Oral Sciences n3
Braz J Oral Sci. 11(2):88-93
Original Article Braz J Oral Sci.
April | June 2012 - Volume 11, Number 2
Sensitivity and accuracy of panoramic
radiography in identifying calcified
carotid atheroma plaques
Janaína Sens Bastos¹, Thalita Queiroz Abreu¹, Sebastião Barreto de Brito Filho²,
Kelston Paulo Felice de Sales³, Fernanda Ferreira Lopes4, Ana Emília Figueiredo de Oliveira5
1MSc student, Graduate Program in Dentistry, School of Dentistry, Federal University of Maranhão, Brazil
2MSc, Professor, Department of Medicine II, School of Medicine, Federal University of Maranhão, Brazil
3MSc student in Vascular Surgery, School of Medicine, Federal University of São Paulo, Brazil
4PhD, Professor, Discipline of Semiology, Department of Dentistry I, School of Dentistry, Federal University of Maranhão, Brazil
5PhD, Professor, Department of Dentistry I, School of Dentistry, Federal University of Maranhão, Brazil
Correspondence to:
Janaína Sens Bastos
Rua 01, Lote 08, Condomínio Village Intermares,
Casa 31 - Planalto Vinhais I
CEP: 65074-856 - São Luís – MA, Brasil
Phone: +55 98 32464787
E-mail: janaina100s@gmail.com
Abstract
Atherosclerosis is a chronic inflammatory disease that can cause death and physical and/or
mental disabilities. It represents a serious public health problem owing to the high healthcare costs
involved in rehabilitating patients. Among the different methods available for diagnosing
atherosclerotic disease, color Doppler examination may be considered the “gold standard.” On
the other hand, panoramic radiography of the jaws (PRJ) is a diagnostic resource commonly
used by dentists, and the obtained images allow examining other structures apart from the maxilla
and the mandible. Aim: To evaluate the sensitivity and accuracy of panoramic radiography in
identifying calcified carotid atheroma, and compare the results to those obtained with color Doppler
examination. Methods: Forty-two cervical regions were evaluated in panoramic radiographs
and color Doppler scans. The kappa test (p < 0.05) was used to assess agreement between the
examinations. Data were tested for sensitivity, specificity and negative predictive value, as well as
positive and negative likelihood ratios. Results: The kappa value was 0.11. The sensitivity and
specificity of PRJ were 73.9 and 36.8%, respectively, and the positive and negative likelihood
ratios were 1.2 and 0.7, respectively. Conclusions: Although a low correlation between PRJ
and color Doppler examination was observed, as shown by the kappa test, the sensitivity of PRJ
in identifying calcified carotid atheroma was considered acceptable.
Keywords: stroke, carotid artery diseases, radiography, panoramic.
Introduction
Atherosclerosis is an inflammatory disease that produces circulatory changes
caused by fat deposits on the walls of the arteries. When the carotid arteries are
involved, it can cause stroke – a cerebral vascular accident (CVA) – that can
be ischemic or hemorrhagic1. The formation of atheromatous plaques in the carotid
artery – also called calcified carotid atheromatous plaques (CCAP) – is not a simple
and inevitable degenerative process resulting from advanced age, but rather
a chronic inflammatory disease that can develop into an acute clinical condition
owing to plaque rupture, rendering the patient susceptible to thromboem-
bolism or stroke2.
Received for publication: November 29, 2011
Accepted: April 18, 2012
8989898989
Braz J Oral Sci. 11(2):88-93
Stroke is the third leading cause of death in the United
States, accounting for over 150,000 deaths/year, ranking only
behind cardiovascular disease and cancer3-4. By 2009, it was
the first cause of death in Brazil, claiming over 300,000 deaths/
year5. It represents a serious public health problem because it
causes death and physical and/or mental disabilities –
approximately 60% of survivors suffer from such disabilities6 –
and have high costs involved in treating and rehabilitating patients.
