Association of carotid artery calcifications detected on panoramic radiographs with systemic diseases in dental implant patients: a cross-sectional study in a Turkish population

Abstract

Background

Carotid artery calcification (CAC) detected on panoramic radiographs can serve as an early indicator of systemic atherosclerotic disease. This study aimed to determine the prevalence of CAC in digital panoramic radiographs of dental implant patients and to evaluate its association with systemic diseases in a sample of the Turkish population.

Methods

This retrospective cross-sectional study included 254 implant patients who attended follow-up visits between December 2022 and January 2024. Age, gender, number of implants, presence of CAC, and systemic disease status (hypertension, diabetes mellitus, hyperlipidemia, atherosclerosis, cardiovascular disease) were analyzed. All panoramic radiographs were assessed by one experienced oral and maxillofacial surgeon in two separate sessions with a 2-week interval to evaluate intra-observer consistency. Cohen’s kappa (κ = 0.86) confirmed excellent agreement. Logistic regression was performed to determine associations between systemic variables and CAC.

Results

CAC was detected in 60 of 254 patients (23.6%). Hypertension was the most prevalent systemic condition associated with CAC (46.7% of affected patients). Logistic regression revealed significant associations between CAC and several systemic diseases: hypertension (OR = 48.04), diabetes mellitus (OR = 43.57), cardiovascular disease (OR = 40.92), hyperlipidemia (OR = 33.20), and atherosclerosis (OR = 26.38) (p < 0.05).

Conclusion

Significant associations were observed between CAC and systemic diseases; however, the magnitude of these associations should be interpreted with caution. On the other hand, panoramic radiographs in dental clinics can incidentally reveal carotid artery calcifications (CAC), which reflect underlying systemic atherosclerosis. Therefore, dentists play a crucial role in the early prevention of stroke and cardiovascular events by identifying carotid artery calcification and referring patients for medical evaluation.

Background

Atherosclerosis is a chronic inflammatory disease characterized by lipid accumulation and calcification within the arterial wall, leading to vascular obstruction and ischemic events. It primarily affects large and medium-sized arteries such as the carotid, coronary, and cerebral vessels and remains a leading cause of cardiovascular morbidity and mortality worldwide [1–3].

Early identification of vascular calcifications associated with atherosclerosis can play an important role in the prevention of stroke and myocardial infarction [4, 5].

Carotid artery calcifications (CACs) can occasionally be detected on panoramic radiographs, which are routinely used in dental practice. These calcifications typically appear near the third cervical (C3) - fourth cervical (C4) vertebral levels as circular, irregular or heterogeneous, and unilateral or bilateral radioopacities. These plaques have different shapes. They may have a predominantly circular appearance when they are small; however, large atheromas have a linear or thin rectangular appearance [6–8].

Although panoramic radiography is primarily designed for dental evaluation, it can incidentally reveal significant systemic conditions such as atherosclerosis [9].

Advanced imaging modalities such as Doppler ultrasonography, computed tomography (CT), and cone-beam computed tomography (CBCT) provide higher diagnostic accuracy for the detection and localization of CACs. However, panoramic radiographs remain the most cost-effective and widely available imaging modality in dental clinics. Their accessibility allows dental professionals to incidentally detect calcifications and refer patients for further medical evaluation, serving as a potential screening tool for early cardiovascular risk [10, 11].

A critical limitation of panoramic imaging is that several non-atheromatous calcified structures—such as the triticeous cartilage (TC), stylohyoid ligament, phleboliths, and tonsilloliths—may mimic CACs. Differentiation between these entities is essential, as failure to exclude TC calcifications may result in false-positive diagnoses and overestimation of CAC prevalence. Studies have reported the prevalence of TC calcification in individuals over 40 years as approximately 8–12%, underlining the need for careful anatomic distinction during radiographic evaluation [12, 13].

