Arthur H. Friedlander

The prevalence of carotid atheromas seen on panoramic radiographs of patients with obstructive sleep apnea and their relation to risk factors for atherosclerosis

PURPOSE Persons with obstructive sleep apnea syndrome (OSAS) suffer inordinately high rates of stroke, but the cause remains in doubt. Atherosclerosis (atheroma formation) of the extracranial carotid artery has been suggested as a possible cause. Because atheromas can be recognized on panoramic radiographs, this study compared their prevalence in subjects with OSAS and normal controls and analyzed their relation to atherogenic risk factors. PATIENTS AND METHODS Panoramic radiographs and medical records of 54 male subjects (mean age, 60.4 years) with OSAS (apnea/hypopnea index [AHI] of 15 or greater and a history of snoring and excessive daytime sleepiness) were assessed for atheromas and risk factors. Age-matched controls were likewise assessed. RESULTS Twelve individuals (22%) with OSAS showed atheromas on their radiographs. The radiographs of the controls showed that 3.7% had atheromas. This finding was statistically significant (P = .0079). The prevalence of type 2 diabetes mellitus among individuals with OSAS and atheroma formation (7 of 12 persons, 58%) was far greater than the prevalence of diabetes (10 of 42 persons, 24%) experienced by individuals with OSAS but free of atheroma formation. This finding was also statistically significant (P = .035). The lesions seen in both the subject and control populations were similar and were located in the neck, 1.5 to 2.5 cm inferior-posterior to the angle of the mandible. CONCLUSIONS Persons with OSAS are more likely to manifest calcified atheromas on their panoramic radiographs than age-matched controls. Type 2 diabetes is significantly more prevalent in individuals with both OSAS and calcified atheromas.

The prevalence of calcified carotid artery atheromas on the panoramic radiographs of patients with type 2 diabetes mellitus.

BACKGROUND People with type 2 diabetes mellitus are disproportionately at risk of experiencing stroke, because hyperglycemia and other risk factors associated with diabetes accelerate development of cervical carotid artery atheromas. Removal of these atheromas may reduce the incidence of stroke. The authors conducted a study to ascertain if those treated without insulin (noninsulin-treated, or NIT) would have a lower prevalence of atheromas on their radiographs and a lower prevalence of risk factors than those treated with insulin (insulin-treated, or IT). METHODS The authors evaluated the panoramic radiographs and medical records of 46 neurologically asymptomatic men (n = 34) and women (n = 12) (age range 62-77 years, mean age 68.5 years) with type 2 diabetes. They used Fisher exact test to perform a statistical comparison of the prevalence of atherogenic atheromas and risk factors between groups. RESULTS The radiographs showed that 24 percent of the NIT patients and 36 percent of the IT patients had atheromas; this difference was not statistically significant (P = .52). The groups had similar risk factors--that is, high levels of glycosylated hemoglobin A, or HbA1c; smoking; hypertension; and obesity (P > .05). When compared with the 4 percent atheroma prevalence rate among healthy people of similar age, the rates were significantly higher in both the NIT (P = .02) and IT (P = .0006) patients. CONCLUSION These results demonstrate that people with type 2 diabetes, irrespective of treatment modality, have high rates of atheromas as visualized on their panoramic radiographs. CLINICAL IMPLICATIONS Dentists treating patients with type 2 diabetes mellitus must review their panoramic radiographs carefully for evidence of atheroma formation. Patients with atheromatous lesions must be referred to their physicians for further evaluation and treatment, because the modification of atherogenic risk factors and the surgical removal of atheromas in certain people have been shown to reduce the likelihood of stroke.

Prevalence of detectable carotid artery calcifications on panoramic radiographs of recent stroke victims

Cerebrovascular accidents are responsible for killing or disabling half a million Americans every year and are the third leading cause of death in this country. Finding cost-effective means of decreasing stroke mortality and morbidity is of great humanitarian and economic importance. Panoramic dental radiography was done on 19 white men who had a recent cerebrovascular accident and who were hospitalized at a Department of Veteran Affairs medical center. Inclusion criteria included clinical suspicion or imaging study evidence that the stroke arose from atheroembolic disease of the carotid artery bifurcation. Women were omitted from the study because of their paucity in the patient pool, and African-Americans and Asian-Americans were omitted because strokes in those groups usually develop as a result of disease of intracranial vessels. Carotid arterial calcifications appearing as a radiopaque nodular mass adjacent to the cervical vertebrae at or below intervertebral space C3-4 were noted in seven persons (37%). These patients had an average age of 65 years and demonstrated multiple risk factors (prior transient ischemic attacks, prior stroke, hypertension, obesity, tobacco and alcohol abuse, hyperlipidemia) associated with occurrence of a stroke. We concluded that some white men at risk for a cerebrovascular accident may be identified in the dentists office by appropriate review of the panoramic dental radiograph and medical history. The presence of carotid artery calcifications demands an expeditious referral to an appropriate practitioner who can assist in the control of risk factors and arrange prophylactic surgical removal of the carotid arterial plaque, which are both safe and reliable methods of reducing the incidence of stroke.