The main risk factors said to favor or accelerate the
atherosclerotic process are: heredity, dyslipidemia, smoking,
hypertension, diabetes, viral infections, elevated homo-cysteine (an
amino acid derived from eating meat and dairy products) in the
blood, obesity, sedentary lifestyle and stress7. Preventive measures
and early diagnosis are key factors to reduce the prevalence of
the disease. However, a non-invasive, inexpensive and reliable
diagnostic method still lacks. Angiography, which
considered the “gold standard” for diagnosing this disease,
is an invasive method that can cause major complications8,
and Color Doppler (also known as Laser Doppler flowmetry or
Duplex Scan), although fast, accurate, noninvasive and
painless9, is not yet widely accessible to all strata of society
because of its high costs (Figures 1A, 1B).
Fig. 1B - Color Doppler – CCAP
Fig. 1A - Color Doppler – CCAP
Since 1981, the presence of radiopaque images on panora-
mic radiographs has been described as a sign of the presence
of CCAP10-11, indicating that this examination could contribute
to the early diagnosis of stroke risk. There are studies
reporting that partially calcified atherosclerotic lesions can
be observed in panoramic radiographs of the jaws (PRJ)12-13. The
image of the calcification is described as a nodular,
radiopaque mass in one or more areas, either elongated or
triangular, of various sizes, measuring from 1.5 to 4.0 cm,
and as observable below and posteriorly to the angle of the
mandible, adjacent to the intervertebral spaces between C2,
C3, and C48,14-15 (Figures 2A, 2B).
Fig. 2A - Panoramic Radiography of the Jaws
Fig. 2B - Panoramic Radiography of the Jaws - CCAP
Some studies have reported calcifications in dental
panoramic radiographs between the second, third and
fourth cervical vertebrae, which were later confirmed by color
Doppler examination as atheromatous plaques16-17. Because
panoramic radiography may be able to detect CCAP during
routine examinations, thus enabling proper referral of
patients for appropriate treatment, it has the potential to
promote a significant reduction in the morbidity rate caused
by this disorder, and a substantial reduction in the healthcare
costs associated with atherosclerosis18. Nevertheless, because
panoramic radiographs cover several different anatomical
areas, developing the ability to perform differential diagnosis
of the structures that comprise the carotid region is of utmost
importance. This ability involves comprehensive anatomical
knowledge of structures such as the hyoid bone, epiglottis,
calcified submandibular and styloid ligaments, and triticeous
Sensitivity and accuracy of panoramic radiography in identifying calcified carotid atheroma plaques
Braz J Oral Sci. 11(2):88-93
cartilage, as well as of pathological processes such as
sialoliths, phleboliths, and calcified lymph nodes19.
In view of these considerations, it is reasonable to
assume that PRJ has a great potential in identifying CCAP,
or should at least be further investigated as a diagnostic tool
for atherosclerosis. Nevertheless, there is still controversy in
the literature about its use as a reliable method for this purpose,
and great divergence in results. This could be explained by
the different methodologies used and because the methods
used for comparative analysis of panoramic radiographs in
these studies are not considered the “gold standard,” and
are based solely on radiographic interpretation for diagnostic
conclusion.
Based on the methodological limitations of the existing
studies, on the fact that dentists use panoramic radiographs
routinely, and on the fact that early detection of patients at
risk for developing atherosclerosis is an important public
health goal, the purpose of the present study was to
evaluate the sensitivity and accuracy of PRJ in identifying
CCAP compared with color Doppler examination.
Material and methods
Sample
In this study, the accepted ethical principles governing
human experimentation were followed closely, after approval
was obtained from the Ethics Committee of the Federal
University of Maranhão (Protocol n. 2311-005753/2009-57).
The sample was calculated based on the estimated
prevalence of calcification in the carotid artery, approximately
2%. The following parameters were used for calculating sample
size: significance level of 0.05 and maximum permissible
error of ± 5%, thus producing n = 31.
