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ORIGINAL ARTICLE
Year : 2019  |  Volume : 10  |  Issue : 1  |  Page : 21-25

Prevalence of detected soft tissue calcifications on digital panoramic radiographs


Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Selcuk University, Selcuklu, Konya, Turkey

Date of Web Publication15-Mar-2019

Correspondence Address:
Derya Icoz
Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Selcuk University, Selcuklu, Konya
Turkey
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DOI: 10.4103/srmjrds.srmjrds_60_18

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  Abstract 

Objectives: Some calcifications of the head and neck region may be seen on dental panoramic images due to the superimpositions and proximity of structures. The aim of the present study was to evaluate the prevalence of soft tissue calcifications observed on digital panoramic images and the relationship of the calcifications with age and gender. Materials and Methods: Four thousand two hundred and sixty-three digital dental panoramic radiographs of the individuals aged between 6 and 89 who had visited the faculty of dentistry for different oral and dental complaints were evaluated retrospectively and detected calcifications were recorded with the age and gender information. Data were analyzed by means of descriptive statistics, Pearson Chi-squared, and independent samples t-test. Results: Two hundred and seventy calcifications (6.4%) were detected in the whole study population. Observed calcification types were tonsillolith (2.5%), carotid artery calcification (2.3%), sialolith (1%), and calcified lymph node (0.6%). The prevalence of calcifications for all types increased with age (P < 0.001). Conclusions: The prevalence of calcifications seen on the dental panoramic images is relatively rare, but the detection during routine dental examinations is important in terms of the need for more detailed evaluation of the patients.

Keywords: Calcification, carotid artery, panoramic radiography, prevalence, sialolith


How to cite this article:
Icoz D, Akgunlu F. Prevalence of detected soft tissue calcifications on digital panoramic radiographs. SRM J Res Dent Sci 2019;10:21-5

How to cite this URL:
Icoz D, Akgunlu F. Prevalence of detected soft tissue calcifications on digital panoramic radiographs. SRM J Res Dent Sci [serial online] 2019 [cited 2019 Aug 21];10:21-5. Available from: http://www.srmjrds.in/text.asp?2019/10/1/21/254248


  Introduction Top


The ability of dental panoramic radiographs to view both maxilla and mandible in a single image makes it a valuable radiological technique. Because of the different anatomic properties of the patients, it is not possible to construct a panoramic device which only includes the jaws in the focal trough so that the soft tissue opacities located near the jaws may be visualized on panoramic images.[1] Soft tissue radiopacities include calcification, ossification, and foreign objects.[2] In the present study, radiopacities compatible with the calcification around the mandibular angle area were included. Deposition of the calcium salts in soft tissues in an unorganized fashion is called heterotopic calcification which is divided into three categories as metastatic, dystrophic, and idiopathic.[3] Metastatic calcifications usually occur when the serum levels of calcium or phosphate increase and minerals precipitate into normal tissue. Metastatic calcifications occur bilaterally and symmetrically which are the result of hypercalcemia secondary to metabolic causes or skeletal deposits of malignant disease.[2],[3],[4] Dystrophic calcifications contain the majority of soft tissue calcifications seen in the head and neck region and include rhinolith, antrolith, phlebolith, tonsillolith, arteriosclerotic plaque, and arteriosclerosis.[2],[4] Despite the normal serum and calcium phosphate levels, dystrophic calcifications are considered as pathological and occur in degenerative or dead tissues caused by trauma, inflammation, injections, presence of parasites, and changes arising from disease.[3] Idiopathic calcifications cannot be classified as either dystrophic or metastatic. Serum calcium concentration is in normal limits and the effected tissue is healthy.[2] Soft tissue calcifications of the maxillofacial area is uncommon and usually detected during routine radiographic examination such as panoramic radiography. Anatomical location, distribution, number, size, and shape of the calcifications are the important diagnostic criteria for evaluation of the calcifications.[5]

