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 Table of Contents  
Year : 2021  |  Volume : 8  |  Issue : 1  |  Page : 28-32

Prevalence of carotid artery calcifications in Riyadh from digital panoramic radiographs and its relationship with cardiovascular disorders: A retrospective cross-sectional study

1 Dentist, College of Dentistry, Riyadh Elm University, Riyadh, Kingdom of Saudi Arabia
2 Department of OMFS and Diagnostic Sciences, Riyadh Elm University, Riyadh, Kingdom of Saudi Arabia

Date of Submission15-Aug-2020
Date of Decision07-Sep-2020
Date of Acceptance18-Oct-2020
Date of Web Publication17-Apr-2021

Correspondence Address:
Dr. Alaa Ziad Sinjab
College of Dentistry, Riyadh Elm University, P.O. Box 8963, Riyadh 11492
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjos.SJOralSci_78_20

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Introduction: Atherosclerosis of the external division of the carotid artery contributes to approximately 20% among all the reasons leading to stroke. The strategies for the prevention of stroke remain underutilized despite the advancements in healthcare. Dentists can contribute in the prevention of stroke by identifying patients at risk from the details revealed in radiographic imaging.
Aim: The aim of this study is to determine the prevalence of carotid artery calcifications (CACs) detected on digital panoramic radiographs in Riyadh and its relationship with cardiovascular disorders.
Methodology: A retrospective cross-sectional study was conducted in Riyadh Elm University using digital panoramic radiographs. A total of 158 panoramic radiographs were analyzed with patients aged ≥18 years. The presence of CAC was determined and confirmed by an oral radiologist. Medical records were retrieved and collected from the digital data base after ethical approval. Chi-square test of independence was performed to examine the relationship between variables (age, gender, and medical problems) and the presence of calcification.
Results and Discussion: From the data scrutinized, 158 panoramic radiographs were included for the study. 111 radiographs did not have any calcifications. 47 radiographs depicted the presence of soft tissue calcification, out of which 20 radiographs were of CAC and the remaining contributed to other soft tissue calcifications seen in the neck region. There was significant correlation between age and calcification, P = 0.003 with the highest prevalence in 40–69 years. Correlation between gender, CAC, and medically compromised conditions associated with cardiovascular systems was not significant.
Conclusion: The prevalence of CAC in the Riyadh population was 1.12%. CAC comprised of 12.66% among all the soft tissue calcifications of the neck in this study. Patients are not aware of the underlying cardiovascular risk that CAC can pose. Dentists' diagnostic efficiency in analyzing CAC, which is a risk factor for cardiovascular events, can reduce further morbidities or mortality rates enhancing the quality of life and life span.

Keywords: Atheromas,a atherosclerosis, cardiovascular disease, cardiovascular diseases, carotid artery, calcification, digital imaging, panoramic radiograph, stroke risk

How to cite this article:
Sinjab AZ, Soman C, Sahab LA. Prevalence of carotid artery calcifications in Riyadh from digital panoramic radiographs and its relationship with cardiovascular disorders: A retrospective cross-sectional study. Saudi J Oral Sci 2021;8:28-32

How to cite this URL:
Sinjab AZ, Soman C, Sahab LA. Prevalence of carotid artery calcifications in Riyadh from digital panoramic radiographs and its relationship with cardiovascular disorders: A retrospective cross-sectional study. Saudi J Oral Sci [serial online] 2021 [cited 2023 Jan 27];8:28-32. Available from: https://www.saudijos.org/text.asp?2021/8/1/28/313929

  Introduction Top

Atherosclerosis is a serious chronic inflammatory disease that consists of fatty plaque build-up in the walls of arteries. Over time, continuous accumulations of lipids, cholesterol, calcium, and inflammatory cells cause calcifications that project themselves into the vessel lumen.[1] Blockages, especially in larger arteries, can have a deleterious effect on the blood and oxygen flow to the designated organ. The incidence of atherosclerosis is associated with cardiovascular disease (CVD) which is one of the main leading causes of death worldwide.