Panoramic radiography is routinely performed for dental implant planning and follow-up, particularly in middle-aged and older adults who often present with systemic comorbidities. Therefore, implant patients constitute an ideal population for investigating the incidental detection of CACs and their relationship with systemic diseases [14–16].

Despite numerous studies from different regions, there is limited evidence regarding the prevalence and clinical implications of CACs among implant patients within the Turkish population. Understanding this relationship may enhance clinicians’ awareness of systemic vascular risk during routine dental imaging.

Therefore, the present study aimed to determine the prevalence of CACs detected on panoramic radiographs of dental implant patients and to evaluate their association with systemic diseases in a sample of the Turkish population [1, 17].

Materials and methods

Study design and ethical approval

This retrospective cross-sectional study was conducted in accordance with the principles of the Declaration of Helsinki and approved by the Ethics Committee of Harran University, Faculty of Dentistry (Approval No: [HRU/22.25.03], Date: 2023). All procedures were performed following institutional ethical standards, and patient confidentiality was maintained throughout the study.

Sample selection

Panoramic radiographs of 254 dental implant patients who attended postoperative control visits between December 2022 and January 2024 were retrieved from the institutional digital archive. Only high-quality diagnostic images with clear cervical visualization were included.

Inclusion criteria

• Adult patients aged 18 years or older who had undergone dental implant placement,

• Availability of postoperative panoramic radiographs taken 6–12 months after implantation,

• Radiographs obtained with standardized exposure parameters using the same panoramic unit,

• Complete medical records including systemic disease history,

• Radiographs providing clear visualization of the cervical vertebral region and mandibular angle.

Exclusion criteria

• Radiographs exhibiting motion artifacts, blurring, or incomplete visualization of the cervical region,

• Patients with a history of head and neck radiotherapy, vascular malformations, or developmental anomalies,

• Cases presenting with multiple systemic diseases (to avoid confounding comorbidity overlap),

• Images where non-atheromatous calcifications (e.g., TC, stylohyoid ligament, phleboliths, tonsilloliths) could not be reliably differentiated,

• Patients with missing demographic or clinical data.

Imaging protocol and assessment

All panoramic radiographs were obtained using the same digital panoramic imaging system (Vatech PCH-2500 Digital Panoramic Imaging System (Gyeonggi-do, South Korea)) under standardized exposure settings (70–75 kVp, 10–12 mA, 13–15 s). Radiographs were analyzed on a calibrated medical-grade monitor in a dimly lit room. The assessment was performed using ImageJ software (NIH, Bethesda, MD, USA) on a full HD screen with a maximum screen resolution of 1920 × 1080 and a screen size of 15.6 inches.

Each image was examined by a single experienced oral and maxillofacial surgeon with ten years of experience in two independent sessions separated by a 2-week interval to evaluate intra-observer reliability. The examiner was blinded to the patients’ systemic disease status during the first evaluation. Cohen’s kappa (κ = 0.86) indicated excellent intra-observer agreement.

CACs were identified as irregular, heterogeneous radiopaque masses located near the C3–C4 vertebral levels, typically inferior and posterior to the mandibular angle. The distance between each calcified area and adjacent anatomical landmarks (second cervical vertebrae (C2)– third cervical vertebrae (C3) interspace, hyoid bone) was measured digitally to confirm anatomical positioning consistent with CAC morphology. To standardize the anatomical localization of suspected carotid artery calcifications, linear distance measurements were performed between the radiopaque lesion and predefined anatomical landmarks. Since panoramic radiography is known to present inherent magnification and geometric distortion, measurements were not interpreted as absolute anatomical distances. Instead, they were used only for relative localization and consistency between observers. No calibration-based correction factor was applied, as the purpose of measurement was anatomical standardization rather than quantitative morphometric analysis.

Data collection and variables

For each patient, the following data were recorded:

• Age, sex, and number of dental implants,

• Presence or absence of CAC on panoramic radiograph,

• Systemic disease status including hypertension, diabetes mellitus, hyperlipidemia, atherosclerosis, and cardiovascular disease.