When calcification has occurred in carotid arteries, these lesions may be visible in panoramic radiographs, allowing to observe first cervical vertebrae, and it is an important tool to detect calcifications on carotid artery.[6] These calcifications are usually located either superior or inferior to greater cornu of the hyoid bone and adjacent to the cervical vertebrae C3, C4, or the intervertebral space between them.[7] They are mostly circular when small and mostly linear and thin rectangular when enlarged. They may be observed as unilateral or bilateral.[6]

The most common location for the calcified lymph nodes is the submandibular region at or below the inferior border of the mandible near the angle.[3] Calcified nodes may appear as single or multiple irregular-shaped radiopacities typically described as “cauliflower-like” appearance.[8],[9]

Another pathology that exhibits calcifications is sialolithiasis, the most common disease in salivary glands after parotiditis.[5] The submandibular gland is more often involved than parotid and sublingual glands. Sialoliths located in the duct of the submandibular gland are usually cylindric and very smooth. Furthermore, the stones in the hilus tend to be larger and more irregularly shaped. Some stones are homogenously radiopaque, and others may have multiple layers of calcification.[7] Large and well-calcified submandibular stones are clearly visible in panoramic images, but when superimposed over the mandible, the opacity may be interpreted as enostosis.[10]

In this study, we aimed to evaluate the prevalence of calcifications near the mandibular angle area detected on digital panoramic radiographs and the relationship of calcifications with age and gender.


  Materials and Methods Top


The present research project was approved (2018/08) by the Ethical Committee of Selcuk University, Dentistry Faculty of Konya. Digital dental panoramic radiographs of 4263 individuals who had visited the dentistry faculty of Selcuk University for routine dental procedures approximately in a 2-year period, between January 2017 and October 2018 were included in this study. The images in bad diagnostic quality, lack of clarity, and the presence of wide pathologic lesions or maxillofacial operations in the related area were excluded from the study. All the images were obtained with Kodak 8000 Digital Panoramic Dental X-ray System (Carestream Health Inc., Rochester, NY, USA) and evaluated by an oral and maxillofacial radiologist. Calcifications were interpreted according to the site, distribution, number, shape, and appearance on full screen according to the criteria shown in [Table 1]. The interested regions on panoramic radiographs were inferior border of the mandibular body, posterior border of the ramus, mandibular angle, and anterior border of the cervical spine.
Table 1: Localization and radiographic appearance of the calcifications

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Statistical analysis

Data were analyzed using SPSS software package (version 15, SPSS Inc., Chicago, IL, USA). Descriptive statistics was computed and frequency of the data was calculated. The distribution of the calcifications according to gender and relationship with calcifications was determined using Pearson Chi-squared test, and the relationship of age with calcifications was determined using independent sample t-test.


  Results Top


Of the 4263 images, 2422 were females and 1841 were males. The age range of patients was 6 to 89 years; mean age was 28,3 years.

A total of 270 (6.4%) calcifications were detected in all the evaluated images, of which 150 were females and 120 were males. The calcifications seen on the images were compatible with tonsilloliths, calcified lymph nodes, carotid artery calcifications, and sialoliths [Figure 1]. The mean age of the individuals with calcification was 40.37 ± 14.77 and without calcification was 27.44 ± 15.85 [Figure 2]. There was a significant difference with regard to the age between individuals with and without calcifications and also for all calcification types (P ≤ 0.001), and there was no significant difference between genders with regard to the presence of calcification (P = 0.666). However, the difference of calcification types between the genders was significant (P ≤ 0.01). The distribution of the calcifications according to gender is shown in [Table 2]. In the present study, mostly detected soft tissue calcification was tonsillolith followed by carotid artery calcification, sialolith, and calcified lymph node [Figure 3].
Figure 1: (a) The white arrow on the panoramic image shows the tonsilloliths as radiopaque masses superimposed on the ramus. (b) The white arrow on the panoramic image presents a large calcified lymph node located near the mandibular angle with a “cauliflower-like” appearance. (c) The white arrow on the panoramic image shows a sialolith over the right mandibular border. (d) The white arrow shows the carotid artery calcification seen on panoramic image at the level of third cervical vertebrae

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Figure 2: Mean age of patients with and without calcifications

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Table 2: Distribution of calcifications according to the gender of individuals

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Figure 3: Distribution of images according to the presence of calcifications