According to a recent study published by the World Health organization (WHO) in 2018, the leading cause of death in Saudi Arabia is CVD.[2] Ischemic heart disease (113.9 deaths per 100,000 population) and stroke (49 deaths per 100,000 population) were the leading cause of death in the top 10 causes of death among both genders in Saudi Arabia, in 2019 in Global Health Estimates, Leading Causes of Death, 2019 by the WHO. However, the leading cause of disability adjusted life year (DALY) estimates rank ischemic heart disease as the top most reason (3368.6 DALYs per 100,000 population) and third in line is stroke (1525.9 DALYs per 100,000 population).[3]

Blockage or occlusions in the common carotid artery (CCA) can lead to a decrease in blood volume to the brain. These obstructions can increase the risk factor for future vascular impediments for the patients including cerebrovascular accidents and myocardial infarction.[4] When the plaque build-up or atheromas affect the carotid artery, they form carotid artery calcification (CAC). In most cases, atherosclerosis can remain undetected with no symptoms until its late stages resulting in mortality and morbidity. Therefore, early detection particularly with a minimally invasive technique such as panoramic radiograph can help in identification of CAC and early intervention from CVD.

Calcifications located in the bifurcation of the CCA were first observed on panoramic radiographs by Friedlander and Lande, 1981.[5] Furthermore, Cohen et al., 2002 observed that CAC appears as small nodular radiopacities near the angle of the mandible.[6] Radiographically, CAC may differ in radiopacity depending on the quantity of plaque, likewise, and according to recent studies, it may appear as a single or multiple small radiopaque lesions inferior to the angle of the mandible at the level of C3–C4 in a vertical direction.[7]

Several radiopaque or calcified anatomical structures can be differentiated using panoramic radiographic near the neck region, including hyoid bone, cricoid cartilage, the superior horn of the calcified and epiglottic thyroid cartilage, and lesions such as sialoliths, elongation, and calcifications of the styloid process, and calcifications in the stylomandibular and stylohyoid ligaments.[8] To distinguish the similar structures, Vatansever et al., 2018 concluded that CCA ascends from the posterolateral side of the larynx, and therefore, atherosclerotic plaques that form are located more laterally than triticeous cartilage.[9] Therefore, proper and vigilant analysis of the panoramic radiograph needs to be acquired.

  Methodology Top

This research is a retrospective cross-sectional study registered and approved by the institutional review board. It complies with the ethical requirements as stated in the Declaration of Helsinki. The radiographs analyzed included both of male and female patients aged ≥18 years from 2016 to 2019. Exclusion criteria followed the research done by Juliana-Mara-Oliveira Santos et al.[10] Therefore exclusion criteria used were as follows: Images that did not include the region of cervical vertebrae or presented low radiographic quality, and/or structures overlapping the diagnostic region, blurred image. Calcifications were categorised according to their side, size, position, shape, pattern, and quantity.

The panoramic radiographs were taken using the digital ORTHOPHOS XG 5/CG 5 DS/Ceph panoramic unit by Sirona Dental Systems. The radiation exposure settings range was from 60 kV/3 mA to 90 kV/12 mA, the exposure time range was from 10 to 15 s, as well as the resolution was 0.027mm pixel size. CAC was considered present if it is visible in the panoramic radiograph in the soft tissues of the neck either superior or inferior to the greater cornua of the hyoid bone and adjacent to the cervical vertebrae C3, C4, or the intervertebral space between them.[11]

The medical history of the patients was retrieved from the electronic data system. It is the protocol to document any medical conditions, medications, and previous medical and dental treatments for every new patient. Patients with positive CAC detection were contacted via phone to confirm medical records. Data collected were analyzed for inclusion and cross evaluated by the contributors. The diagnosis was made under the supervision of an oral and maxillofacial radiologist.

  Results Top

In this study, over 1781 radiographs were viewed. According to the inclusion and exclusion criteria, only 158 (76 males, 82 females) radiographs were included in the study. The remaining 1623 images did not include the region of cervical vertebrae C3, C4 region. Out of the 47 patients with calcifications, 20 were identified with CAC. CAC patterns and distribution were further classified[Table 1]. Among the 20 CACs, 14 were female, and six were male. In this study, multiple soft tissue calcifications were visible in the panoramic radiograph and were categorized as follows: 36% unilateral CAC, 15% calcified lymph nodes, 13% laryngeal calcification, 9% pharyngeal tonsilolith, 9% cricoid calcification, 6% bilateral CAC, 6% palatine tonsilolith, and 6% calcified stylohyoid ligament. According to the location of CACs, 85% were unilateral and 15% were bilateral as detailed in [Table 2].
Table 1: Characteristics of soft tissue calcifications on the orthopantomograph

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Table 2: Characteristics of the carotid artery calcification

