Abstract
Background:
Soft tissue calcifications are inconspicuous entities seen on orthopantomograms as incidental findings, often overlooked, which may be a result of underlying disorders. Hence, it is important to evaluate their location, extent, and cause, to determine their clinical significance which may warrant further investigations and appropriate interventions to avoid any complications.
Purpose:
To determine the prevalence of soft tissue calcifications on digitally acquired panoramic radiographs.
Materials and Methods:
This cross-sectional, retrospective study analyzed panoramic radiographs of 2000 individuals to assess the prevalence and characteristics of soft tissue calcifications, which were tabulated based on parameters such as type of calcification, age, gender, and site.
Results:
The most common calcification noted on orthopantomogram was calcification of Stylohyoid ligament 139 (57.2%), followed by Tonsillolith 55 (22.6%), whereas the least common was Phlebolith 1 (0.4%). The maximum number of calcifications were present in the older age group, i.e., 53–70 years (41.2%).
Conclusion:
Soft tissue calcifications are frequently detected on digital panoramic radiographs. While seemingly trivial, they may be an early indicator unsuspected pathology. Their prevalence increases with age, often indicating underlying systemic changes, which warrants early detection, timely referral and prompt management.
KEYWORDS: Dystrophic calcification, idiopathic calcification, metastatic calcification, orthopantomogram
INTRODUCTION
Calcium is a crucial micronutrient essential for various bodily functions, including cellular processes, nerve conduction, and the development of bones and teeth.[1] Ordinarily, calcium phosphate is deposited in the skeleton; however, when deposition occurs in an unorganized manner within soft tissues, it is termed heterotopic calcification.
The location, size, shape, distribution, and number of calcifications are crucial for making an accurate radiographic diagnosis.[2] In certain cases, calcifications may indicate underlying serious systemic disorders.
Orthopantomographs (OPGs) are becoming widely used in maxillofacial radiology nowadays due to its easy accessibility, low cost and reduced radiation exposure along with the ability to simultaneously assess both jaws.[3] Therefore, this study was conducted to evaluate the prevalence of incidental soft tissue calcifications detected on digital panoramic radiographs.
The present retrospective study was conducted in the Department of Oral Medicine and Radiology, after obtaining approval from the Institutional Ethical Committee (EC/NEW/INST/2021/1896/168/02/2024).
The study aimed to include 2000 panoramic radiographs from the archives of the department. However, panoramic radiographs with radiographic artifacts, facial deforming pathologies, history of trauma or surgery, obscure images with superimposition of structures, and those lacking diagnostic quality were excluded from the study.
For ease of identification, the panoramic radiographs were divided into eight equal quadrants by drawing one horizontal line to split the OPG into two horizontal halves and three vertical lines to divide each horizontal half into four quadrants vertically as shown in the Figure 1.
Figure 1.
Quadrants of OPG
Statistical analysis of the data was performed using Chi-square tests with Cramer’s V for effect size, in SPSS version 26.0 (Chicago, IL, USA), where P value > 0.05 was considered nonsignificant, P value < 0.05 was considered significant*, and P value < 0.01 was considered highly significant**.
RESULTS
A total of 243 soft tissue calcifications were detected among 2000 panoramic radiographs evaluated. The prevalence of different calcification types is presented in Table 1. The age-wise distribution in Table 2: The gender-wise distribution in Table 3: Overall, statistically significant associations were observed for calcified lymph nodes, styloid ligament calcifications, sialoliths, and tonsilloliths with respect to the studied demographic and anatomical parameters.
Table 1.
Prevalence of various types of soft tissue calcifications
| Type of calcification | Frequency | P | ||
|---|---|---|---|---|
| Antrolith | 2 (0.82%) | 0.793 | ||
| Calcified Atheromatous plaque | 3 (1.23%) | 0.7 | ||
| Calcified lymph node | 6 (2.469%) | 0.02 | ||
| Carotid canal calcification | 2 (0.82%) | 0.793 | ||
| Phlebolith | 1 (0.411%) | 0.362 | ||
| Rhinolith | 3 (1.23%) | 0.7 | ||
| Sialolith | 21 (8.64%) | 0.05* | ||
| Styloid ligament calcification | 139 (57.2%) | 0.000** | ||
| Tonsillolith | 55 (22.63%) | 0.05* | ||
| Triticeous cartilage | 11 (47.82%) | 0.05* | ||
| Total | 243 (100%) | |||
Table 2.
