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Radiology - A Quarterly Newsletter on Dental SpecialtiesJADA Specialty Scan

Using digital panoramic images to detect risk indicators for fatal stroke in African American women

The rate of fatal stroke in African American women has been reported to be 30% higher than that in white women, and the rate of fatal coronary heart disease has been reported to be twice as high. In a retrospective, cross-sectional study published in the May issue of Oral Surgery Oral Medicine Oral Pathology Oral Radiology, the authors evaluated digital panoramic images from African American women for the presence of calcified carotid artery atheromas (CCAAs).

The study was composed of 171 self-identified African American women 45 years and older for whom comprehensive electronic medical records (EMRs) and digital panoramic images were available from the Los Angeles Veterans Affairs Medical Center. The patients had undergone digital radiography to evaluate the need for dental treatment between January 1, 2007, and March 30, 2014, the authors wrote. Their mean (standard deviation [SD]) age was 58.2 (8.0) years.

The panoramic images were obtained by means of a Planmeca unit and Romexis image transfer system (Planmeca Oy, Helsinki, Finland). The investigators viewed the images on medical-grade computer monitors in a darkened room. They obtained demographic data (age and ethnicity) and proatherogenic variables (hypertension, type 2 diabetes mellitus, and dyslipidemia) from the patients’ EMRs, the authors wrote.

The researchers considered a patient to be CCAA+ if her panoramic image revealed unilateral or bilateral CCAA. After ruling out confounding radiopacities close to the vessel, the researchers diagnosed CCAA+ as heterogeneous radiopacities in a verticolinear orientation in proximity to the hyoid bone and epiglottis approximately at the level of cervical intervertebral space C3-4. The CCAA– group consisted of participants whose panoramic images did not exhibit a CCAA, the authors wrote.

The investigators reported that 41 patients (24%) were CCAA+. Their mean (SD) age was 61.4 (10.1) years, and they were significantly older (P = .02) than those in the CCAA– group (mean [SD] age, 57.2 [7.0] years), wrote the authors. In addition, patients who were CCAA+ had a higher prevalence of diabetes (P = .04) and dyslipidemia (P = .03) than those who were CCAA–.
The retrospective nature of the study was its primary limitation, the researchers pointed out. Consequently, they could not capture all atherogenic risk factors, including smoking history, body mass index, family history of cardiovascular disease, and specific delineation of menopausal status. They also could not obtain carotid artery ultrasound studies to evaluate the degree of associated vessel stenosis.

The authors expressed the belief that their “findings will strengthen the resolve of dentists with access to panoramic images of [African American women] to evaluate them for the presence of vascular disease.”

“Despite a decline in stroke mortality in all race-gender groups,” the authors wrote, the fatal stroke rate in African American women is nearly 2-fold higher than that in white women.

Read the original article.

 

Consulting Editor: Laurie C. Carter, DDS, PhD
Past president, American Academy of Oral and Maxillofacial Radiology

CBCT images compared on 3 display systems, tablet

The popularity of implant dentistry has led to an increasing reliance on 3-dimensional imaging of the maxillofacial region in treatment planning and presurgical workup. To evaluate systems for viewing images acquired from cone-beam computed tomographic (CBCT) scans, the authors compared 4 displays. The findings were published in the June issue of Implant Dentistry.

In this study, researchers evaluated 32 deidentified CBCT scans that were acquired with a Hitachi CB MercuRay unit (Hitachi Medical Technology), using parameters of 120 kilovolts and 15 milliamperes. Inclusion criteria were a missing posterior tooth or teeth in the maxilla or mandible and CBCT scans, with a 6-inch field of view, acquired to evaluate an edentulous implant site. The researchers excluded scans with artifacts and those that were not of diagnostic quality.

All CBCT scans were analyzed by means of 4 display systems: a medical-grade picture archiving and communication system (PACS) liquid crystal display (LCD) monitor (Planar PX212M), a consumer-grade LCD monitor (HP Compaq LA2205wg) with CBWorks software (Cybermed), a 13-inch MacBook Pro (Apple) with OsiriX Digital Imaging and Communications in Medicine (DICOM) reader software (Pixmeo), and an iPad 4 with retina display (Apple) also with OsiriX DICOM reader software, the authors wrote.

The investigators used the CBWorks and OsiriX software systems to measure the length and width of edentulous posterior regions. The cross-sectional image slicer tool was used to create cross-sectional images.

Length was determined by measuring the bone from a repeatable point in the middle of the alveolar crest to the border of the cortical bone, and width was determined by measuring the distance between the buccal and palatal/lingual cortices in the center of the measured length, the authors wrote.

An experienced oral and maxillofacial radiologist and a senior oral and maxillofacial radiology resident reviewed each CBCT image twice (in 2 sessions) in the oral and maxillofacial radiology clinic under standardized lighting and sound conditions. The iPad 4 with OsiriX software was used in a room with fluorescent light to simulate normal dental office conditions, the authors wrote. The users manipulated the images using multiple functions, such as zoom and histogram tools that control brightness and contrast. The region of interest (ROI) was set to the edentulous areas of the maxilla and mandible in the premolar and molar regions.