In the period from August 2009 to June 2010, panoramic two
dental radiologists evaluated PRJ of patients of both genders
in a clinic commissioned by the Public Health System in the
city of São Luis, MA, Brazil. Radiographic diagnosis of CCAP
was considered conclusive when there was agreement between
both examiners regarding the presence of CCAP and the side
in which its presence was detected. Twenty-one panoramic
radiographs were considered by the examiners as
undoubtedly positive for the diagnosis of CCAP, on at least one
side, thus leading to an analysis of 42 cervical regions (n = 42).
The inclusion criteria for all participants of this study
was the detection of an image suggestive of CCAP on at
least one side of the PRJ in patients who were at least 40 years
of age, and who agreed to undergo color Doppler angiography.
Radiographic examination
PRJ was performed using the standard positioning
technique, Orthophos 3 Ceph X-ray equipment (Sirona Dental
Systems GmbH, Germany) and 15 x 30 cm panoramic
film (Eastman Kodak Co., Rochester, NY, USA). The films
were processed automatically (Revell-XTec Ltd., São Paulo,
SP, Brazil), with appropriate developer and fixer solutions
(Kodak Brazilian Trade and Industry Ltd., Sao José
dos Campos, SP, Brazil).
Interpretation of the radiographic images was
performed by two dentists, with less than three years of
experience as radiology specialists, and in an environment
with dimmed light and using a light box. The presence
of CCAP could be unilateral or bilateral. Both sides of each
one of the 21 patients were evaluated, for a total of
42 cervical exams (n = 42).
Doppler Examination
All 21 patients with positive radiographic exams for
CCAP on at least one side of the PRJ were subjected to
Doppler examination at the Presidente Dutra University
Hospital, São Luis, MA, Brazil. A Dupplex Scan equipment
(General Electric, New York, USA) was used owing to its
reliability in demonstrating blood flow in the artery under
study. A physician specialized in angiology had previously
determined the presence of stenosis and/or obstruction caused
by an atheromatous plaque. In the same way as done in the
radiographic examination, both sides of each exam
were evaluated, also totaling 42 cervical analyses (n = 42).
Statistical methods
Data were analyzed statistically using BioEstat 5.0
software, according to criteria adopted by the related
literature20. The kappa agreement test (p < 0.05) was used
to assess and compare sensitivity, specificity, negative
predictive value (NPV), accuracy (ACC), positive likelihood
ratio (PLR) and negative likelihood ratio (NLR) for the
different examinations. The kappa values and their
interpretations were < 0 (no agreement), 0 to 0.19 (very weak
agreement), 0.20 to 0.39 (poor agreement), 0.40 to 0.59
(moderate agreement), 0.60 to 0.79 (substantial agreement),
and 0.8 to 1.0 (excellent agreement), following criteria
previously approved 21.
The sensitivity test was used to match the PRJ’s ability
to detect the disease when its presence was confirmed, i.e.,
to assess how many positive and negative results were found
using PRJ for the cases found positive in the color Doppler
examination (“gold standard”)18. Sensitivity was calculated
as follows:
Sensitivity (%) = true positives / (true positives +
false negatives) x 100.
The specificity test was used to identify the true
negatives determined by PRJ in individuals who were
genuinely healthy, as revealed by the Doppler examination. It
was calculated as follows:
Specificity = true negatives / (true negatives + false
positives) x 100.
The NPV for PRJ was calculated to assess how many
test results among those that proved negative were actually
negative according to the Doppler examination. It was
calculated as follows:
NPV (%) = true negatives / (true negatives + false
negatives) x 100.
PRJ’s accuracy was defined as the proportion of
successful examinations, i.e., the total number of true
9090909090Sensitivity and accuracy of panoramic radiography in identifying calcified carotid atheroma plaques
Braz J Oral Sci. 11(2):88-93
9191919191
positives and true negatives, as confirmed by the Doppler
examination. It was calculated as follows:
ACC = (true positives + true negatives) / total.
The likelihood ratio is a means of describing the
performance of a diagnostic test. It expresses how many times
the result of a given test is more likely (or less likely) to
occur in affected subjects compared to unaffected subjects. If
a test is dichotomized (positive/negative), two types of
likelihood ratio describe its ability to separate those affected
from those not affected: one associated with a positive test
and another associated with a negative test, respectively
calculated as follows:
PLR = sensitivity / (1 - specificity), and
NLR = (1 - sensitivity) / specificity.
