Implications of intracranial lesions
The clinical significance of identifying incidentally detected intracranial lesions is unmistakable, according to findings published in the November 2014 issue of the Journal of Oral and Maxillofacial Surgery.
Imaging studies have frequently shown that intracranial internal carotid artery calcific atherosclerotic lesions (IICACALs) are the likely cause of stroke or are associated with coronary artery disease. But uniform consensus about their clinical significance was lacking, according to a multidisciplinary team of scientists at the University of California in Los Angeles.
Researchers designed a systematic review of the literature using the PubMed database and two searches querying calcified intracranial vascular lesions. The first search linked the search term “cone beam computed tomography” (CBCT), and garnered few results. They performed a second search linking “non-contrast-enhanced computed tomography” (CT), and included articles using CBCT or CT imaging that enrolled neurologically asymptomatic or symptomatic patients from any ethnic group in the systematic review.
The initial search using the terms “cone-beam computed tomography” and “calcified intracranial vascular lesions” yielded three articles that dealt specifically with the identification of IICACALs on CBCT scans. Researchers also identified five articles using the term “non-enhanced CT,” rather than CBCT, for detailed review.
The three CBCT studies described lesion identification in almost 1,500 dental patients. Two of the three fully addressed the subject, from the systematic reviewer’s perspective. In one, researchers described a 17 percent prevalence rate of intracranial internal carotid artery calcifications from CBCT images of 318 patients averaging 63 years old. The authors of that study found systemic implications of identifying intracerebral vascular calcification and emphasized the need for referral and further workup.
The other CBCT study found that 2.4 percent of 169 older patients (age 50 to 85) showed such lesions. Basing their conclusion on related findings of previous research, those investigators determined that patients with these CBCT findings do not require referral for further evaluation.
However, scientists conducting the systematic review noted a missed finding in the previous research to which the investigators had referred, namely that “the presence of intracranial calcification was associated with a history of cardiac disease and a history of ischemic cerebrovascular disease.”
Of the five CT articles emerging from the search using the term “non-enhanced CT” rather than CBCT, one was conducted in neurologically asymptomatic patients and was deemed uniquely relevant to patients undergoing CBCT for dental treatment. It found that among 885 Caucasian healthy adults, larger calcification volume in the IICA was prominently associated with development of cognitive impairment.
The remaining four non-contrast enhanced CT studies also confirmed that IICACALs are a validated risk marker of advanced stenotic disease in the cerebral circulation, central brain atrophy and concomitant advanced atherosclerotic disease in the cardiovascular circulation and may foreshadow future adverse ischemic events. One study, conducted in South Korea, found a highly illustrative relation between IICACALs and coronary artery disease, which has been substantiated by autopsy studies.
Authors determined that the timely follow-up of incidentally detected IICACALs has tremendous potential to decrease disease morbidity and potential adverse effects on quality of life. “These lesions are validated risk markers of a diffuse atherosclerotic process in the cerebral circulation and likely concomitant disease in other vascular distributions.”
They said all non-contrast-enhanced CT studies emphasized the clinical significance of these lesions in relation to cerebral and cardiovascular disease. “IICACALs seen on CBCT and CT scans present the same risk and should prompt referral for further evaluation.”
Consulting Editor: Laurie C. Carter, DDS, PhD
Past president, American Academy of
Oral and Maxillofacial Radiology
CBCT and the evidence on endodontic treatment and outcomes
Radiologic examination is an essential part of the diagnosis and management of endodontic treatments. Although intraoral radiography is currently the first choice, cone beam computed tomography (CBCT) appears to be superior in managing endodontic diagnosis and complications, according to researchers publishing in the December 2014 issue of the Journal of Endodontics.
Scientists who reviewed the evidence aimed to review and report about CBCT features and how the technology can be applied to improve diagnosis, treatment planning and assessing the outcome of endodontic complications.
They conducted an electronic PubMed search of dental publications and articles written from January 1995-January 2014 and identified 112 articles eligible for detailed analyses in areas including:
- Radiation dose.
- Limitations of CBCT imaging.
- Application of CBCT imaging in the management of endodontic problems.
- Assessment of root canal anatomy.
- Detection of apical periodontitis.
- Presurgical assessment.
- Root canal treatment quality assessment.
- Assessment of endodontic complication: root fracture, resorption or perforation.
The dental literature review showed the greatest limitation of conventional radiography to be the inability to fully describe the 3D anatomy of teeth and their related structures.