Dental management of the cocaine addict

Addiction to cocaine is a growing problem in the United States. The detrimental physiologic aspects of addiction require that certain precautions be observed during dental care to avoid a morbid reaction or a possible fatality. The adverse psychological and social aspects of addiction must also be understood by the dentist in order to properly manage this troubled group of patients.

The role of panoramic radiography in determining an increased risk of cervical atheromas in patients treated with therapeutic irradiation

PURPOSE Therapeutic irradiation of the neck is a common component of treatment for those with carcinoma of the oral cavity, pharynx, and larynx. Such irradiation, however, has been implicated as the cause of accelerated atherosclerosis of the cervical carotid artery and subsequent stroke. Panoramic radiography, previously shown to be capable of identifying carotid artery atherosclerosis in non-irradiated individuals, was used to assess the carotid vasculature of patients who had been treated for cancer with therapeutic irradiation. METHODS The panoramic radiographs of 33 male subjects who had received therapeutic irradiation (> or = 50 Gy) to the neck 30 or more months previously were assessed for the presence of calcified carotid artery atherosclerotic lesions. Age-matched controls, similarly liable for oropharyngeal malignancy and atherosclerosis by virtue of their medical and habitual risk factors (hypertension, smoking, obesity) were assessed in a like manner. RESULTS The panoramic radiographs of the irradiation-treated subjects (age range, 32 to 84 years; mean age, 66.1 years) showed that 21% (7 of 33 subjects) had calcified atherosclerotic lesions. The mean age of these seven subjects was 64.6 years; four had unilateral lesions and three had bilateral lesions. The radiographs of the control subjects showed that 4.7% (5 of 107 subjects) had calcified atherosclerotic lesions. The mean age of these five subjects was 67; three had unilateral lesions and two had bilateral lesions. The lesions seen in the two populations had similar morphologic appearances. The discrete radiopaque calcifications were located within the soft tissues of the neck, approximately 2.5 cm inferior-posterior to the angle of the mandible. CONCLUSIONS Subjects who had received therapeutic irradiation of the neck had a statistically higher risk (p = 0.007, according to Fishers Exact Test) of the development of calcified carotid artery atherosclerotic lesions than age-matched, risk-matched, non-irradiated control subjects. These lesions can be detected on routine panoramic radiographs.

The prevalence of calcified carotid artery atheromas in patients with obstructive sleep apnea syndrome

PURPOSE Persons with obstructive sleep apnea syndrome (OSAS) suffer cerebrovascular accidents at three to six times the rate of other Americans. Atherosclerosis of the cervical portion of the carotid artery has been suggested as a possible cause of these strokes. Lateral cephalometric radiographs used to determine the site of upper airway obstruction in sleep apnea patients can also image calcified cervical carotid artery atheromas. However, their prevalence in this group of patients has not been previously reported. PATIENTS AND METHODS The radiographs of 47 male subjects (mean age 59.2 years, range 45 to 77 years) diagnosed as having OSAS (apnea/hypopnea index [AHI] of > or = 15 and a history of snoring and excessive daytime sleepiness) were assessed for calcified carotid atheromas. Healthy, age-matched (+/-18 months) controls were likewise assessed. RESULTS The radiographs of the subjects with OSAS showed that 21.3% had calcified atheromas. The radiographs of the controls showed that only 2.5% had calcified atheromas. This finding was statistically significant (P = < .000001). The lesions seen in both populations were similar, and located within the soft tissues of the neck at the level of C3 and C4. The lesions were superimposed over these tissues, the prevertebral fascia, and the pharyngeal airspace. CONCLUSIONS The results of this study seem to indicate that persons with OSAS have a greater prevalence of calcified carotid artery atheromas than healthy, age-matched persons. These lesions, a possible cause of future stroke, can be detected on lateral cephalometric radiographs.

Panoramic dental radiography as an aid in detecting patients at risk for stroke

PURPOSE Atherosclerotic lesions in the region of the bifurcation of the common carotid artery and in the internal carotid artery are the most common cause of stroke. On occasion these lesions are calcified and visible on a panoramic dental radiograph. METHODS Six subjects receiving outpatient dental treatment and denying a history of previous transient ischemic attacks or stroke had bilateral calcified carotid arterial lesions noted on their routine panoramic dental radiograph. RESULTS Electronic thermography (ET) demonstrated that these patients had significant temperature differences bilaterally between their medial supraorbital region and the ipsilateral remainder of their forehead when compared with control subjects. These findings are consistent with the presence of calcified stenotic intraluminal plaques altering blood flow, tissue perfusion, and skin temperature readings. The presence of stenotic plaques was verified by Doppler spectral analysis and imaging. CONCLUSION ET of the face, currently considered an investigational procedure, demonstrates promise as an ancillary imaging system capable of confirming the diagnosis of patients at risk of stroke. Such individuals should be referred to an appropriate physician for consideration of medications and/or surgical removal of the plaque. In selected individuals, these are safe and relatively reliable methods of preventing stroke.