Results
Of the 42 cervical analyses (L and R sides of 21 patients),
17 images visualized on the PRJ were confirmed by the
Doppler examination (true positives), with 6 non-visualized
sides (false negatives). PRJ identified 12 images of CCAP
that were not confirmed by the Doppler examination (false
positives), with 7 sides that were truly without disease (true
negatives) (Table 1).
Doppler
Present Absent Total
PRJ + 17 (a) 12 (b) 29 (a + b)
PRJ - 6 (c) 7 (d) 13 (c + d)
Total 23 (a + c) 19 (b + d) 42 (N)
Table 2 - Accuracy (ACC) of the panoramic radiography in
identifying calcified carotid atheroma plaques (n, %).
PRJ: Panoramic radiography of the Jaws
ACC = [(a + d)/N]*100
ACC = 57.1%
Table 1 - Assessment of the agreement between
panoramic radiography and color Doppler in identifying
calcified carotid atheroma plaques (n, %).
Kappa = 0.11 / p = 0.2265
PRJ: Panoramic radiography of the Jaws
Doppler
Sick (%) Healthy (%) Total
PRJ + 17 (73.9) 12 (63.2) 29 (69.0)
PRJ - 6 (26.1) 7 (36.8) 13 (31.00)
Total 23 (100) 19 (100) 42 (100)
We found a kappa value of 0.11 (p = 0.2265), indicating
that the agreement between the Doppler and the PRJ examinations
was weak and not significant (Table 1). The
sensitivity calculated for PRJ was 73.9%, indicating
that 73 out of 100 patients with the disease
were correctly identified and 26 were considered erroneously
healthy. The calculated specificity was 36.8%, indicating
that 36 out of 100 patients with the disease were identified
as healthy and 63 were considered erroneously sick.
The NPV of PRJ was found to be 53.8%, indicating that
53 out of 100 patients who had a negative result in the PRJ
examination actually did not have CCAP, or, stated differently,
53.8% of the diagnoses found to be negative by PRJ were
correct, and 46.2% of the diagnoses initially
considered negative by PRJ were actually positive in the color
Doppler examination.
The likelihood ratios were as follows: PLR = 1.2 and NLR
= 0.7. The higher the PLR, the better the test, and, in order to
be considered a good test, the PLR should be significantly
higher than 1. This would mean that a positive outcome is
more likely to be a true-positive than a false-positive. The
lower the NLR (closer to 0), the better the test. This would
mean that a negative result is more likely to be a real negative
than a false negative.
The accuracy found for PRJ was 57.1%, indicating
that this examination provided a correct diagnosis – a true
positive or a true negative – in 57 out of 100 patients. The
sensitivity and accuracy results obtained with the use
of PRJ for the identification of calcifications in the carotid
artery indicate that this test could contribute to reducing the
risk of patients suffering a stroke (Table 2).
Discussion
When atheromatous plaques of the carotid bifurcation
region are identified, the first feature to note is the size of
the obstruction. If it blocks less than 60% of the artery, simply
inhibiting platelet aggregation associated with thrombus
formation can treat the patient. When the obstruction is greater
than 60%, invasive procedures are required to remove the
plaque22. Panoramic radiography is limited to identifying
CCAPs, and cannot evaluate its exact location, or the degree
of the obliteration13.
The main limitation of this study was that the population
evaluated consisted of a selective group (patients with an
image suggestive of CCAP detected in panoramic
radiographs), rather than the general population. Nonetheless,
this bias can also be considered one of its strengths, from a
methodological standpoint, because it compared the
sensitivity and accuracy of PRJ to that of the “gold standard”
method (Doppler) in identifying the presence of
atherosclerotic plaques, considering that PRJ is an exam
commonly requested by dentists, in which the occasional
presence of CCAP is a radiographic finding.