“CBCT imaging showed the tendency to more accurately identify fractured files, cast post deviations and perforations compared with radiographs,” authors reported. “These results corroborate the fact that CBCT imaging is a more accurate tool than PRs [periapical radiographs] for the assessment and management of complex endodontic problems.”
They forecasted that CBCT has the potential to become the first choice for endodontic treatment planning and assessment, “especially when new scanners with lower radiation doses and better resolutions become available.”
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Mandible measurements and osteoporosis
Radiography that measures mandibular bone density should be included as a routine procedure in dental examinations to identify patients with undetected low bone mineral density (BMD), according to a report published in the March 2014 issue of the Journal of Clinical and Diagnostic Research.
Although radiographic studies have shown reductions in mandibular cortical thickness in older females, growing evidence suggests that the jaws of many people lose bone at a rapid rate as they age. Scientists in Bangalore, India, found little in the dental literature to evaluate mandibular bone changes among men and younger women and no studies comparing mandibular values between digital and analog radiographs. Additionally, they found no studies that had divided subjects on the basis of gender or different equal age groups.
Scientists collected 128 digital and 128 analog radiographs of patients between the ages of 21 to 60 years old to evaluate the influence of gender and age on radiomorphometric indices and to assess if differences occurred in the values on digital and analog panoramic radiographs. After dividing the radiographs into eight age groups with five-year intervals between them and equal gender distribution, they analyzed values shown to be relevant in the dental literature: mandibular cortical index (MCI), mental index (MI) and panoramic mandibular index (PMI).
Scientists observed mild to moderately and severely eroded cortex measurements increased among females as their ages advanced, presumably reflecting age-related bone loss. For example, mild to moderately eroded cortex measurements were seen in females 26-30 years old and in males 31-35 years old. Severely eroded cortex measurements were seen in females at around age 40 and in males at around age 50.
The relationship between mental index (the measurement of the cortical width at the mental foramen region), and age was significantly different between males and females, being smaller among older females as compared to males of the same age group. Digital radiographs were more accurate, as errors were found among manual measurements.
“Although these indices are regarded as an ancillary method used for the diagnosis of osteoporosis, they should be included as a routine procedure in dental examinations, to identify patients with undetected low BMD,” authors said. “In conclusion, it can be stated that low radiomorphometric indices studied on panoramic radiographs can be used as important criteria for further assessment of bone mineral density.”
Panoramic radiography, periodontitis and osteoporosis detection
Osteoporosis and periodontitis are two separate diseases with different origins. But some scientists believe these diseases may be linked, in part, because they both lead to bone damage.
Scientists publishing in the July-August 2014 issue of the Journal of Contemporary Dental Practice followed up on previous research that showed that panoramic radiography can be a reliable tool for predicting low bone density in patients referred to a dentist. They conducted their own study to determine if a relationship between periodontal disease and markers for osteoporosis of the jaw exists.
Scientists recruited 82 subjects with chronic periodontitis and 80 periodontally healthy individuals who had been referred to a private oral and maxillofacial radiology clinic and were matched in terms of age and gender. Scientists calculated the same panoramic values in each of the groups that previous studies indicated may be useful in screening for osteoporosis in patients referred to a dentist, including the mandibular cortex index (MCI), the mental index and the panoramic mandibular index.
Researchers found that the only measurement significantly different between the two groups was the MCI. The two groups showed differences in mandibular cortical layer porosity resulting from reduced bone mass.
“Since periodontitis leads to local connective tissue degeneration and bone destruction, the difference between the two groups could be attributed to periodontitis,” authors said. “Our results, along with those of other studies, showed that MCI might be used as an indicator of mandibular bone loss in osteoporosis or periodontitis, two diseases with connective tissue destruction.”
Authors said their study showed a significant relationship between the MCI in panoramic radiography and chronic periodontitis, but did not show strong evidence of a relationship between osteoporosis and periodontitis.
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What is Specialty Scan?
This is one in a series of quarterly newsletters updating dentists on selected specialties in dentistry. Information presented is aggregated and summarized from previously published materials, each item attributed to its publication of origin. This issue of JADA Specialty Scan focuses on oral and maxillofacial radiology, the first in the series on this topic for 2015. Other Specialty Scan issues are devoted to periodontics, orthodontics, endodontics and prosthodontics. The ADA has engaged the specialty organizations in these areas as well as its own divisions of Science and Legal to assist with these newsletters. We welcome feedback on this and all Specialty Scan issues.
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