Systemic disease data were obtained retrospectively from institutional electronic medical records and patient anamnesis forms routinely completed before implant treatment.

All panoramic radiographs were taken during routine follow-up visits to ensure anatomical stability and consistent head positioning.

Statistical analysis

Statistical analyses were performed using R software (version 4.5.0). The Shapiro–Wilk test was used to assess normality of continuous variables. Depending on data distribution, Wilcoxon rank-sum, Kruskal–Wallis, or Chi-square/Fisher’s exact tests were used to compare groups. Binary logistic regression was applied to evaluate associations between CAC presence and systemic variables. A p-value < 0.05 was considered statistically significant. In the multivariate logistic regression model, systemic diseases (hypertension, diabetes mellitus, cardiovascular disease, hyperlipidemia, and atherosclerosis) were included as separate binary categorical variables (0 = absent, 1 = present). Age was entered as a continuous variable, and sex as a categorical variable. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to estimate the strength of associations. Model explanatory power was assessed using the Nagelkerke pseudo-R² statistic.

Justification for imaging modality

Although CBCT and Doppler ultrasonography offer superior spatial resolution and diagnostic accuracy, panoramic radiography was chosen due to its routine use in implant follow-up, lower radiation dose, and retrospective data availability. This methodological limitation has been acknowledged and discussed in detail in the Discussion section.

Results

After applying the inclusion and exclusion criteria, a total of 254 panoramic radiographs of dental implant patients were included in the study.

Of the study participants, 128 were male (50.39%) and 126 were female (49.61%; Table 1). No statistically significant difference was found between sexes (p > 0.05). The average age of the participants was 45.78 ± 12.80 years (range: 21–81) (Table 2). No systemic diseases were found in 115 (45.28%) of the patients who participated in the study. Among the 139 patients with systemic diseases, hypertension was the most common, followed by diabetes, cardiovascular disease, hyperlipidemia, and atherosclerosis (Table 1).

Table 1.

Frequency Distribution Table for Demographic Information

Variable	Category	n	%
Gender	Male	128	50.39
Gender	Female	126	49.61
Systemic disease	None	115	45.28
Systemic disease	Atherosclerosis	13	5.12
Systemic disease	Diabetes mellitus	26	10.24
Systemic disease	Hyperlipidemia	17	6.69
Systemic disease	Hypertension	62	24.41
Systemic disease	Cardiovascular disease	21	8.27
CAC	Absent	194	76.38
CAC	Present	60	23.62

This table presents the distribution of gender, systemic diseases, and carotid artery calcification status among the 254 implant patients included in the study. Percentages were calculated based on the total sample size

CAC  Carotid artery calcification

Table 2.

Descriptive statistics of age and number of implants in the study population

Variable	N	Mean ± SD	Median	Min–Max
Number of implants	254	3.61 ± 2.82	3	1–14
Age (years)	254	45.78 ± 12.80	45	21–81

Continuous variables are presented as mean ± standard deviation (SD), median, and range (minimum–maximum)

Carotid artery calcifications were generally observed as round, irregular, or heterogeneously radiopaque on panoramic radiographs between the C3 and C4 vertebrae (Figs. 1 and 2). Only 60 (23.62%) of the 254 patients in the study had CAC lesions (Table 1).

Fig. 1.

Carotid artery calcification (indicated by arrow) observed on panoramic radiograph between the C3 and C4 vertebrae, appearing as a radiopaque nodular mass

Fig. 2.

The heterogeneous nodular radiopaque appearance indicated by the arrows is consistent with the typical carotid atheroma morphology reported in the literature. Additionally, Fig. 2 presents another representative example of bilateral CACs detected at the C3–C4 level

The logistic regression model was statistically significant (p < 0.001). The Nagelkerke R² value was 0.399, indicating that approximately 39.9% of the variance in CAC presence was explained by the independent variables. Based on the analysis, the estimated model has sufficient fit since p > 0.05. The model was created by correctly classifying the dependent variable with a rate of 77.6% (Table 3). Model goodness-of-fit was evaluated using the Hosmer–Lemeshow test, which indicated adequate model fit (χ² = 10.92, df = 8, p = 0.206).