The NPV found in this study was not
substantial (63.2%), considering that atherosclerotic diseases
are among the major causes of death worldwide. However, the
sensitivity of PRJ in identifying CCAP was significant (73.9%)
when compared to angiographic examination (color Doppler
imaging), which is considered the “gold standard” (Figure 3)
Although the sensitivity of PRJ in identifying
CCAP was 73.9%, its accuracy was only 57.1% and its
specificity was 36.8%, a trend confirmed by the kappa test
(0.11). Thus, PRJs should not be suggested as a diagnostic
imaging examination for the identification of CCAP, as
proposed by some authors. The results of the present study
Sensitivity and accuracy of panoramic radiography in identifying calcified carotid atheroma plaques
Braz J Oral Sci. 11(2):88-93
9292929292
corroborate those of previous studies19, which stated that a
radiopacity between C2, C3 and C4 in a panoramic radiograph
does not always represent a CCAP.
Our results differ from those of a previous study23 that
found PRJ sensitivity and specificity values of 22.2% and
90.0%, respectively, for identifying CCAP using CT as the
“gold standard.” The authors also concluded that panoramic
radiographs could be considered a diagnostic method with
moderate accuracy and low sensitivity for the detection
of CCAP. This difference may be explained by the different
“gold standards” adopted for comparison with PRJ.
In a previous study24, PRJ presented low sensitivity and
no accuracy for detecting calcification or stenosis. Only one
dental radiologist interpreted the panoramic radiographs in
that study, and the authors used two different radiographic x-
ray apparatuses (Siemens Corp., Iselin, New Jersey, USA or
Gendex Corp., Milwaukee, Wisconsin, USA) for image
acquisition. In contrast, the authors also mentioned that the
Doppler images were obtained at various locations, and
interpreted by different radiologists.
A study assessing the performance of digital PRJ in forty
patients with carotid atherosclerotic disease diagnosed by
angiography found NPV and sensitivity values of 46%
and 60%25, which differ from those found in our study (53.8%
and 73.9%, respectively). One possible explanation for this
divergence in results is the different characteristics of the
projection devices used, particularly the rotation system, the
section thickness and the apparatus calibration19.
A survey8 conducted at the Health Department of the
city of Valença, RJ, Brazil, reviewed panoramic radiographs
and Doppler images of 16 patients to investigate whether
there was agreement between the diagnosis of CCAP in the
Doppler color and in the PRJ images. The results indicate
substantial agreement between these tests (kappa = 0.78),
contrasting with those of the present study. This
difference may be explained by the different sample sizes and
by the different number of evaluators used to assess the
panoramic radiographs.
In another study8, calcifications were observed in 9.4%
of PRJs, but not confirmed by the color Doppler examination,
and were considered false positives; in the same study, 3.1%
of results were considered false negatives, meaning that
the color Doppler examination revealed the presence of
calcifications that went undetected in the PRJs. In contrast,
Fig. 3 - Assessment of the agreement between panoramic radiography and color
Doppler in identifying calcified carotid atheroma plaques (n, %).
the present study showed even higher values for false positives
(63.2%) and false negatives (36.8%).
It is noteworthy that the identification of CCAP in
panoramic radiographs may not be a simple task. Published
articles8,23, and ours alike, have used dental radiologists in
their methodology, leading one to believe that false results,
whether positive or negative, could be even greater if the
radiographic analysis were performed by general dentists,
less trained to visually identify pathologies. A previous study8
showed that a general dentist, who is more familiar with
evaluating the maxilla, mandible and temporomandibular
joint cannot adequately perform the identification of CCAP
in panoramic radiography. In that study8, dental radiologists
found evidence of calcification in the carotid artery in 9 out
of 1,818 panoramic radiographs examined, whereas the
general dentist, examining the same panoramic radiographs,
failed to identify any of these calcifications.
Misinterpretation could be linked to the various
anatomical structures existing in the cervical region studied,
representing differential diagnoses. In 1981, when
the panoramic radiograph was described for the first time as
an aid in identifying patients at risk for stroke, calcification in
the region of the carotid artery bifurcation was identified
in 2% of cases, of which 88% were actually carotid artery
calcifications and the remaining 12% were calcified lymph
nodes or salivary calculi11.