The users evaluated the displays with respect to the accuracy of linear measurements (height and width) relative to the PACS monitor, considered to be the criterion standard, wrote the authors. They also assessed diagnostic quality, defined as the “ability to visualize predetermined specific anatomical landmarks and trabecular bone pattern.” Image resolution needed to be high enough to show the ROI and demonstrate any pathology, the authors noted.

The statistical analyses revealed no significant differences between the displays, the authors wrote. They reported a high level of agreement between the 2 observers in their evaluations of the 4 displays. In addition, intraoperator reliability was high. The study results showed that the iPad 4 was comparable to the more expensive and heavier displays in terms of measurement accuracy and image visualization, the authors wrote. In terms of portability, however, the users gave the PACS monitor the lowest score (1 = very poor) on a 5-point Likert scale and the iPad 4 the highest score (5 = very good).

The resolution of all 4 displays provided “consistent and reliable results in linear measurements and visualization of anatomical landmarks in the CBCT volumes,” the authors concluded. The iPad 4 with retina display was comparable to the medical-grade PACS LCD monitor and provides an inexpensive, portable, and reliable screen to use for treatment planning and during surgery.

Read the original article.

 
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Using CBCT to assess the anatomy of the maxillary sinuses before sinus augmentation

Insufficient information regarding the anatomy of the maxillary sinuses may lead to sinus floor augmentation complications, such as perioperative bleeding. In this study, published in the March issue of Imaging Science in Dentistry, researchers used cone-beam computed tomography (CBCT) to assess the prevalence and position of the posterior superior alveolar artery (PSAA) within the maxillary sinuses.

During 2014-2015, the researchers conducted a retrospective, cross-sectional study in the periodontology department of Shahed University in Tehran, Iran. The randomly selected study sample consisted of 300 patients (156 women, 144 men) with edentulous posterior maxillae who visited the radiology clinic between 2013 and 2015. The mean (standard deviation) age of participants was 62.4 (10.6) years, with a range from 33 through 86 years.

Inclusion criteria were availability of CBCT scans of the posterior maxilla with maxillary molars and premolars missing in at least 1 quadrant, visibility of up to 2 centimeters above the maxillary sinus roof, and absence of motion or scattering artifacts. The researchers excluded images showing changes in the morphology of the sinus walls due to trauma or pathologic conditions.

The CBCT scans were obtained with a NewTom VG unit (NewTom) set at a tube voltage of 110 kilovolt (peak) and a tube current of 13.11 to 20.18 milliamperes, the authors wrote. Two types of scans were performed: the first with a 0.3-millimeter voxel size for a larger field of view (FOV) and the second with a 0.24-mm voxel size for a smaller FOV. The axial thickness was 0.24 mm or 0.3 mm (isotropic voxel reconstruction), and the slice thickness of the multiplanar reconstruction images was 1 mm, wrote the authors.

Using NNT workstation software (Version 4.5, QR), the investigators assessed the posterior superior alveolar canal along the posterolateral wall of the maxillary sinus on the coronal sections of the images. They then recorded the data in each patient’s medical record.

They assessed the PSAA according to the following factors: distance from the inferior border of the PSAA to the alveolar crest (the closest distance to the edentulous ridge was measured), greatest diameter of the PSAA, position of the PSAA (intraosseous, beneath the membrane, or over the external cortex of the lateral sinus wall), distance from the PSAA to the zygomatic arch, closest distance from the PSAA to the nasal septum, and determination of the type of residual alveolar ridge, according to Lekholm and Zarb’s classification based on the amount of resorption.

The researchers detected the PSAA on the CBCT scans of 261 of 300 patients (87%). In 123 of these patients (47%), the PSAA was located beneath the membrane; in 123 patients (47%), the PSAA was intraosseous; and in 15 patients (6%), the PSAA was located on the external cortex of the lateral sinus wall, the authors wrote. The statistical analysis showed a significant difference between men and women in the position of the PSAA (P < .05). In 69 men (47.9%), the PSAA was intraosseous, whereas it was intraosseous in only 54 women (34.6%). In 75 women (48%), the PSAA was beneath the membrane, but it was in this position in only 48 men (33.3%), the authors wrote.

In 74.8% of patients, the PSAA diameter was between 1 and 2 mm; in 4.5% of patients, it was greater than 2 mm; and in 20.7% of patients, it was less than 1 mm. Again, the results of the statistical analysis revealed a significant difference (P < .05) between men and women regarding the PSAA diameter, the authors wrote. In addition, the study findings showed that the PSAA was detected in a significantly (P < .05) smaller percentage of completely edentulous patients (74.3%) than in partially edentulous patients (93.8%).

The authors noted that maxillary sinus floor augmentation is a highly predictable procedure for placement of dental implants in atrophic posterior maxillae. “Knowledge of the anatomy of the region is especially important for the success of this treatment modality,” they wrote.

Read the full article here.