Detection of radiation-induced cervical atheromas by panoramic radiography

Therapeutic irradiation of the neck is frequently used to treat patients with head and neck carcinoma. The irradiation, however, has been implicated as the cause of cervical carotid artery atherosclerotic lesions and subsequent stroke. Panoramic radiography previously shown capable of demonstrating isolated lesions was used to assess their development over time. Individuals with a pre-irradiation radiograph free of atheromas were enrolled for study. The prevalence rate of atheroma formation on post-irradiation (bilateral portals at >/=45 Gy) radiographs obtained at an interval of >/=36 months was determined. A control group of non-irradiated patients having similar risk factors for head and neck carcinoma and atherosclerosis and having an initial radiograph free of atheroma formation were likewise enrolled for study. The prevalence rate of atheroma formation on a second radiograph obtained from these individuals at an interval of >/=36 months was determined. The study population consisted of 17 patients, with a mean age of 56.5 (range 21.5-77.8) years who received a mean therapeutic irradiation dose of 53.2 Gy (range 45-71) to each side of their neck. The prevalence rate of atheromas manifested on the post-irradiation radiographs was 53%. These radiographs were obtained, on average, 69.7 (range 37-133) months after completion of radiation therapy. The prevalence rate of atheromas manifested on the second radiograph of patients in the control group was 5.9%. These radiographs were obtained, on average, 53.5 (range 52-55) months after the first. The difference in prevalence rates was statistically significant (p=0.0003). Individuals who have received therapeutic irradiation to the neck are more likely to develop carotid artery atheromas after treatment than are risk-matched control patients who have not been irradiated. These lesions can be detected by panoramic radiography.

Dental management of the patient with major depression.

Major depression is a psychiatric disorder in which mood, thought content, and behavioral patterns are impaired for long periods of time. It is a common disorder, with an increasing prevalence among young adults. It may be associated with a disinterest in performing appropriate preventive oral hygiene techniques, a cariogenic diet, diminished salivary flow, rampant dental decay, advanced periodontal disease, and oral dysesthesias. Many medications used to treat the disease magnify the xerostomia and increase the incidence of dental disease. Appropriate dental management necessitates a vigorous preventive dental education program, the use of saliva substitutes and anticaries agents containing fluoride, and special precautions when prescribing or administering analgesics and local anesthetics.

Detection of Radiation-Induced, Accelerated Atherosclerosis in Patients with Osteoradionecrosis by Panoramic Radiography

PURPOSE Osteoradionecrosis (ORN) of the mandible has long been considered the most destructive complication of head and neck irradiation. Recently, therapeutic irradiation has been implicated as the cause of induced/accelerated atherosclerosis of the cervical carotid artery and subsequent stroke. Panoramic radiography, previously shown to be capable of identifying carotid artery atherosclerosis in nonirradiated individuals, was used to assess the carotid vasculature of patients being treated for ORN. PATIENTS AND METHODS The panoramic radiographs of 61 men (mean age, 60.5 years; range, 41 to 77 years) who received therapeutic irradiation to the neck 36 months or more previously were assessed for the presence of carotid artery atherosclerotic lesions. Sixty-one control subjects who never received therapeutic irradiation, but who were similarly susceptible to atherosclerosis by virtue of age, were assessed in a like manner. RESULTS The irradiated individuals sustained a dose of 40 to 72 Gy to the area of the carotid bifurcation. Seventeen individuals (27.9%) with an irradiation dosage to the carotid bifurcation that averaged 59.2 Gy had a panoramic radiograph with a carotid atheroma (11 with unilateral lesions and six with bilateral lesions). The radiographs of the control subjects showed that three individuals (4.9%) had calcified carotid lesions. The mean age of these subjects was 66.1 years; two had unilateral lesions, and one had bilateral lesions. The difference in the proportion of individuals with ORN who manifested carotid artery atherosclerosis on their panoramic radiographs was statistically significant (P = .001) when compared with the nonirradiated control subjects. The lesions seen in both populations had a similar morphologic appearance and were radiographically located within the soft tissues of the neck 1.5 to 4.0 cm inferior-posterior to the angle of the mandible. CONCLUSIONS Individuals with radiation doses sufficient to cause osteoradionecrosis of the mandible are at significantly higher risk of developing carotid artery atherosclerotic lesions than age-matched, nonirradiated controls.