Table 3.

Logistic Regression Analysis Results

Variable	B	SE	Wald	df	p	OR	95% CI (Lower–Upper)
Gender	0.21	0.36	0.33	1	0.565	1.23	0.61–2.46
Atherosclerosis	3.27	0.95	11.84	1	0.001	26.38	4.09–170.15
Diabetes	3.77	0.83	20.84	1	0.001	43.57	8.62–220.31
Hyperlipidemia	3.50	0.90	15.31	1	0.001	33.20	5.74–191.92
Hypertension	3.87	0.77	25.53	1	0.001	48.04	10.70–215.73
Cardiovascular disease	3.71	0.85	18.89	1	0.001	40.92	7.67–218.21
Number of implants	0.10	0.06	2.29	1	0.130	1.10	0.97–1.25
Age	0.03	0.01	3.39	1	0.066	1.03	1.00–1.05
Constant	-5.75	1.01	32.49	1	0.001	0.003	—

Binary logistic regression was performed to evaluate the relationship between demographic variables, systemic disease categories, and the presence of CAC. Odds ratios (OR) and 95% confidence intervals (CI) are presented. The model showed a statistically significant association between all systemic diseases and CAC (p < 0.05)

OR Odds ratio, CI Confidence interval

Although logistic regression yielded high odds ratios (26–48×), these values should be interpreted with caution due to limited sample size and possible multicollinearity among systemic variables. This issue is further addressed in the Discussion section.

Gender, age, and the number of dental implants had no statistically significant effect on the dependent variable carotid artery calcification (p > 0.05). Systemic diseases had a statistically significant effect on the dependent variable CAC (p < 0.05). Those with systemic atherosclerosis had a 26.382 times higher likelihood of carotid artery calcification compared to those without systemic disease. Systemic diabetes mellitus increased the likelihood of carotid artery calcification by 43.57 times compared to those without systemic disease. Hyperlipidemia increased the likelihood of CAC by 33.201 times in those with systemic disease compared to those without systemic disease. Hypertension increased the likelihood of CAC by 48.041 times in those with systemic disease compared to those without systemic disease. Those with systemic cardiovascular disease had a 40.922 times higher likelihood of CAC compared to those without systemic disease (Table 3).

While 58.25% of those without CAC and 3.3% of those with CAC had no systemic disease, 4.64% of those without CAC and 6.67% of those with CAC had systemic atherosclerosis (Table 4).

Table 4.

Association between CAC and systemic diseases

Systemic disease	CAC Absent n (%)	CAC Present n (%)	Total	p
None	113 (58.25%)	2 (3.33%)	115	0.001
Atherosclerosis	9 (4.64%)	4 (6.67%)	13
Diabetes	15 (7.73%)	11 (18.33%)	26
Hyperlipidemia	11 (5.67%)	6 (10.00%)	17
Hypertension	34 (17.53%)	28 (46.67%)	62
Cardiovascular	12 (6.19%)	9 (15.00%)	21

This table compares the frequency of systemic diseases between patients with and without CAC. A significant association was observed between CAC and hypertension, diabetes mellitus, hyperlipidemia, and cardiovascular disease (p < 0.05). Pearson’s Chi-square test was used for the overall comparison between CAC status and systemic disease categories (p = 0.001)

Hypertension was the most frequent systemic disease among CAC-positive patients (46.7%), followed by diabetes mellitus (16.7%) and cardiovascular disease (15%) (Table 4). Logistic regression confirmed significant associations between CAC and all systemic diseases (p < 0.05).