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Chi-square test of independence was performed to examine the relationship between variables (age, gender, and medical problems) and the presence of calcification. The relationship between age variable and calcification was significant, χ2 (2) = 11.817, P = 0.003. Age group of 40–69 years was more likely than other age groups to get calcification. However, gender χ2 (1) = 3.815, P = 0.051 and medical problems χ2 (1) 0.327, P = 0.568 did not show any significant relation with calcification as shown in [Table 3].
Table 3: Characteristics of the study participants and soft tissue calcification

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  Discussion Top

CVD-related deaths are estimated to increase to unfortunate 23 million by 2030.[12] Several studies concluded that the prevalence of CAC among the adult population ranges from 3% to 15%.[13] In the present study, the prevalence of CAC in Riyadh was 1.12% and contributed to 12.66% of all soft tissue calcifications in the neck region. This is in contrast to the studies by Alzoman et al. (5%) in Saudi Arabia[12] and Nasseh and Aoun (6.8%) in Lebanon.[13] A study recently published in Abha, Saudi Arabia, by Halwani et al., with a sample size of 412 individuals, found that 50 (12.2%) patients had CACs.[14] The marked difference in the prevalence rates might be due to the difference in sample size as a confounding factor and also human errors in calibrated examiners, which effect the reliability and also generalizability of the results. In addition, in Brazil, Juliana-Mara-Oliveira Santos et al., 2018 also had similar results and found no statistical significance between the sex groups.[10] In a study by Azimi et al., 2016 in Iran, authors found that there was a significant association between age, and the prevalence of CAC (7%); as well as more CAC found in males than females.[15] Moreover, in Korea, Yoon et al., 2014 showed the highest incidence ever reported in Korean males with an 18.3% prevalence of CACs in patients aged 50 years or more.[16] In one of the recent studies piloted in Yemen, Helmi et al., 2020 found a prevalence of 15.6% among their study group. Contrastingly, they stated that CAC was more prevalent among females.[17]

Although more than half of the patients did not have any underlying risk factors, examination by Johansson et al., 2015 in Sweden found that patients with CAC tend to have undiagnosed underlying risk factors including hypertension and hyperlipidemia.[18],[19] In this study, 75% of patients were not aware of any underlying medical risk factors. Ardakani et al. (2007) and Madden et al., 2007 found correlation between increasing age with the highest prevalence of common CACs.[1],[20],[21]A study performed in 2017 to find the prevalence of coronary artery calcification in Saudi patients with normal myocardial perfusion documented that there is a strong association between the presence of CAC and age, male sex, and diabetes.[22] According to the data of the present study, age of patients who were identified with CAC was between 40 and 69 years and it is statistically significant and comparable to the study by Helmi et al., in which the mean age of patients with CAC was between 41 and 65 years.[17]

Azimi et al., 2016 concluded that, out of the 373 observed on the panoramic radiograph, nearly 6% had unilateral CAC while 2% had bilateral CAC.[15] In this current study, 85% were found to be unilateral, and 15% were found to be bilateral. According to Halwani et al., 2018, CACs were unilateral in 34 patients (68%) and bilateral in 16 patients (32%).[14] The results of the study also pointed out that the characteristics of CAC in Riyadh population were unilateral, single, round, and homogeneous. These results were in agreement with the observation patterns detailed by Alves et al.[1]

Studies in recent literature had also reported relationship between the presence of renal stones and CAC. In an article published by Patil et al., 2016 in 120 patients with renal stones, prevalence of CAC was slightly higher in the patients with renal stones. However, this observation was not statistically significant. With our current results, we did not come across any patients diagnosed with renal medical complications.[23]

According to Alves et al.'s study, individuals with systemic diseases had a higher prevalence of CAC than in the general population, reaching up to 38.8%.[1] Based on the limited knowledge provided by patients in regard to possible underlying CVD or other risk factors, the present study was not able to correlate the prevalence of CAC to CVD. CVD-related deaths are estimated to increase to an unfortunate 23 million by 2030.[23] Early diagnosis of atherosclerosis can initiate prompt treatment by the appropriate professional, with the objective of repairing or mitigating acute or chronic ischemic lesions.[24]

As well stated in the literature, diagnosis of CAC in patients should be referred to specialists for further workup such as Duplex ultrasound, which is the current gold standard for the diagnosis of stenosis.[25],[26] The diagnostic reliability of panoramic radiographs has also been proved to show moderate-to-high efficacy comparable to the results of ultrasound evaluations, which makes it a reliable tool for dentists.[26] The study is also consistent with the prevalence rate of CAC in Saudi Arabian population which is below 5.5% and the overall global prevalence to be less than 15%,[12],[13],[14],[15],[16],[17],[18],[19],[20],[22],[24],[25],[26] which confirms the generalizability of the study.