Distribution of soft tissue calcifications according to age groups
| Type of Calcification | AGE GROUP |
Total | P | |||||||
|---|---|---|---|---|---|---|---|---|---|---|
| 18–35 | 36–52 | 53–70 | ||||||||
| Antrolith | 1 (50%) | 1 (50%) | 0 | 2 | 0.393 | |||||
| Calcified Atheromatous plaque | 0 | 2 (66.67%) | 1 (33.33%) | 3 | 0.548 | |||||
| Calcified lymph node | 1 (16.67%) | 1 (16.67%) | 4 (66.67%) | 6 | 0.404 | |||||
| Carotid canal calcification | 0 | 1 (50%) | 1 (50%) | 2 | 0.784 | |||||
| Phlebolith | 0 | 1 (100%) | 0 | 1 | 0.463 | |||||
| Rhinolith | 0 | 2 (66.67%) | 1 (33.33%) | 3 | 0.548 | |||||
| Sialolith | 6 (28.57%) | 8 (38.09%) | 7 (33.33%) | 21 | 0.505 | |||||
| Styloid ligament calcification | 31 (22.3%) | 53 (38.12%) | 55 (39.56%) | 139 | 0.401 | |||||
| Tonsillolith | 7 (12.72%) | 19 (34.54%) | 29 (52.72%) | 55 | 0.112 | |||||
| Triticeous cartilage | 1 (9.09%) | 8 (72.72%) | 2 (18.18%) | 11 | 0.069 | |||||
| TOTAL | 47 (19.34%) | 96 (39.5%) | 100 (41.15%) | 243 (100%) | ||||||
| P | 0.00001** | |||||||||
Table 3.
Distribution of soft tissue calcifications according to gender
| Type of calcification | Gender |
Total | P | |||||
|---|---|---|---|---|---|---|---|---|
| Male | Female | |||||||
| Antrolith | 2 (100%) | 0 | 2 | 0.501 | ||||
| Calcified Atheromatous plaque | 0 | 3 (100%) | 3 | 0.096 | ||||
| Calcified lymph node | 5 (83.33%) | 1 (16.67%) | 6 | 0.222 | ||||
| Carotid canal calcification | 0 | 2 (100%) | 2 | 0.211 | ||||
| Phlebolith | 1 (100%) | 0 | 1 | 1.000 | ||||
| Rhinolith | 1 (33.33%) | 2 (66.67%) | 3 | 0.596 | ||||
| Sialolith | 12 (57.14%) | 9 (42.85%) | 21 | 0.934 | ||||
| Styloid ligament calcification | 62 (44.6%) | 77 (55.39%) | 139 | 0.001** | ||||
| Tonsillolith | 44 (80%) | 11 (20%) | 55 | 0.000** | ||||
| Triticeous cartilage | 4 (36.36%) | 7 (63.63%) | 11 | 0.376 | ||||
| Total | 131 (53.9%) | 112 (46.09%) | 243 (100%) | |||||
| P | 0.035 | |||||||
DISCUSSION
In this study, the prevalence of soft tissue calcifications was 12.15%. However, it contrasts sharply with the study by Jain et al.,[4] who reported a 61% prevalence of soft tissue calcifications, which may be ascribed to the smaller sample size of along with the difference in geology of the population included.[4]
In this study, styloid ligament calcification was the most prevalent finding 57.20%, which is consistent with the results of Pagare et al.[5] However, our findings contrast with those of Darwin et al.,[6] who reported a much lower prevalence of 2.7%. This discrepancy may be attributed to the wide age range in their study population, with younger individuals comprising 31.5% of the sample.
According to our study, the least common calcification was phlebolith, accounting for only 0.41% of cases. This finding is similar to the results of the present study. However, our results contrast with those of Darwin et al.,[6] who reported a prevalence of 17.6%. This difference may be due to the wider age range included in their study population.
In our study, a higher prevalence of calcifications was observed in the older age group 41.15%, which is consistent with our findings. However, Darwin et al.[6] presented a contrasting result, showing a higher prevalence in the middle-aged group (40–59 years). This variation may be due to the difference in the division of participants in age groups.
According to our study, there was a higher prevalence of calcifications in men (53.9%), which is consistent with the results of the study conducted by Khojastepour et al.,[7] who reported a male prevalence of 57.05%. However, these results contrast with the study conducted by Darwin et al.,[6] which showed a higher prevalence in women (59.2%). This variation can be explained by the gender distribution of the study populations.
CONCLUSION
This study divulged a notable prevalence of soft tissue calcifications on panoramic radiographs, usually incidental, with calcified stylohyoid ligament being the most common finding. Routine evaluation of panoramic radiographs can aid in timely diagnosis and management, ultimately improving patient outcomes.
Conflicts of interest
There are no conflicts of interest.
Acknowledgement
The authors are thankful to the department of oral medicine and radiology, GDCHJ, for providing OPGs from their archives to conduct this study.
Funding Statement
Nil.
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