Implant number and age were compared between CAC-positive and CAC-negative groups using the Mann–Whitney U test. Patients with CAC had significantly higher implant numbers (p < 0.05). Values are presented as mean, median, range, and standard deviation (SD). In univariate analysis (Mann–Whitney U test), age was significantly higher in the CAC-positive group (mean = 49.98 ± 11.66 vs. 44.48 ± 12.88, p < 0.05). However, in the multivariate logistic regression model adjusting for systemic diseases, age did not remain an independent predictor of CAC (p = 0.066), (Table 5).

Table 5.

Implant number and age compared by CAC status

Variable	CAC Status	n	Mean	Median	Min–Max	SD	p
Implants	Absent	194	3.41	2	1–13	2.71	0.026
Implants	Present	60	4.27	3	1–14	3.09
Age	Absent	194	44.48	44	21–81	12.88	0.002
Age	Present	60	49.98	48	22–75	11.66

Mann–Whitney U test was used for non-normally distributed variables

Although implant number was significantly higher in the CAC-positive group in univariate analysis (p = 0.026), it did not remain a significant independent predictor in the multivariate logistic regression model (p = 0.130)

When analyzed by gender, CAC was slightly more frequent in females (22.6%) than in males (21.0%), though this difference was not statistically significant (p > 0.05).

Hypertension and hyperlipidemia were more common among females, whereas cardiovascular disease was slightly more prevalent among males.

Discussion

Finding the prevalence of CAC on digital panoramic radiographs of patients receiving dental implants and examining the connection between it and systemic diseases were the objectives of this study. In the present study, CAC was detected in 23.62% of implant patients, indicating that nearly one in four individuals exhibited radiographic findings suggestive of carotid atherosclerosis. Among systemic diseases, hypertension demonstrated the strongest association with CAC.

Friedlander and Lande reported in 1981 that panoramic radiographs may be useful in detecting carotid artery calcification, which is among the important causes of stroke and is observed at the C3–C4 vertebral level [16]. However, Baker stated that stroke risk may be present in approximately 5% of asymptomatic patients based on panoramic radiographs [18]. Reported CAC prevalence rates in panoramic-based studies generally range between 3% and 20% [19, 20]. Compared to lower rates reported by Bayram et al. (2.1%) and Agacayak et al. (8.8%) [19, 21], the prevalence observed in our study appears higher (23.62%). Differences in the study populations, specifically with relation to age, food habits, physical activity, and the radiography procedures employed, may be related to this disparity. Additionally, this difference may partly reflect the demographic characteristics of implant patients, who are typically middle-aged or older individuals—an established risk group for atherosclerotic changes. Differences in study populations and imaging protocols may also contribute to variability in reported rates. However, our results are more consistent with those of Alves et al., who found that 38.8% of patients with systemic diseases had CAC. In our study, the rate of CAC was approximately 23%. Alves et al. reported a higher rate of CAC than our study, reaching 38.8% in individuals with systemic diseases [22]. Even though non-atheromatous cervical calcifications such as TC, stylohyoid ligament calcification, phleboliths and tonsilloliths were carefully considered during image interpretation, complete exclusion of these entities cannot be guaranteed. Residual misclassification may therefore have contributed to the relatively high CAC prevalence observed in our study.

CAC can be observed as nodular radiopaque masses near the C3–C4 level, typically inferior/posterior to the mandibular angle [23]. According to Cohen, panoramic radiographs may be an important marker for detecting atheroma plaques, and patients with CAC should be referred for cardiovascular and cerebrovascular risk assessment.” [24]. Sisman et al. reported that 31.58% of their patients had hyperlipidemia [17]. Agacayak et al. found that 56.4% of individuals had hypertension compared to other systemic diseases [19]. In our study, we detected hypertension in 46.67% of patients with carotid artery calcification. Additionally, those with hypertension and systemic disease had a 48.041 times higher likelihood of having CAC compared to those without systemic disease. Therefore, patients with hypertension should be advised to have a medical evaluation for the presence of an atheroma plaque, and patients with an atheroma plaque should be advised to have a medical evaluation for the presence of hypertension. Logistic regression analysis demonstrated markedly elevated odds ratios for systemic conditions, particularly hypertension; however, these estimates should be interpreted cautiously. The magnitude of the odds ratios may have been influenced by the relatively limited sample size and possible multicollinearity among systemic variables rather than reflecting the true clinical effect size.