Limitations encountered in the study included panoramic radiographs where the C3 and C4 vertebrae were not visible and overlapping of the hyoid bone. The previous studies in Saudi Arabia did not specify the reasons of other soft tissue calcifications in the neck in their CAC study which can be a confounding factor, leading to overestimation of prevalence rates in their studies. Insufficient documentation of patient medical records based on the information provided by the patient and patients' unwillingness to disclose the relevant information was also a limitation to assess the correlation of CAC to CVD. Integration and auto-linking of resident or civil identity cards with health records may be beneficial to access data for future studies beneficial for the identification of patients with CAC and risk of stroke. This will enable in early intervention and less morbidity and mortality rate as associated with CVD and its complications.

  Conclusion Top

In most cases, atherosclerosis can remain undetected with no symptoms until its late stages. Therefore, early detection by dentists, particularly in a minimally invasive panoramic radiograph, can help alert the patient of a more severe underlying illness. This research projects the importance of identifying CAC in relation to the health sector to enhance patient's quality of life.


The authors would like to acknowledge Dr. Ashwaq Al Fkieh for her help in the data collection.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Alves N, Deana NF, Garay I. Detection of common carotid artery calcifications on panoramic radiographs: Prevalence and reliability. Int J Clin Exp Med 2014;7:1931.  Back to cited text no. 1
World Health Organization. Noncommunicable Diseases Country Profiles. Geneva: World Health Organization; 2018.  Back to cited text no. 2
World Health Organization. Global Health Estimates 2019: Global Health Estimates: Life Expectancy and Leading Causes of Death and Disability 2019. https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates. [Last accessed on 2019 Aug 10].  Back to cited text no. 3
Garoff M, Ahlqvist J, Levring Jäghagen E, Johansson E, Wester P. Carotid calcification in panoramic radiographs: Radiographic appearance and the degree of carotid stenosis. Dentomaxillofac Radiol 2016;45:20160147.  Back to cited text no. 4
Friedlander AH, Lande A. Panoramic radiographic identification of carotid arterial plaques. Oral Surg Oral Med Oral Pathol 1981;52:102-4.  Back to cited text no. 5
Cohen SN, Friedlander AH, Jolly DA, Date L. Carotid calcification on panoramic radiographs: An important marker for vascular risk. Oral Surg Oral Med Oral Pathol Oral Radiol Endodontol 2002;94:510-4.  Back to cited text no. 6
Nasseh I, Sokhn S, Noujeim M, Aoun G. Considerations in detecting soft tissue calcifications on panoramic radiography. J Int Oral Health 2016;8:742.  Back to cited text no. 7
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Friedlander AH, Gratt BM. Panoramic dental radiography as an aid in detecting patients at risk for stroke. J Oral Maxillofac Surg 1994;52:1257-62.  Back to cited text no. 8
Vatansever A, Demiryürek D, Tatar İ, Özgen B. The triticeous cartilage redefining of morphology, prevalence and function. Folia Morphol (Warsz) 2018;77:758-63.  Back to cited text no. 9
Juliana-Mara-Oliveira Santos GC, Soares AP, Lúcio-Mitsuo Kurita PG, Silva FW. Prevalence of carotid artery calcifications among 2,500 digital panoramic radiographs of an adult Brazilian population. Med Oral Patol Oral Cirugía Bucal 2018;23:e256.  Back to cited text no. 10
White SC, Pharoah MJ. Oral Radiology-E-Book: Principles and Interpretation. 7th ed. Missouri: Mosby Elsevier, Elsevier Health Sciences; 2014.  Back to cited text no. 11
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Halwani M, Alshahrani MR, Motaen SA, Asiri MA, Alkhairy SI. Detection of common carotid artery calcifications in panoramic radiographs and its relationship to some chronic diseases for local population in Abha Southern Kingdom of Saudi Arabia-2017-2018: Prevalence and reliability. Int Ann Med 2017;2:10.24087/IAM.2018.2.1.405.  Back to cited text no. 14
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  [Table 1], [Table 2], [Table 3]


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