MN, images. Some machines are likely to Brass LM, Malone ME, Goldberg S, be less able to detect carotid Booss J, Hanley DF, Toole JF, calcification than are others. Greengold NL, Rhew DC. Prevention of a first stroke: a Factors to consider include the review of guidelines and a positioning of labels with multidisciplinary consensus demographic information and date statement from the National of exposure, lead indicators of the Stroke Association. JAMA side – and sometimes their ghost 1999;281:1112-20. 3. Friedlander AH, Friedlander IK. a head and neck cancer Identification of stroke prone population. J Dent Res patients by panoramic dental 2001;80(SI):70 (Abstr.276). radiography. Oral Health 12. Friedlander AH, Friedlander IK, 1996;86:7-10. Yueh R, Littner MR. The 4. Friedlander AH, Identification prevalence of carotid of stroke-prone patients by atheromas seen on panoramic panoramic and cervical spine radiographs of patients with radiography. Austr Dent J obstructive sleep apnea and 1998;43:51-4. their relation to risk factors for 5. Friedlander AH, Lande A. atherosclerosis. J Oral Panoramic radiographic Maxillofac Surg 1999;57:516-21. identification of carotid 13. The Asymptomatic Carotid arterial plaques. Oral Surg, Oral Atherosclerosis Study Group. Med, Oral Pathol 1981;52:102-4. Clinical advisory: carotid 6. Friedlander AH, August M. The endarterectomy for patients Fig. 4. Care needs to be taken to role of panoramic radiography with asymptomatic internal differentiate between calcified in determining an increased risk carotid artery stenosis. Stroke atheroma and other structures in 1994; 2523-5. the same vicinity that can also of cervical atheromas in 25: calcify. Such structures include the patients treated with 14. Towne JB. Current status of thyroid cartilage, the thyroid therapeutic irradiation. Oral operative treatment for gland, the triticeous cartilage, and Surg Oral Med Oral Pathol Oral asymptomatic carotid steno- the epiglottis. Radiol Endod 1998;85:339-44 sis. Can J Surg 1994;37:128-34. 7. Baron MG. Significance of 15. Clagett GP, Graor RA, Salzman coronary artery calcification. EW. Antithrombotic therpy in Radiology 1994;192:613-4. peripheral arterial occlusive 8. Carter LC, Discrimination disease. Chest 1992;102: between calcified triticeous 516S-28S. cartilage and calcified carotid 16. Cesarone MR, Laurora G, atheroma on panoramic DeSanctis MT, Incandela L, radiography Oral Surg Oral Fugazza L, Giradello R, Poli A, Med Oral Pathol Oral Radiol Peracino L, Ambrosoli L, Endod 2000;90:108-10. Belcaro G. Effects of trifusal on 9. Friedlander AH, Maeder LA. The arteriosclerosis progression prevalence of calcified assessed with high-resolution carotid atheromas on the arterial ultrasound. Angiology panoramic radiographs of 1999;50:455-63. patients with type 2 diabetes 17. Dunbabin DW, Sandercock mellitus. Oral Surg Oral Med PAG. Preventing stroke by Fig. 5. Anterior-Posterior (AP) neck Oral Pathol Oral Radiol Endod modification of risk factors. view made using reduced exposure to 2000;89:420-4. Stroke 1990;21(Suppl 4):1V 36-9. highlight the soft tissues. The right 10. Friedlander AH, Eichstaedt RM, 18. Fausto N. Atherosclerosis in common carotid artery is calcified Friedlander IK, Lambert PM. young people. The value of the throughout its length (arrows) with Detection of radiation- autopsy for studies of the calcifications of both internal and induced, accelerated epidemiology and external carotid arteries. Calcified atherosclerosis in patients with pathobiology of disease. Am J atheroma is also noted in the region osteoradionecrosis by Pathol 1998;153:1021-2. of the carotid bifurcation on the left panoramic radiography. J Oral side. The AP view is a useful adjunct Maxillofac Surg 1998;56:455-9. to rule out calcifications being in 11. Chen J, Beckstrom B, Greenwell midline structures. H, Drisko CL, Abaskaron M, Khan Z, Farman AG. Incidence of carotid artery calcifications in In The Recent Literature:

Mandibular trauma. Panoramic physician were 0.96, 1.00, and 0.92 Down syndrome. radiographs are equal in sensitivity for PS and 0.88, 0.92, and 0.96 for MS. Shapira J, Chaushu S, Becker A. and specificity to high-quality four- Again there was no significant Prevalence of transposition, view mandibular series for the difference between the two third molar agenesis, and maxillary detection of fractures. methods (p > 0.625, p > 0.50, and p = canine impaction in individuals with Guss DA, Clark RF, Peitz T, Taub M. 1.00, respectively, McNemar’s Down syndrome. Angle Orthod 2000; Pantomography vs mandibular binomial test). It can be concluded 70:290-6. [from the Department of series for the detection of that a panoramic radiograph is Pediatric Dentistry, Hebrew mandibular fractures. Acad Emerg equal to a high quality four-view University-Hadassah Faculty of Med 2000;7:141-5. [from the mandibular series. Dental Medicine, Jerusalem, Israel.] Department of Emergency Medicine, UCSD Medical Center, San Diego, CA Age determination. The panoramic Anomalies in the size, morphology 92103-8676, USA.] radiograph is useful for assessment and number of teeth are among the of the dental ages of children and many inherited disorders that have The two primary radiographic adolescents. been reported in individuals having techniques used for the evaluation Frucht S, Schnegelsberg C, Schulte- Down syndrome. By contrast, third of mandible injury are the Monting J, Rose E, Jonas I. Dental molar agenesis and tooth panoramic radiograph (PS) and the age in southwest Germany. A transposition have been largely standard four-view mandibular series radiographic study. J Orofac Orthop ignored and the prevalence of (MS). The hypothesis of this study was 2000;61:318-29. [from the Department canine impaction had not been that there is no difference in of , University of reported previously. The intent of sensitivity or specificity between a Freiburg, Germany.] this study was to quantify the panoramic radiograph and a high- A cross-sectional study was made to occurrence of such anomalies in a quality standard MS for the assess the biological dental age of group of individuals with Down detection of mandibular fractures. A healthy children between the syndrome, using standardized prospective, blinded study of 54 chronological ages of 2 and 20 records, which included a clinical patients presenting with acute years. 1,003 panoramic radiographs examination, dental casts, and a mandibular injury was performed to were studied, and all were from panoramic radiograph. A high compare PS to MS. Two board- children in southwest Germany. The prevalence of third molar agenesis certified emergency physicians and permanent teeth of the left side of (74% of individuals older than 14 a single staff radiologist read the the lower were rated, except for years), canine impaction (15%), and series of PS and MS films in a the third molars. The development maxillary canine/first premolar randomized fashion without access of each tooth was divided into 8 transposition (15%), was found in to clinical information or identifying defined stages. Statistical comparison to published findings patient data. For fractures present, evaluation revealed a correlation from other populations. The the truth was determined by a between chronological age and anomalies should not be seen as neuroradiologist with access to both biological age for both genders (r = separate, independent entities, but the panoramic radiographs and the 0.85 for girls; r = 0.89 for boys). Two as associated phenomena. Perhaps plain film series, as well as pertinent gender-specific equations for the maxillary canine/first premolar clinical information. Thirty patients calculating dental age were transpositions represent a pheno- had 47 mandibular fractures. The devised and a marked sexual typic expression of this trisomy. sensitivities for fractures detection dimorphism was found. Girls showed for each physician were 0.79, 0.74, Locating unerupted teeth. The accelerated dental development in and 0.83 with PS and 0.85, 0.77, and negative beam angulation of a comparison with boys. 0.89 with MS. There was no significant panoramic radiograph can be difference between the two Prevalence of dental anomalies in combined with the different vertical methods (p > or = 0.51, p > or = 1.00, Down syndrome patients: angulation of an occlusal and p > or = 0.51, respectively, Panoramic radiographs can be radiograph for achieving parallax. McNemar’s binomial test) with used successfully for evaluation of Jacobs SG. Radiographic regard to sensitivity. The specificity the dental condition in special localization of unerupted for fractures detection for each patients such as those having mandibular anterior teeth. Am J Orthod Dentofacial Orthop radiograph makes the tube shift patients were sorted according to 2000;118:432-8. [from the Dental Health effect easier to discern when the patient’s age group (up to 20- Services Victoria, Australia.] comparing the relative positions of years of age, 21-40 years, 41-60 years, dental structures depicted in the and older than 60 years). 