CAC may be responsible for the occurrence of ischemic cerebrovascular diseases, which account for half of all deaths in Western countries. Indeed, cerebrovascular diseases are the most common cause of death in the United States of America after cardiovascular diseases and cancer [25]. As in the United States, the third most common cause of death in Turkey is cerebrovascular disease [19]. The diagnosis of CAC is extremely important because carotid artery disease may not present symptoms until complete occlusion occurs [25]. Friedlander and Cohen evaluated CAC with panoramic radiographs and reported that approximately 26% of males experienced myocardial infarction with revascularization-like vascular events [26].

Hypertension, age, gender, diabetes, atherosclerosis, hyperlipidemia and smoking are among the most important risk factors for CAC. Although lifestyle-related factors such as diet, physical activity, and smoking have been associated with atherosclerosis in previous studies, these variables were not directly assessed in the present retrospective study [19]. Therefore, interpretations involving lifestyle factors should be considered cautiously.

Our study found a similar prevalence of CAC in men (24) and women (30). However, Bayram et al. showed that the prevalence in women was almost three times higher than in men [21]. Agacayak et al. reported that CAC in female patients was double that in male patients [19].

In our sample, hypertension and hyperlipidemia were slightly more common among women, whereas cardiovascular disease tended to be more frequent in men; however, these differences did not reach statistical significance, which may partly explain the absence of a clear sex effect on CAC prevalence.

In addition to hypertension, hyperlipidemia, diabetes and cardiovascular diseases, smoking, and periodontitis have been associated with CAC [17]. A study investigating CAC in the Thai population reported that 52.9% of patients had hypertension, 29.4% had diabetes, and 29.4% had hyperlipidemia [27]. Lewis and Brooks reported that hypertension and diabetes were responsible for the formation of CAC in 77.8% and 22.2% of patients, respectively [28]. Agacayak et al., evaluating 844 panoramic X-rays by limiting the prevalence of CAC to patients aged over 60, reported that 56.4% of patients with CAC had hypertension and diabetes, atherosclerosis, cardiovascular disease, and hyperlipidemia [19]. In line with the literature, we found comparable results in our investigation. In our study, hypertension was the leading systemic disease in which CAC occurred with a rate of 46.67%. Diabetes followed hypertension with a rate of 18.33%.

From a clinical perspective, these findings highlight the important role of dentists in the early identification of patients at increased vascular risk. Implant candidates and follow-up patients routinely undergo panoramic radiography, and incidental detection of CAC in this context may provide a valuable opportunity for timely medical referral and further cardiovascular or cerebrovascular assessment. Integrating a systematic screening approach for CAC into routine radiographic evaluation may therefore contribute to stroke and cardiac event prevention, particularly in patients with coexisting hypertension and other systemic diseases. The novelty of our study lies not in its methodological aspects, but rather in its contribution to raising awareness of cardiovascular risk indicators in a specific patient group (patients undergoing dental implant treatment).

However, there are also studies in the literature reporting that CAC has no relationship with diseases such as hypertension, hyperlipidemia, and diabetes [29, 30].