Although PRJ may not be considered a reliable
method to detect calcifications in the carotid artery, it should
be used as a referral for the Doppler25 examination (the “gold
standard”) and other specialists8.
Merely detecting calcifications or stenosis of the carotid
artery in PRJ is of limited value in assessing the risk of
stroke, insofar as it does not take into account plaque
vulnerability26-28. According to a recommendation of the
American Heart Association, physicians should routinely
assess the vulnerability of all major arterial plaques 27,
including their morphology, as well as biochemical and
molecular factors, none of which can be identified by means
of panoramic radiography.
Dental clinicians should refer all patients with atheroma-
like lesions to a physician, since early aggressive treatment
has been shown to reduce strokes, fatal or otherwise11. On the
other hand, owing to the wide divergence of results observed,
it remains unclear whether dentists could be adequately trained
to reduce the number of false positive diagnoses to an
acceptable level. Otherwise, unnecessary referrals to physicians
could occur, leading to unnecessary tests and increased
healthcare spending 29. We believe that knowledge of
this topic should be generalized, and general dentists should
be trained in identifying carotid artery alterations.
Within the limitations of the present study,
PRJ presented good sensitivity and only moderate accuracy
in identifying calcified carotid atheroma plaques compared
with color Doppler examination. These results were confirmed
by the observed positive likelihood and negative likelihood
ratios. These results support previous findings and point to
enhancing the prospects of an interdisciplinary approach,
Sensitivity and accuracy of panoramic radiography in identifying calcified carotid atheroma plaques
9393939393
Braz J Oral Sci. 11(2):88-93
where dentists can refer their patients to other specialists, who,
in turn, may reach a definitive diagnosis based on specific
tests and prescribe the proper treatment.
References
1. Manual Merck. [cited 2012 Feb 6]. Available from:http://mmspf.
msdonline.com.br/pacientes/manual_merck/ secao_03/cap_026.html.
2. Lusis AJ. Atherosclerosis. Nature. 2000; 407: 233-41.
3. Hertzer NR, O’Hara PJ, Mascha EJ, Krajewski LP, Sullivan TM, Beven
EG. Early outcome assessment for 2228 consecutive carotid
endarterectomy procedures: the Cleveland clinic experience from 1989 to
1992. J Vasc Surg. 1997; 26: 1-10.
4. Almog DM, Illig KA, Khin M, Green RM. Unrecognized carotid artery
stenosis discovered by calcifications on a panoramic radiograph. J Am
Dent Assoc. 2000; 131, 1593-7.
5. Ministério da Saúde. [cited 2012 Feb 6]. Available from: http://
189.28.128.178/sage/.
6. Uthma, AT, Al-Saffar, AB. Prevalence in digital panoramic radiographs of
carotid area calcification among Iraqi individuals with stroke-related disease.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008; 105: 68-73.
7. Azevedo JRD. Aterosclerose. [cited 2012 Feb 6] .Available from: http://
boasaude.uol.com.br/lib/ShowDoc.cfm?LibDocID=3118& Return
CatID=1770.
8. Romano-Sousa CM, Krejci L, Medeiros FMM, Graciosa-filho RG, Martins
MFF, Guedes VN, et al. Diagnostic agreement between panoramic
radiographs and color Doppler images of carotid atheroma. J Appl Oral
Sci. 2009; 17: 45-8.
9. Frauchiger B, Schimid HD, Roedel C, Moosmann P, Staub D. Comparison
of carotid arterial resistive indices with intima-media thickness as sonographic
markers of atherosclerosis. Stroke. 2001; 32: 836-41.
10. Levy BA, Mandel DDS. Calcified carotid artery imaged by computed
tomography. J Oral Maxillofac Surg. 2010; 68: 218-20.
11. Friedlander AH, Lander A. Panoramic X-ray identification of carotid arterial
plaques. Oral Surg Oral Med Oral Pathol. 1981; 51: 102-4.
12. Friedlander AH. Identification of stroke prone patients by panoramic and
cervical spine radiography. Dentomaxillofac Radiol. 1995; 24: 160-4.