718 The parallax method using two occlusal radiograph to their relative stylohyoid chains were clearly radiographs taken with different positions in a panoramic radiograph. demonstrated and, of these, 221 beam angulations is a method (30.8%) showed elongation of the Stylohyoid ligament calcification: commonly used to locate unerupted styloid process or ossification of the Panoramic radiography is useful in teeth. Most often this method is stylohyoid ligament. With increasing evaluating calcification of the described using a pair of intraoral age, there was an increase in the stylohyoid ligament. Calcification radiographs. The author instead incidence and length of stylohyoidal progresses with increasing age, recommends the use of a panoramic ossifications (p < 0.01). A linear especially up to age 20 years. radiograph and an occlusal correlation between the length of Krennmair G, Lenglinger F, Lugmayr H. radiograph. This combination involves the stylohyoidal ossifications and Variants of ossification of the a vertical x-ray tube shift. Case age was found only in the youngest stylohyoid chain. Rofo Fortschr Geb reports are presented that age group (up to 20 years; p < 0.01). In Rontgenstr Neuen Bildgeb Verfahr demonstrate the proposed this age group, calcifications were 2001;173(3):200-4. [from the University combination can accurately locate most commonly restricted to the Clinic for Oral and Maxillofacial unerupted mandibular anterior teeth. superior stylohyoidal segment. With Surgery, University of Vienna, Austria.] A deceptive appearance of the increasing age, the middle and labiolingual position of the Age-related differences in the inferior stylohyoid segments were unerupted tooth can be produced if incidence, length and topographic more frequently ossified. In solely depending on an occlusal location of ossifications in the conclusion, stylohyoidal ossifications radiograph. Increasing the vertical stylohyoid chain were examined. evidenced age-related differences angle of the tube for the occlusal Panoramic radiographs of 380 in incidence, length and topography. Frequently Asked Questions About Film Reimbursement: Q:Is it true insurance will pay for enters those findings in the patient “necessary” periapicals to panoramic films every 3 to 5 years? record as a separate dated and complete the assessment and A: This may or may not be factual, signed report, or, even better, as render a diagnosis worthy of a depending on the individual case. part of the treatment record for D0150 comprehensive oral As with all radiographs taken, that day’s visit. If there is no evaluation. When submitting a dental or medical, there must documentation of radiographic panoramic film plus bitewings in be a clinical justification for taking findings, there is no liability for lieu of D0210 — complete series, the film. This justification must be payment. third party payors will most likely noted in the patient file, and in reimburse at 80 to 85% of D0210, some circumstances, on the Q:How many films are included in including any necessary insurance forms. The frequency D0210 — Intraoral — complete series periapicals. and number of films taken is not (including bitewings)? determined by the insurance, but A: Whatever number of films the NOTE: Questions on insurance and by the clinical necessity. There is dentist needs to complete the reimbursement are very difficult as only liability for payment when the radiographic assessment of this each represents a unique situation. dentist puts on the hat of patient according to the needs of We have enlisted the aid of experts in the field and the above Radiologist and determines that the patient and the professional information has been excerpted with there is, or is not, suspected judgement of the doctor. The same permission from DENTAL INSURANCE pathology and subsequently holds true for D0330 panoramic film TODAY, a newsletter published by plus “necessary” bitewings and any Atlanta Dental Consultants. For more information on this newsletter contact Atlanta Dental Consultants at 404-252-7808.

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