The existence of carotid artery calcification as a risk indicator for cerebrovascular diseases remains debatable. CAC is identified using various methods. The first suggestion is that ultrasound imaging is rapid and inexpensive. However, Positron emission tomography-computed tomography (PET-CT) imaging with 18 F-sodium fluoride (18 F-NaF) was recently reported in the literature as a new technique that can detect initial microcalcifications [31]. Unfortunately, we had no opportunity to refer our patients in whom we detected CAC with panoramic radiographs to such techniques. Pre-implant surgery evaluation is performed with panoramic radiography in most centers; CBCT is requested as an additional scan when bone volume and surgical planning are required. While panoramic radiography is routinely available for all implant patients, CBCT is not mandatory for every patient. Despite its high resolution advantage, CBCT is not a standard modality for CAC assessment because the carotid artery region is often outside the imaging field due to the regional nature of the current CBCT scans of patients. Panoramic radiography, on the other hand, is considered the first-step method for incidental screening of CAC. The literature indicates that panoramic radiography has great potential in the early diagnosis of carotid calcification in patients with or without associated risk factors, and complements the usual techniques of carotid calcification screening [6]. Nonetheless, we advise using these techniques for additional cardiovascular and cerebrovascular assessment. Therefore, clinicians must have an excellent knowledge of normal anatomical structures, pathologies, and potential film errors to differentiate them and determine which diagnostic method is more appropriate in which situation. A limitation of this study is that we did not confirm the detection of CAC by ultrasound, 18 F-NaF, and PET-CT imaging.

Limitations of the study

This study has various limitations. First, panoramic radiographs—which have lower sensitivity and specificity than more sophisticated imaging modalities like Doppler ultrasonography, CT or PET-CT were the only method used to identify carotid artery calcifications. Therefore, it is impossible to rule out both false positives and false negatives. Therefore, the true nature of the observed calcifications (e.g., atheroma vs. other calcified structures) remains ambiguous, which may limit the diagnostic precision of our findings (27). Second, a single observer interpreted every radiograph. The lack of numerous reviewers may induce observer bias, even when intra-observer reliability was taken into consideration. Third, the study’s retrospective and cross-sectional design precludes drawing conclusions about causality. Fourth, because the study sample consisted of implant patients from a single center in Turkey and individuals with multiple systemic diseases were excluded, the generalizability of our findings to broader or more medically complex populations is limited. Fifth, this study did not investigate whether CAC occurs before or after implantation, or whether CAC formation is directly related to implants. Longitudinal studies comparing pre- and post-implantation radiographs could be conducted in the future to investigate the existence of this relationship. Lastly, the absence of data on lifestyle-related factors such as diet, physical activity, smoking status, and socioeconomic background represents an additional limitation of this study.

Conclusions

Panoramic radiographs may serve as a valuable adjunct for the incidental detection of suspected carotid artery calcifications (CAC), which may indicate an increased cardiovascular and cerebrovascular risk. In this study, CAC was significantly associated with several systemic diseases, particularly hypertension. These findings highlight the potential role of dentists in identifying patients who may benefit from further medical assessment. However, panoramic radiography should be regarded strictly as a screening tool rather than a confirmatory diagnostic method. When CAC is detected, referral for appropriate medical evaluation should be considered, as early identification of vascular risk factors may contribute to the prevention of adverse cardiovascular and cerebrovascular events.

Abbreviations

CAC

Carotid Artery Calcification

C3

Third Cervical Vertebrae

C4

Fourth Cervical Vertebrae

CBCT

Cone-beam Computed Tomography

CT

Computed Tomography

TC

Triticeous Cartilage

18F-NaF

18 F-Sodium Fluoride

PET-CT

Positron Emission Tomography-Computed Tomography

Authors’ contributions

MBB and MAK contributed to the conception and design of the study, MBB contributed to the acquisition of data, MAK contributed to drafting the article, MBB contributed to the analysis and interpretation of data, MBB and MAK revised it critically for important intellectual content, and all the authors agreed and gave final approval of the version to be submitted.

Funding

The authors received no financial support for the research, authorship, or publication of the article.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Ethics committee approval was obtained for this study from Harran University Clinical Research Ethics Committee with protocol number HRU/22.25.03. This study was performed in accordance with the Declaration of Helsinki. Since this was a retrospective study using anonymized data, individual written informed consent was not required, in accordance with the approval from the Harran University Clinical Research Ethics Committee (HRU/22.25.03).

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.