13. Manzi FR, Tuji FM, Almeida SM, Neto FH, Bóscolo FN. Panoramic
radiography as an auxiliary in detecting patients at risk for cerebrovascular
accident. Rev Assoc Paul Cir Dent. 2001; 55: 131-3.
14. Senosiain-Oroquitea A, Pardo-López B, de Carlos-Villafranca F, González-
Montoto, Cobo-Plana J. Detección de placas de ateroma mediante
radiografias dentales. RCOE. 2006; 11: 297-303.
15. Pornprasertsuk-Damrongsri S, Thanakun S. Carotid artery calcification
detected on panoramic radiographs in a group on Thai population. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod. 2006; 101: 110-5.
16. Freymiller EG, Sung EC, Friedlander AH. Detection of radiation-induced
atheromas by panoramic radiography. Oral Oncology. 2000; 36: 175-9.
17. Almog DM, Tsimidis K, Moss ME, Gottilieb RH, Carter LC. Evaluation of
a training program for detection of carotid artery calcifications on panoramic
radiographs. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007;
90: 111-7.
18. Ramesh A, Pabla T. Panoramic radiographs: a screening tool for calcified
carotid atheromatous plaque. J Mass Dent Soc. 2007; 56: 20-1.
19. Kamikawa RS, Pereira MF, Fernandes A, Meurer MI. Study of the
localization of radiopacities similar to calcified carotid atheroma by means
of panoramic radiography. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod. 2006; 102: 579-81.
20. Ayres M, Ayres Jr M, Ayres DL, Santos AS. BioEstat Versão 5.0.Belém:
Sociedade Civil Mamirauá, MCT-CNPq; 2007.
21. Teixeira AC, Cruvinel DL, Roma FR, Luppino LF, Resende LHP, Sousa T,
et al. Evaluation of the agreement between clinical and laboratorial exams in
the diagnosis of leprosy. Rev Soc Bras Med Trop. 2008; 41: 48-55.
22. Guimarães GO, Oliveira IE, Nobile Junior D, Messina Calderón JC,
Saddy MS. Radiografia panorâmica: identificação de pacientes suscetíveis
ao acidente vascular cerebral por meio da detecção de ateromas na
bifurcação da carótida. ConScientiae Saúde 2005; 4: 97-104.
23. Yoon SJ, Yoon W, Kim OS, Lee JS, Kang BC. Diagnostic accuracy on
panoramic radiography in the detection of calcified carotid artery.
Dentomaxillofac Radiol. 2008; 37: 104-8.
24. Madden RP, Hodges JS, Salmen CW, Rindal DB, Tunio J, Michalowicz
BS, et al. Panoramic Radiography Does Not Reliably Detect Carotid
Artery Calcification Nor Stenosis. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod. 2007; 103: 543-8.
25. Damaskos S, Griniatsos J, Tsekouras N, Georgopoulos S, Klonaris C,
Bastounis E, et al. Reliability of panoramic radiograph for carotid atheroma
detection: a study in patients who fulfill the criteria for carotid endarterectomy.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008; 106: 736-42.
26. Nighoghossian N, Derex L, Douek P. The vulnerable carotid artery plaque:
current imaging methods and new perspectives. Stroke. 2005; 36: 2764-72.
27. Naghavi M, Libby P, Falk E, Casscells SW, Litovsky S, Rumberger J,
et al. From vulnerable plaque to vulnerable patient: a call for new definitions
and risk assessment strategies: Part I. Circulation. 2003; 108: 1664-72.
28. Bhatia V, Bhatia R, Dhindsa S, Dhindsa M. Imaging of the vulnerable
plaque: new modalities. South Med J. 2003; 96: 1142-7.
29. Farman AG, Farman TT, Khan Z, Chen Z, Carter LC, Friedlander AH. The
role of the dentist in detection of carotid atherosclerosis. SADJ. 2001; 56:
549-53.
Sensitivity and accuracy of panoramic radiography in identifying calcified carotid atheroma plaques