 

Three sinus augmentation procedures compared

Maxillary sinus floor elevation (SFE) procedures have become a popular technique for compensating for inadequate vertical residual bone height (RBH). In this study, published in the June issue of Journal of Clinical Periodontology, investigators compared 3 sinus augmentation procedures to assess volumetric graft changes, Schneiderian membrane swelling, and patient discomfort.

From 2012 through 2015, the authors enrolled 18 patients in this pilot prospective clinical trial. Inclusion criteria were no history of systemic diseases, nonsmoking status, no previous attempt at undergoing an SFE procedure, and no sinus pathology (as assessed by means of preoperative cone-beam computed tomography [CBCT]), the authors wrote. In addition, all patients needed bilateral SFE procedures to undergo implant-supported rehabilitation. Patients’ mean RBH was 3.1 millimeters, with a range from 0.7 to 6.1 mm.

The researchers assigned participants to 1 of 3 procedures based on the RBH of the left and right maxillary sinuses. Patients whose RBH was 4 mm or greater were randomly assigned to the lateral SFE (lSFE), transcrestal SFE (tSFE), or Intralift (IL) procedure, the authors wrote. Those whose RBH was less than 4 mm were randomly assigned to the IL or lSFE procedure. Of the 36 SFE procedures performed, 13 were lSFE, 8 were tSFE, and 15 were IL. A total of 59 implants were placed in augmented sites, 21 of which were placed simultaneously with the SFE and 38 were placed after a 6-month healing period.

The investigators used the Dutch version of the McGill Pain Questionnaire to assess postoperative pain. Patients completed the questionnaire daily, starting from the day of surgery and ending on day 7. They marked the minimum and maximum pain experienced during the previous 24 hours on a 100-mm visual analog scale (0 = no pain, 100 = worst pain imaginable).
As part of the treatment protocol, high-resolution CBCT images were obtained (3D Accuitomo 170, Morita) before surgery and at 1 and 6 weeks after surgery. The researchers used a 100- × 100-mm field of view to include both maxillary sinuses. Scanning parameters were set at 90 kV, 5 mA, 17.5 seconds’ exposure time, and a standard 180-degree rotation. The researchers exported all data sets in the Digital Imaging and Communications in Medicine (DICOM) format with an isotropic voxel size of 250 cubic micrometers.

The authors spatially matched the postoperative CBCT scans to the preoperative CBCT scan using rigid image registration. They then imported the aligned scans into MeVisLab software (MeVis Medical Solutions). An experienced implant surgeon who was blinded to the SFE technique used the semi-interactive live wire boundary extraction tool to extract the sinus cavity and membrane. A 3-dimensional surface of the sinus and membrane was then reconstructed, the authors wrote.

The mean preoperative Schneiderian membrane volume (SMV) at all surgical sites was 4.53 cubic centimeters, the authors wrote. One week after surgery, the mean SMV rose to 11.27 cm3. The study findings did not show any statistically significant differences in swelling among the 3 treatment techniques. Moreover, simultaneous placement of implants had no significant effect on Schneiderian membrane swelling, the authors pointed out. At 6 weeks, the mean SMV was 6.85 cm3, about 39% lower than the volume at week 1.

At week 1, the overall mean graft volume was 1.87 cm3 (range, 0.12-4.72 cm3). At week 6, the overall mean graft volume decreased 27.6%, to 1.33 cm3 (range, 0.10-4.29 cm3), the authors wrote. In terms of specific procedures, the decrease was –23.13% for the tSFE, –24.55 for the lSFE, and –33.71% for the IL.

Regarding postoperative pain, the study results showed that tSFE evoked more pain during the early stages of healing (at 8 hours compared with lSFE and at 8 and 12 hours as well as at day 2 compared with IL). By day 3, no significant differences in postoperative pain were observed between tSFE and IL. Overall, the IL procedure resulted in significantly better pain scores than those for lSFE at days 4, 5, 6, and 7, the authors wrote.

The authors concluded that the 3 SFE techniques provided sufficient graft volume for implant placement. However, tSFE provokes the most intense early postoperative pain, lSFE provides good visibility of the operative field and the ability to manage complications, and IL allows for augmentation of large quantities of graft material. The authors stated that a CBCT scan obtained 6 weeks after surgery appears to be clinically important with respect to visualizing the graft volume and increased thickness of the Schneiderian membrane.

Read the original article.

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JADA+ Specialty Scans and JADA+ Scans

JADA+ Specialty Scans and JADA+ Scans are quarterly newsletters updating dentists on the latest research in selected specialties and disciplines in dentistry. ADA Publishing and the consulting editors from the represented specialties and disciplines aggregate and summarize research from previously published materials, each item attributed to its publication of origin. JADA+ Scan specialties and disciplines include endodontics, oral pathology, orthodontics, pediatric dentistry, periodontics, prosthodontics, radiology, cosmetic/esthetic and osseointegration. The ADA has engaged the specialty organizations in these areas as well as its own Science Institute and Division of Legal Affairs to assist with these newsletters. View past issues here.

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