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  Discussion Top


Soft tissue calcifiactions are usually detected incidentally because they are mostly asymptomatic and have no signs. The localization and identification of the soft tissue calcifications of the head and neck region are difficult because the structures are in close proximity to each other, and it is difficult to discriminate the radiopacity which is located either in the bone or soft tissue due to the superimpositions.[3],[11]

The present study has the classic limitations of retrospective studies because it is impossible to reach the patients' entire history. However, it is important because a large size of sample being 4263 digital panoramic images were evaluated about all soft tissue calcifications located near the mandibular angle area except stylohyoid ligament ossifications. The reason for not including the stylohyoid ligament ossifications in the present study is the presence of organized bone formation not calcium salt deposits at the soft tissue level.[5]

In the present study, the prevalence of soft tissue calcifications was found as 6.4%, while Garay et al. reported as 2.61%, Vengalath et al. as 8%, and Ribeiro et al. as 19.7%.[3],[5],[12] The reason of high difference for the study of Ribeiro et al. may be the inclusion of stylohyoid ligament ossifications. The most observed calcification type was tonsilloliths in the present study with the percentage of 38.9 of all calcifications and 2.5 of all individuals of the present study sample. Tonsilloliths are not uncommon but they are usually microscopic and may not be visible on panoramic images.[13] Exact etiology and pathogenesis of the tonsillolith is unknown, but repeated episodes of the inflammation may result with dystrophic calcification in the crypts of the palatine tonsils. Consistency of tonsilloliths ranges from soft to hard as stone, and the size of the tonsilloliths are usually of small sizes but may vary from a few millimeters to several centimeters.[14],[15]

According to the present study's results, the second most observed calcification type was carotid artery calcification with the percentage of 2.3% of all study samples. The prevalence of carotid artery calcifications was reported as between 3% and 5% of population; it may be due to the age of the study sample which was older than 30.[16] According to the results of the same study, women are affected more commonly, and this result is in consistency with the present study. This relationship was stated due to a decline in the estrogen level after menopause, which affects the lipoprotein metabolism by preventing the formation of atheromatous plaques and its reduced levels may increase the prevalence.[17] According to the literature and the results of the present study, more frequent occurrence of the carotid artery calcifications in advanced age in women may be explained with the increase in postmenapousal period.[3]

Third most observed calcification of this study was sialoliths. El Deeb et al. reported that sialoliths affect the 0.01%–1% of the population and according to Garay et al., it is 0.3%.[5],[18] The result of the present study is compatible with El Deeb et al. with the percentage of 1%. The most affected gland is submandibular (83%–94%) followed by parotid gland (4%–10%) and sublingual and minor salivary glands (1%–7%), respectively.[19] The reason for increased incidence of submandibular gland sialoliths compared to other glands is more mucous nature of gland's secretion, more alkaline pH which helps precipitate salts, the higher concentration of hydroxyapatite and phosphatase, and long, tortuous, and uphill course of the duct. Sialoliths are usually radiopaque and have a laminated appearance; however, 20% of submandibular gland and 40% of parotid gland liths are not visible in routine plain films because of the small size and/or noncalcified nature.[10]

The least seen type of the calcifications was calcified lymph node for the present study. It was detected 0.6% of the evaluated images, and this result is slightly higher than the study of Vengalath et al. which is 0.12%.[3] In the literature, nodal calcification of the head and neck region is reported as 1% of enlarged nodes.[20] They are usually discovered incidentally, but the patients have an inflammation history in the area such as sinusitis or tonsillitis. Infrequently, lymph node calcification of the head and neck region may be related with malignant diseases, so these liths must be evaluated for the underlying systemic diseases.[21]


  Conclusion Top


The presence of calcifications in the digital panoramic images is relatively rare, but as maxillofacial radiologists and dentists, we are responsible for the detection of incidental findings on the images taken for routine dental procedures. Cervical calcifications may indicate the presence of some systemic diseases and alert the clinician for patient's medical history and referral to the specialist.

In conclusion, the prevalence of calcifications increases with age for all calcification types. The most common calcification type is tonsillolith, and carotid artery calcifications tend to be more common in females than males.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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