Clinical Significance and a Review of Incidental Findings in CBCT
the vertebral artery often at the level of the foramen magnum . 48 Appropriate referral is indicated when vertebral artery calcifications are identified on CBCT images due to the increased risk of cerebrovascular accident .
Figure 14
Coronal view of CBCT image showing well-circumscribed , radiolucent vertebral soft tissue gas bubble in the right side .
Soft Tissue Gas Bubble in cervical spine The presence of gas bubbles in soft tissue ( Figure 14 ) may be indicative of the presence of an abscess or infectious process , 49 specifically secondary to anaerobic bacteria resulting in the formation of gases which appear radiographically as ovoid or circular radiolucent areas within soft tissue . 50 Recognizing this and correlating with clinical findings will help the patient . Less commonly , air may be introduced into the subcutaneous soft tissues , intraoperatively , such as through the use of air-driven handpieces by a clinician , 51 or postoperatively as a result of increased intraoral pressure . 52 Clinicians must be able to identify and report these since there is a potential for serious complications due to infection or iatrogenic issues from the presence of these air bubbles .
DISCUSSION
The use of CBCT has increased dramatically in dentistry in the past two decades . Improved diagnostic accuracy and medicolegal considerations have led to the use of three-dimensional imaging to become the standard of care in many procedures . Dental practitioners are obligated to familiarize themselves with new technologies necessary for appropriate patient care and must understand the technical aspects of CBCT and the inherent risks and benefits to patient health .
Multiple studies have shown how common these incidental findings are and the clinical importance of some of these findings . 10-12 , 15 The potential for serious complications exists with these incidental findings and the dentist must be able to identify and refer the patients for appropriate care .
Sialoliths and tonsilloliths are mostly asymptomatic but early detection and presence of patient discomfort should prompt further evaluation . Lymph node calcifications , which are common in submandibular region 9 but are also seen in cervical region could be potential malignant process , where a delay can be disastrous for the patient . 14
Multiple studies 17 , 22 have shown some association between external carotid arteries and intracranial internal carotid arteries calcifications and increased risk for stroke , which is one of the most common cause of death in the USA . 16 Combined with possibility of misinterpretation of the carotid artery calcifications with thyroid or triticeous calcifications in a panoramic radiograph 45 general dentists must be aware on how to distinguish between these conditions and identify them .
Other intracranial calcifications like pineal and choroid plexus calcifications although part of the of the physiological process can be harbingers of serious issues like Alzheimers ’ 29 and neurofibromatosis and toxoplasmosis respectively . 32
Vertebral artery calcifications have an increased risk of cerebrovascular accident 47 and soft tissue gas bubble in cervical spine region may indicate infection . 49 Clinicians must recognize and refer patients to appropriate medical practitioners to be evaluated .
Dermal fillers have potential for complications like filler migration , tissue necrosis , allergic and sensitivity reactions , and inflammatory reactions 38 and practitioners must be aware of these reactions and act on them accordingly .
CONCLUSION
All practitioners are ethically and legally responsible for interpreting the entirety of the images that they prescribe and therefore must be able to identify normal anatomic variations , benign processes , and , most importantly , malignancies and other systemic conditions which warrant further treatment or appropriate referral . CBCT has become a routine three-dimensional imaging for many practitioners . 53 When incidental findings are noted on the routine images recognizing and referring them appropriately is the legal responsibility for the dentist . 54 If the dentists are unable to comfortably interpret , they can consider sending the scan to an Oral & Maxillofacial Radiologist for a consultative opinion . Familiarity with common and the uncommon incidental findings , their clinical significance and their potential impact on patient care must of primary importance to practitioners . Missing or misidentifications of these findings can be detrimental to patient health . This review emphasizes the need for all general dentists utilizing CBCT imaging to be able to recognize and refer appropriately clinically significant incidental findings or seek radiographic interpretation from a specialist in the field . and ensuring that their patients receive the appropriate and best possible care .
FUNDING
This research did not receive any specific grant from funding agencies in the public , commercial , or not-for-profit sectors .
MAY / JUNE 2022 | PENNSYLVANIA DENTAL JOURNAL 29